Health


The journal Molecular Autism this week published an article about the links between Hans Asperger and the Nazis in world war 2 Vienna, Austria. Hans Asperger is the paediatric pscyhiatrist on whose work Asperger’s syndrome is based, and after whom the syndrome is known. Until recently Asperger was believed to have been an anti-Nazi, someone who resisted the Nazis and risked his own career to protect some of his developmentally delayed patients from the Nazi “euthanasia” program, which killed or sterilized people with certain developmental disabilities for eugenics reasons.

The article, entitled Hans Asperger, National Socialism, and “race hygiene” in Nazi-era Vienna, is a thorough, well-researched and extensively documented piece of work, which I think is based on several years of detailed examination of primary sources, often in their original German. It uses these sources – often previously untouched – to explore and rebut several claims Asperger made about himself, and also to examine the nature of his diagnostic work during the Nazi era to see whether he was resisting or aiding the Nazis in their racial hygiene goals. In this post I want to talk a little about the background of the paper, and ask a few questions about the implications of these findings for our understanding of autism, and also for our practice as public health workers in the modern era. I want to make clear that I do not know much if anything about Asperger’s syndrome or autism, so my questions are questions, not statements of opinion disguised as questions.

What was known about Asperger

Most of Asperger’s history under the Nazis was not known in the English language press, and when his name was attached to the condition of Asperger’s syndrome he was presented as a valiant defender of his patients against Nazi racial hygiene, and as a conscientious objector to Nazi ideology. This view of his life was based on some speeches and written articles translated into English during the post war years, in particular a 1974 interview in which he claims to have defended his patients and had to be saved from being arrested by the Gestapo twice by his boss, Dr. Hamburger. Although some German language publications were more critical, in general Asperger’s statements about his own life’s work were taken at face value, and seminal works in 1981 and 1991 that introduced him to the medical fraternity did not include any particular reference to his activities in the Nazi era.

What Asperger actually did

Investigation of the original documents shows a different picture, however. Before Anschluss (the German occupation of Austria in 1938), Asperger was a member of several far right Catholic political organizations that were known to be anti-semitic and anti-democratic. After Anschluss he joined several Nazi organizations affiliated with the Nazi party. His boss at the clinic where he worked was Dr. Hamburger, who he claimed saved him twice from the Gestapo. In fact Hamburger was an avowed neo-nazi, probably an entryist to these Catholic social movements during the period when Nazism was outlawed in Vienna, and a virulent anti-semite. He drove Jews out of the clinic even before Anschluss, and after 1938 all Jews were purged from the clinic, leaving openings that enabled Asperger to get promoted. It is almost impossible given the power structures at the time that Asperger could have been promoted if he disagreed strongly with Hamburger’s politics, but we have more than circumstantial evidence that they agreed: the author of the article, Herwig Czech, uncovered the annual political reports submitted concerning Asperger by the Gestapo, and they consistently agreed that he was either neutral or positive towards Nazism. Over time these reports became more positive and confident. Also during the war era Asperger gained new roles in organizations outside his clinic, taking on greater responsibility for public health in Vienna, which would have been impossible if he were politically suspect, and his 1944 PhD thesis was approved by the Nazis.

A review of Asperger’s notes also finds that he did send at least some of his patients to the “euthanasia” program, and in at least one case records a conversation with a parent in which the child’s fate is pretty much accepted by both of them. The head of the institution that did the “euthanasia” killings was a former colleague of Asperger’s, and the author presents pretty damning evidence that Asperger must have known what would happen to the children he referred to the clinic. It is clear from his speeches and writings in the Nazi era that Asperger was not a rabid killer of children with developmental disabilities: he believed in rehabilitating children and finding ways to make them productive members of society, only sending the most “ineducable” children to institutional care and not always to the institution that killed them. But it is also clear that he accepted the importance of “euthanasia” in some instances. In one particularly compelling situation, he was put in charge – along with a group of his peers – of deciding the fate of some 200 “ineducable” children in an institution for the severely mentally disabled, and 35 of those ended up being murdered. It seems unlikely that he did not participate in this process.

The author also notes that in some cases Asperger’s prognoses for some children were more severe than those of the doctors at the institute that ran the “euthanasia” program, suggesting that he wasn’t just a fairweather friend of these racial hygiene ideals, and the author also makes the point that because Asperger remained in charge of the clinic in the post-war years he was in a very good position to sanitize his case notes of any connection with Nazis and especially with the murder of Jews. Certainly, the author does not credit Asperger’s claims that he was saved from the Gestapo by Hamburger, and suggests that these are straight-up fabrications intended to sanitize Asperger’s role in the wartime public health field.

Was Asperger’s treatment and research ethical in any way?

Reading the article, one question that occurred to me immediately was whether any of his treatments could be ethical, given the context, and also whether his research could possibly have been unbiased. The “euthanasia” program was actually well known in Austria at the time – so well known in fact that at one point allied bombers dropped leaflets about it on the town, and there were demonstrations against it at public buildings. So put yourself in the shoes of a parent of a child with a developmental disability, bringing your child to the clinic for an assessment. You know that if your child gets an unfavourable assessment there is a good chance that he or she will be sterilized or taken away and murdered. Asperger offers you a treatment that may rehabilitate the child. Obviously, with the threat of “euthanasia” hanging over your child, you will say yes to this treatment. But in modern medicine there is no way that we could consider that to be willing consent. The parent might actually not care about “rehabilitating” their child, and is perfectly happy for the child to grow up and be loved within the bounds of what their developmental disability allows them; it may be that rehabilitation is difficult and challenging for the child, and not in the child’s best emotional interests. But faced with that threat of a racial hygiene-based intervention, as a parent you have to say yes. Which means that in a great many cases I suspect that Asperger’s treatments were not ethical from any post-war perspective.

In addition, I also suspect that the research he conducted for his 1944 PhD thesis, in addition to being unethical, was highly biased, because the parents of these children were lying through their teeth to him. Again, consider yourself as the parent of such a child, under threat of sterilization or murder. You “consent” to your child’s treatment regardless of what might be in the child’s best developmental and emotional interests, and also allow the child to be enrolled in Asperger’s study[1]. Then your child will be subjected to various rehabilitation strategies, what Asperger called pedagogical therapy. You will bring your child into the clinic every week or every day for assessments and tests. Presumably the doctor or his staff will ask you questions about the child’s progress: does he or she engage with strangers? How is his or her behavior in this or that situation? In every situation where you can, you will lie and tell them whatever you think is most likely to make them think that your child is progressing. Once you know what the tests at the clinic involve, you will coach your child to make sure he or she performs well in them. You will game every test, lie at every assessment, and scam your way into a rehabilitation even if your child is gaining nothing from the program. So all the results on rehabilitation and the nature of the condition that Asperger documents in his 1944 PhD thesis must be based on extremely dubious research data. You simply cannot believe that the research data you obtained from your subjects is accurate when some of them know that their responses decide whether their child lives or dies. Note that this problem with his research exists regardless of whether Asperger was an active Nazi – it’s a consequence of the times, not the doctor – but it is partially ameliorated if Asperger actually was an active resister to Nazi ideology, since it’s conceivable in that case that the first thing he did was give the parent an assurance that he wasn’t going to ship their kid off to die no matter what his diagnosis was. But since we now know he did ship kids off to die, that possibility is off the table. Asperger’s research subjects were consenting to a research study and providing subjective data on the assumption that the study investigator was a murderer with the power to kill their child. This means Asperger’s 1944 work probably needs to be ditched from the medical canon, simply on the basis of the poor quality of the data. It also has implications, I think, for some of his conclusions and their influence on how we view Asperger’s syndrome.

What does this mean for the concept of the autism spectrum?

Asperger introduced the idea of a spectrum of autism, with some of the children he called “autistic psychopaths” being high functioning, and some being low functioning, with a spectrum of disorder. This idea seems to be an important part of modern discussion of autism as well. But from my reading of the paper [again I stress I am not an expert] it seems that this definition was at least partly informed by the child’s response to therapy. That is, if a child responded to therapy and was able to be “rehabilitated”, they were deemed high functioning, while those who did not were considered low functioning. We have seen that it is likely that some of the parents of these children were lying about their children’s functional level, so probably his research results on this topic are unreliable, but there is a deeper problem with this definition, I think. The author implies that Asperger was quite an arrogant and overbearing character, and it seems possible to me that his assumption that he is deeply flawed in assuming his therapy would always work and that if it failed the problem was with the child’s level of function. What if his treatment only worked 50% of the time, randomly? Then the 50% of children who failed are not “low-functioning”, they’re just unlucky. If we compare with a pharmaceutical treatment, it simply is not the case that when your drugs fail your doctor deems this to be because you are “low functioning”, and ships you off to the “euthanasia” clinic. They assume the drugs didn’t work and give you better, stronger, or more experimental drugs. Only when all the possible treatments have failed do they finally deem your condition to be incurable. But there is no evidence that Asperger considered the possibility that his treatment was the problem, and because the treatment was entirely subjective – the parameters decided on a case-by-case basis – there is no way to know whether the problem was the children or the treatment. So to the extent that this concept of a spectrum is determined by Asperger’s judgment of how the child responded to his entirely subjective treatment, maybe the spectrum doesn’t exist?

This is particularly a problem because the concept of “functioning” was deeply important to the Nazis and had a large connection to who got selected for murder. In the Nazi era, to quote Negan, “people were a resource”, and everyone was expected to be functioning. Asperger’s interest in this spectrum and the diagnosis of children along it wasn’t just or even driven by a desire to understand the condition of “autistic psychopathy”, it was integral to his racial hygiene conception of what to do with these children. In determining where on the spectrum they lay he was providing a social and public health diagnosis, not a personal diagnosis. His concern here was not with the child’s health or wellbeing or even an accurate assessment of the depth and nature of their disability – he and his colleagues were interested in deciding whether to kill them or not. Given the likely biases in his research, the dubious link between the definition of the spectrum and his own highly subjective treatment strategy, and the real reasons for defining this spectrum, is it a good idea to keep it as a concept in the handling of autism in the modern medical world? Should we revisit this concept, if not to throw it away at least to reconsider how we define the spectrum and why we define it? Is it in the best interests of the child and/or their family to apply this concept?

How much did Asperger’s racial hygiene influence ideas about autism’s heritability?

Again, I want to stress that I know little about autism and it is not my goal here to dissect the details of this disease. However, from what I have seen of the autism advocacy movement, there does seem to be a strong desire to find some deep biological cause of the condition. I think parents want – rightly – to believe that it is not their fault that their child is autistic, and that the condition is not caused by environmental factors that might somehow be associated with their pre- or post-natal behaviors. Although the causes of autism are not clear, there seems to be a strong desire of some in the autism community to see it as biological or inherited. I think this is part of the reason that Andrew Wakefield’s scam linking autism to MMR vaccines remains successful despite his disbarment in the UK and exile to America. Parents want to think that they did not cause this condition, and blaming a pharmaceutical company is an easy alternative to this possibility. Heritability is another alternative explanation to behavioral or environmental causes. Asperger of course thought that autism was entirely inherited, blaming it – and its severity – on the child’s “constitution”, which was his phrase for their genetic inheritance. This is natural for a Nazi, of course – Nazis believe everything is inherited. Asperger also believed that sexual abuse was due to genetic causes (some children had a genetic property that led them to “seduce” adults!) Given Asperger’s influence on the definition of autism, I think it would be a good idea to assess how much his ideas also influence the idea that autism is inherited or biologically determined, and to question the extent to which this is just received knowledge from the original researcher. On a broader level, I wonder how many conditions identified during the war era and immediately afterwards were influenced by racial hygiene ideals, and how much the Nazi medical establishment left a taint on European medical research generally.

What lessons can we learn about public health practice from this case?

It seems pretty clear that some mistakes were made in the decision to assign Asperger’s name to this condition, given what we now know about his past. It also seems clear that Asperger was able to whitewash his reputation and bury his responsibilities for many years, including potentially avoiding being held accountable as an accessory to murder. How many other medical doctors, social scientists and public health workers from this time were also able to launder their history and reinvent themselves in the post-war era as good Germans who resisted the Nazis, rather than active accomplices of a murderous and cruel regime? What is the impact of their rehabilitation on the ethics and practice of medicine or public health in the post-war era? If someone was a Nazi, who believed that murdering the sick, disabled and certain races for the good of the race was a good thing, then when they launder their history there is no reason to think they actually laundered their beliefs as well. Instead they carried these beliefs into the post war era, and presumably quietly continued acting on them in the institutions they now occupied and corrupted. How much of European public health practice still bears the taint of these people? It’s worth bearing in mind that in the post war era many European countries continued to run a variety of programs that we now consider to have been rife with human rights abuse, in particular the way institutions for the mentally ill were run, the treatment of the Roma people (which often maintained racial-hygiene elements even decades after the war), treatment of “promiscuous” women and single mothers, and management of orphanages. How much of this is due to the ideas of people like Asperger, propagating slyly through the post-war public health institutional framework and carefully hidden from view by people like Asperger, who were assiduously purging past evidence of their criminal actions and building a public reputation for purity and good ethics? I hope that medical historians like Czech will in future investigate these questions.

This is not just a historical matter, either. I have colleagues and collaborators who work in countries experiencing various degrees of authoritarianism and/or racism – countries like China, Vietnam, Singapore, the USA – who are presumably vulnerable to the same kinds of institutional pressures at work in Nazi Germany. There have been cases, for example, of studies published from China that were likely done using organs harvested from prisoners. Presumably the authors of those studies thought this practice was okay? If China goes down a racial hygiene path, will public health workers who are currently doing good, solid work on improving the public health of the population start shifting their ideals towards murderous extermination? Again, this is not an academic question: After 9/11, the USA’s despicable regime of torture was developed by two psychologists, who presumably were well aware of the ethical standards their discipline is supposed to maintain, and just ignored them. The American Psychological Association had to amend its code in 2016 to include an explicit statement about avoiding harm, but I can’t find any evidence of any disciplinary proceedings by either the APA or the psychologists’ graduating universities to take action for the psychologists’ involvement in this shocking scheme. So it is not just in dictatorships that public policy pressure can lead to doctors taking on highly unethical standards. Medical, pscyhological and public health communities need to take much stronger action to make sure that our members aren’t allowed to give into their worst impulses when political and social pressure comes to bear on them.

These ideas are still with us

As a final point, I want to note that the ideas that motivated Asperger are not all dead, and the battle against the pernicious influence of racial hygiene was not won in 1945. Here is Asperger in 1952, talking about “feeblemindedness”:

Multiple studies, above all in Germany, have shown that these families procreate in numbers clearly above the average, especially in the cities. [They] live without inhibitions, and rely without scruples on public welfare to raise or help raise their children. It is clear that this fact presents a very serious eugenic problem, a solution to which is far off—all the more, since the eugenic policies of the recent past have turned out to be unacceptable from a human standpoint

And here is Charles Murray in 1994:

We are silent partly because we are as apprehensive as most other people about what might happen when a government decides to social-engineer who has babies and who doesn’t. We can imagine no recommendation for using the government to manipulate fertility that does not have dangers. But this highlights the problem: The United States already has policies that inadvertently social-engineer who has babies, and it is encouraging the wrong women. If the United States did as much to encourage high-IQ women to have babies as it now does to encourage low-IQ women, it would rightly be described as engaging in aggressive manipulation of fertility. The technically precise description of America’s fertility policy is that it subsidizes births among poor women, who are also disproportionately at the low end of the intelligence distribution. We urge generally that these policies, represented by the extensive network of cash and services for low-income women who have babies, be ended. [Emphasis in the Vox original]

There is an effort in Trump’s America to rehabilitate Murray’s reputation, long after his policy prescriptions were enacted during the 1990s. There isn’t any real difference between Murray in 1994, Murray’s defenders in 2018, or Asperger in 1952. We now know what the basis for Asperger’s beliefs were. Sixty years later they’re still there in polite society, almost getting to broadcast themselves through the opinion pages of a major centrist magazine. Racial hygiene didn’t die with the Nazis, and we need to redouble our efforts now to get this pernicious ideology out of public health, medicine, and public policy. I expect that in the next few months this will include some uncomfortable discussions about Asperger’s legacy, and I hope a reassessment of the entire definition of autism, Asperger’s syndrome and its management. But we should all be aware that in these troubled times, the ideals that motivated Asperger did not die with him, and our fields are still vulnerable to their evil influence.

 


fn1: Note that you consent to this study regardless of your actual views on its merits, whether it will cause harm to your child, etc. because this doctor is going to decide whether your child “rehabilitates” or slides out of view and into the T4 program where they will die of “pneumonia” within 6 months, and so you are going to do everything this doctor asks. This is not consent.

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This week the US Congress passed a set of censorship laws, commonly called FOSTA/SESTA, that aimed to prevent online sex trafficking but in practice work to shut down all forms of online sex work advertising. The laws were developed in the wake of claims that the website backpage was being used to buy and sell trafficked women, and basically make the website’s provider criminally liable for any sex trafficking that happens on the site. They do so by creating a trafficking exception to a section of a US law that exempts internet providers from being treated as media organizations. Currently under US law websites are treated as carriers, which means they aren’t responsible for the content of material that their users post online. This exemption is the reason that websites like reddit, craigslist and facebook can host a wide range of user-generated content with impunity.

In jurisdictions where sex work is illegal, sex workers use online resources like craigslist and backpage to advertise their services and screen clients. Many sex workers and porn stars who have a good community following also use Twitter and Instagram and other social networking services to manage their community and their client relationships, including organizing events and dates and discussing their work. But since the new law was passed all these websites have had to shutdown their services or warn users that any solicitation or discussion of business is now illegal. Craigslist has shutdown its personals page, which was often used by sex workers, and websites like Fetlife have had to put strict warnings on user content. Because they can be held liable under the new law for any sex work related content, they have had to tell users that no such content can be tolerated at all. At Fetlife this extends to consensual financial domination activities, and at Craigslist the only way they have been able to stop sex work related activity has been to stop all consensual dating of any kind. Because apps like Tinder are also sometimes used for sex work purposes, it’s also possible that these sites are going to have to toughen up their moderation and rules, though it’s unclear yet how they will do this or how serious the impact of the law will be.

The Cut has an overview of why sex workers disapprove of this law, and Vox has a summary of the history of its development and arguments about its impact. For the past few weeks sex worker rights organizations like SWOP have been providing advice to women about how to back up their online presence and what actions they may need to take to protect their online presence, potentially including self censorship. It is unclear at this stage what impact the law will have on online sexual activities outside of sex work, but it’s clear from Craigslist’s reaction that the effect will be chilling. For countries like the UK, Germany, Australia, Japan and Singapore where sex work is legal to varying degrees and women can safely and legally work in brothels or advertise publicly on locally hosted websites the effect may be minimal, but for women in countries like the USA and parts of Europe the impact will likely be huge. It will force women away from the internet and back onto the streets and into unsafe situations where they are unable to screen potential clients, cannot share information about dangerous clients, and cannot support each other or record client information for self protection. Sex worker rights organizations in the USA have been deeply concerned about the impact of these laws for months and worked hard to prevent them, but in the end the money and the politics was against them.

It is worth considering exactly why these laws were passed and who supported them. Although they were developed and pushed by conservatives and republicans, they were passed with bipartisan support and pushed by a coalition of christian conservatives and feminists. The advertising campaign was supported by liberal comedians like Amy Schumer and Seth Meyers, and after some reform it was also supported by major internet content providers and entertainment organizations like Disney. This should serve as a reminder that Disney is not a liberal organization (despite the complaints of some Star Wars fans that its liberalism wrecked the latest awful episode), and that in the American political landscape “liberals” are actually deeply conservative about sex and sexuality. In particular any feminist organization that supported this law should be ashamed of itself. This includes organizations like Feminist Current and other radical feminist groups that think prostitution is a crime against women, rather than a choice that women make. I have said before that this strain of radical feminism is deeply misogynist and illiberal, and is always willing to use state power to override the personal choices of women it sees as enemies to its cause.

These feminist movements need to recognize though that while tactically they may have scored a win, this strategy is very bad for women everywhere. Nothing angers a christian conservative man more than a woman who is financially and sexually independent, and sex workers are the model of a financially and sexually independent woman. Sex workers are uniquely vulnerable to legislative action and uniquely annoying to these legislators, but they’re just the canary in the coal mine. These christian conservative legislators want to destroy all forms of sexual freedom and they won’t stop at sex work. It’s unlikely that they’re shedding any tears over the fact that their pet law led Craigslist to shut down all its non-sex work dating functions – especially since they were especially well used by LGBT people. You can bet that they are already looking for ways to use some kind of indecency based argument to target a section 230 exception for LGBT people, probably arguing on obscenity or public health grounds; and I don’t doubt that ALEC and the Heritage Foundation are already wondering if there is a racketeering-based argument by which they can make a similar exception that can be used to target unions and other forms of left wing activism. It might trouble Feminist Current a little, but I doubt christian conservatives will be feeling particularly worried if Tinder has to shut down, and if this law makes it harder for consenting adults to fuck freely then conservative christians everywhere will be chuffed. Just as the 1980s alliance of feminists and christians distorted the porn industry and made it more misogynist and male dominated, laws like SESTA will distort the world of casual sex to make it more favourable to predatory men and less safe for ordinary women. Sex workers may always be first in the sights of christian conservatives but they are never last. Whatever your personal beliefs about paying for sex, supporting sex worker rights is always and everywhere better for women, better for LGBT people, and better for liberalism.

As a final aside, I would like to sing the praises of sex worker rights organizations. Their activism is strongly inclusive, and while their focus is obviously on protecting the rights of their sex worker membership, their viewpoint is always strongly liberal and aimed at broadening everyone’s rights. They’re strong supporters of free speech and free association, and they include everyone in their movement. As organizations they are strongly inclusive of all sexualities and genders, they are always aware of disability rights and the needs of people with disabilities, and they are opposed to any forms of restrictions on what consenting adults do. They are a consistent powerful voice for liberal rights, worker’s rights, and sexual freedom. These laws will likely restrict their ability to raise their voice in support of these issues, and that ultimately weakens all our rights. Sex worker organizations are a powerful voice for good, and sex workers are not victims, but an important part of our society doing a difficult job. Wherever you are in the world, you should support these organizations and the women, men and transgender people who do this job. Hopefully with our support they can overturn these laws, and through their work and activism broaden the scope for sexual expression for all humans no matter our gender or our sexual preference.

Nail them to the wall

In September 2017 Philip Morris International (PMI) – one of the world’s largest cigarette companies – introduced a new foundation to the world: The Foundation for a Smoke Free World. This foundation will receive $80 million per year from PMI for the next 12 years and devote this money to researching “smoking cessation, smoking harm reduction and alternative livelihoods for tobacco farmers”, with the aim to draw in more money from non-tobacco donors over that time. It is seeking advice on how to spend its research money, and it claims to be completely independent of the tobacco industry – it receives money from PMI to the tune of almost a billion dollars, but it claims to have a completely independent research agenda.

The website for the Foundation includes a bunch of compelling statistics on its front page: There is one death every six seconds from smoking, 7.2 million deaths annually, second-hand smoke kills 890,000 people annually, and smoking kills half of all its long-term users. It’s fascinating that a company that as late as the late 1990s was claiming there is no evidence its product kills has now set up a foundation with such powerful admission of the toxic nature of its product. It’s also wrong: the most recent research suggests that 2/3 of users will die from smoking. It’s revealing that even when PMI is being honest it understates the true level of destruction it has wrought on the human race.

That should serve as an object lesson in what this Foundation is really about. It’s not an exercise in genuine tobacco control, but a strategy to launder PMI’s reputation, and to escape the tobacco control deadlock. If PMI took these statistics seriously it could solve the problem it appears to have identified very simply, by ceasing the production of cigarettes and winding up its business. I’m sure everyone on earth would applaud a bunch of very rich tobacco company directors who awarded themselves a fat bonus and simply shut down their business, leaving their shareholders screwed. But that’s not what PMI wants to do. They want to launder their reputation and squirm out from under the pressure civil society is placing on them. They want to start a new business looking all shiny and responsible, and the Foundation is their tool.

PMI have another business model in mind. PMI are the mastermind behind iQos, the heat-not-burn product that they are trialling with huge success in Japan. This cigarette alternative still provides its user with a nicotine hit but it does it through heating a tobacco substance, rather than burning it, avoiding much of the carcinogenic products of cigarettes. PMI have been touting this as the future alternative to cigarettes, and are claiming huge market share gains in Japan based on the product. Heat not burn technologies offer clear harm reduction opportunities for tobacco use: although we don’t know what their toxicity is, it’s almost certainly much lower than tobacco, and every smoker who switches to iQos is likely significantly reducing their long term cancer risk. What PMI needs is for the world to adopt a harm reduction strategy for smoking, so that they can switch from cigarettes to iQos. But the tobacco control community is still divided on whether harm reduction is a better approach than prohibition and demand reduction, which between them have been very successful in reducing smoking.

So isn’t it convenient that there is a new Foundation with a billion dollars to spend on a research platform of “smoking cessation, harm reduction and alternative livelihoods.” It’s as if this Foundation’s work perfectly aligns with PMI’s business strategy. And is it even big money? Recently PMI lost a court case against plain packaging in Australia – because although their foundation admits that smoking kills, they weren’t willing to let the Australian government sell packages that say as much – and have to pay at least $50 million in costs. PMI’s sponsorship deal with Ferrari will cost them $160 million. They spent $24 million fighting plain packaging laws in Urugay (population: 4 million). $80 million is not a lot of money for them, and they will likely spend as much every year lobbying governments to postpone harsh measures, fighting the Framework Convention on Tobacco Control, and advertising their lethal product. This Foundation is not a genuine vehicle for research, it’s an advertising strategy.

It’s a particularly sleazy advertising strategy when you consider the company’s history and what the Foundation claims to do. This company fought any recognition that its products kill, but this Foundation admits that the products kill, while PMI itself continues to fight any responsibility for the damage it has done. This company worked as hard as it could for 50 years to get as many people as possible addicted to this fatal product, but this Foundation headlines its website with “a billion people are addicted and want to stop”. This Foundation will research smoking cessation while the company that funds it fights every attempt to prevent smoking initiation in every way it can. The company no doubt knows that cessation is extremely difficult, and that ten dollars spent on cessation are worth one dollar spent on initiation. It’s precious PR in a time when tobacco companies are really struggling to find anything good to say about themselves.

And as proof of the PR gains, witness the Lancet‘s craven editorial on the Foundation, which argues that public health researchers and tobacco control activists should engage with it rather than ostracizing it, in the hope of finding some common ground on this murderous product. The WHO is not so pathetic. In a press release soon after the PMI was established they point out that it directly contravenes Article 5.3 of the Framework Convention on Tobacco Control, which forbids signatories from allowing tobacco companies to have any involvement in setting public health policy. They state openly that they won’t engage with the organization, and request that others also do not. The WHO has been in the forefront of the battle against tobacco and the tobacco industry for many years, and they aren’t fooled by these kinds of shenanigans. This is an oily trick by Big Tobacco to launder their reputation and try to ingratiate themselves with a world that is sick of their tricks and lies. We shouldn’t stand for it.

I think it’s unlikely that researchers will take this Foundation’s money. Most reputable public health journals have a strict rule that they will not publish research funded by tobacco companies or organizations associated with them, and it is painfully obvious that this greasy foundation is a tobacco company front. This means that most researchers won’t be able to publish any research they do with money from this foundation, and I suspect this means they won’t waste their time applying for the money. It seems likely to me that they will struggle to disburse their research funds in a way that, for example, the Bill and Melinda Gates Foundation do not. I certainly won’t be trying to get any of this group’s money.

The news of this Foundation’s establishment is not entirely bad, though. It’s existence is a big sign that the tobacco control movement is winning. PMI know that their market is collapsing and their days are numbered. Sure they can try and target emerging markets in countries like China but they know the tobacco control movement will take hold in those markets too, and they’re finding it increasingly difficult to make headway. Smoking rates are plummeting in the highest profit markets, and they’re forced to slimmer pickings in developing countries where tobacco control is growing in power rapidly. At the same time their market share is being stolen in developed countries by e-cigarettes, a market they have no control over, and as developing nations become wealthier and tobacco control strengthens e-cigarettes grow in popularity there too. They can see their days are numbered. Furthermore, the foundation is a sign that the tobacco companies’ previous united front on strategy is falling apart. After the UK high court rejected a tobacco company challenge to plain packaging laws, PMI alone decided not to join an appeal, and now PMI has established this foundation. This is a sign that the tobacco companies are starting to lose their previous powerful allegiance on strategy against the tobacco control movement. PMI admits they’ve lost, has developed iQos, and is looking to find an alternative path to the future while the other tobacco companies fight to defend their product.

But should PMI be allowed to take their path? From a public health perspective it’s a short term gain if PMI switch to being a provider of harm reducing products. But there are a bunch of Chinese technology companies offering e-cigarettes as an alternative to smoking. If we allow PMI to join that harm reduction market they will be able to escape the long term consequences of their business decisions. And should they be allowed to? I think they shouldn’t. I think the tobacco companies should be nailed to the wall for what they did. For nearly 70 years these scumbags have denied their products caused any health problems, have spent huge amounts of money on fighting any efforts to control their behavior, and have targeted children and the most vulnerable. They have spent huge amounts of money establishing a network of organizations, intellectuals and front groups that defend their work but – worse still – pollute the entire discourse of scientific and evidence based policy. The growth of global warming denialism, DDT denialism, and anti-environmentalism is connected to Big Tobacco’s efforts to undermine scientific evidence for decent public health policy in the 1980s and 1990s. These companies have done everything they can to pollute public discourse over decades, in defense of a product that we have known is poison since the 1950s. They have had a completely pernicious effect on public debate and all the while their customers have been dying. These companies should not be allowed to escape the responsibility for what they did. Sure, PMI could develop and market a heat-not-burn product or some kind of e-cigarette: but should we let them, when some perfectly innocent Chinese company could steal their market share? No, we should not. Their murderous antics over 70 years should be an albatross around their neck, dragging these companies down into ruin. They should be shackled to their product, never able to escape from it, and their senior staff should never be allowed to escape responsibility for their role in promoting and marketing this death. The Foundation for a Smoke Free World is PMI’s attempt to escape the shackles of a murderous poison that it flogged off to young and poor people remorselessly for 70 years. They should not be allowed to get away with it – they should be nailed to the wall for what they did. Noone should cooperate with this corrupt and sleazy new initiative. PMI should die as if they had been afflicted with the cancer that is their stock in trade, and they should not be allowed to worm out from under the pressure they now face. Let them suffer for the damage they did to human bodies and civil society, and do not cooperate with this sick and cynical Foundation.

Last week the Lancet Public Health published a comment piece by me about the challenges it faces in the near future. This comment was linked to a research article that found a huge increase in elderly people with care needs in the UK population over the next 10 years. This article predicted that 10 years from now there will be a 25% increase in the number of people aged over 65 who have care needs, which corresponds to a numerical increase of 560,000 people. The largest growth will be in dementia-related disability, which may perhaps have been a slightly stinging finding for the government given that Prime Minister May had released a deeply unpopular policy for paying for dementia care in the same week. The article and my comment received some media coverage (see e.g. here), focusing on the impending massive increase in care needs and the risks to the NHS. My article made the point that this growth in elderly people needing care comes at a time when a unique combination of policy challenges confronts the incoming government: an underfunded social care service, an NHS in crisis, a looming workforce shortage, and the risk that Brexit will lead to an immediate loss of staff and a long term reduction in the number of staff entering the NHS. I made the simple point that the British health and social care system needs more money and a commitment to expand the local workforce to make up for the looming drop off in European staff. This is particularly pressing for the social care sector, which unlike the NHS employs large numbers of very low paid staff who have a very high turnover rate and are very often European. Once Brexit hits that turnover is going to bite, because new staff simply won’t be there to replace the high churn rate. There is no solution to this problem except to increase pay and improve working conditions to ensure this sector of the economy can attract British workers and retain them.

The problem is not limited to social care, however: something between 5-10% of staff in the NHS are recruited from Europe, which means that even if the final Brexit deal allows existing staff to stay, over the medium term natural attrition will mean that the NHS needs to increase local recruitment to cover that 5-10% of new staff who are not being recruited from Europe. Worse still, Brexit will hit just as the health workforce hits a wave of retirements of staff recruited from the baby boomer generation, and as junior doctors show increasing signs of burnout and the nurses association is talking about striking to preserve pay and conditions (the strikes themselves will not necessarily be a crisis – though I’m sure Jeremy Hunt can turn them into one! – but the underlying problems they signify will be). It takes 10 years to make a new doctor and about 7 years to make a new nurse, so the entire workforce planning system in the UK needs to be restructured and enhanced rapidly in the next 1-2 years if the UK health and social care system is to be ready to handle this. To be clear the issues are huge: A rapid increase in disability and health risks in elderly British people occurring after a decade of leakage of staff back to the EU, as a generation of older staff retire, and just as the cut to the nurse’s bursary and NHS funding leads to a shortfall in new staff, with no way to make it up through EU recruitment. This will affect every aspect of coverage, quality of care, equality of access, and timeliness of access in a system that is already struggling to handle basic pressures.

Today the Nuffield Trust released a report that adds to the pressures revealed by the article I was commenting on, by discussing additional health system pressures that will arise from leaving the EU. This report finds that:

  • If the Brexit agreement does not properly support UK citizens abroad and the welfare sharing arrangements they benefit from, 190,000 elderly Britons will return home and cost the government an extra 500 million pounds a year
  • If these elderly Britons return home they will require hospital beds equivalent to two new hospitals to care for them
  • If the NHS cannot continue to recruit nurses from the EU there will be a shortfall of 20,000 by 2025
  • The 350 million pounds a week that can be saved by leaving the EU was a myth, but in the first two years after leaving there may be more money to pay for health and social care – if the government is willing to spend it

The publication I commented on predicted an extra 560,000 people with care needs by 2027; this Nuffield Trust finds 190,000 more elderly people the study didn’t cover, and suggests they will have significant care needs currently being (basically) paid for by Europe, and it quantifies the shortfall in staff I identified. It’s worth noting that the NHS employs 320,000 nurses, so the 20,000 shortfall is about 6% of the workforce, but this 6% shortfall comes also when a large number of nurses will be retiring, and about the same time as the current reduced nursing student cohort hits the workforce. A lot of these numerical details are very hard to predict, but it appears likely that there is going to be a major reduction in a nursing workforce that is already not well stocked by OECD standards. Nurses are the bedrock of a functioning health system, and although there is no international evidence on the best nursing levels, a rapid decrease in numbers is only a bad thing, especially if combined with a rapid increase in health care demand.

This problem will face whoever wins the election in two weeks, since a lot of these pressures are the result of a Brexit decision we are supposed to believe is set in stone, and population ageing. But any party that does not have a plan to increase the health workforce, to restore funding to social care, and to improve payment, retention, credentialling and work conditions for the workers at the bottom of the social care heirarchy, is not serious about the depth and seriousness of the crisis the NHS faces. Although the Tories like to talk about working better rather than increasing funding, the reality is that the NHS desperately needs more money; and so long as Labour continue to dance around the issue of exactly how they will handle free movement, they present no serious plans to handle the looming workforce crisis. The British people voted for Brexit without having any clear information about what it would mean for the social care sector, while Boris Johnson flounced around the country in a bus that was advertising a clear lie. Now the election looms, and both parties have to come up with policies to handle this unavoidable crisis on a 10 year deadline. I think from a brutally practical standpoint, the real winner of this election will be the party that loses it, because whoever wins is going to be held responsible not just for Brexit’s short term economic damage, but for the long-term health and social care crisis that neither party is properly prepared to deal with.

The NHS needs more money and more staff. Without it, unless the winning party can deliver a truly miraculous Brexit deal, the UK health and social care system is heading for two decades of increasing and unavoidable crisis. I’m not confident that anyone in British politics is ready to deal with this problem, or even listening to the warnings. Let’s hope, for the sake of Britain’s elderly population, that I’m wrong.

In the wake of the Republicans’ catastrophic inability to repeal Obamacare, many people have begun to accept that the Patient Protection and Affordable Care Act is the new basis on which the US health system will be built. This means that for the foreseeable future, assuming the Republicans are not able to suddenly develop a competent and coherent health financing agenda, progress towards universal health coverage (UHC) in the USA will depend upon improvements of and reform to the free market system as it is regulated by Obamacare. Obamacare is unusual among developing nation health financing systems for its heavy reliance on private insurers as the fundamental providers of risk pooling, as opposed to most other health financing systems where some form of government insurer provides the overwhelming majority of national health financing. For a lot of critics of Obama and Clinton from the left this is seen as a failure, and a sign that they are neoliberal sellouts: under this view of health financing reform, no market-based system will work and Obama sold out his own supporters when he put forward a plan that did not include single payer or a public option. For conservative policy makers in non-crazy countries – for example the UK[1] or Canada – and also in developing countries moving towards UHC, this offers an opportunity to see whether a free market approach to health financing can deliver the key goals of universal coverage and financial risk protection. The problem for conservative thinkers on health care is that there seems to be very little evidence that free market systems work, and the problem for left wing critics of Obamacare is that there is no evidence single payer could have been delivered in the modern US political environment. So for both far left critics and moderate right wing admirers of Obamacare the obvious question is: can UHC be achieved without a single payer system?

This week’s issue of the Journal of the American Medical Association has published an opinion piece addressing this issue. Entitled Achieving universal health coverage without a single payer: Lessons from 3 countries, it gives a brief overview of how Singapore, Germany and Switzerland have achieved UHC with at least nominally non single-payer systems. It attempts to address some of the key differences between these systems and the USA, and some ways in which the health market in those countries is different. Since JAMA is behind a pay wall, I thought I would give a brief summary of a few of these points.

First the article opens with a clanger, asserting that “Universal coverage is a top priority not only for Democrats but also for President Trump,” which does lead one to wonder how critical the authors are. It then goes on to dismiss summarily one of the key ideas raised by Republicans for making private health coverage more affordable in the US: high risk pools. The intention of a high risk pool is that patients with high cost or pre-existing conditions be offered insurance from a special fund financed by the government, thus removing them from the main private insurance risk pool and enabling insurance companies to reduce the cost of mainstream health insurance products. The problem with this model is that it is enormously expensive and there is no evidence that it works. The article points out that no US government will be able to justify the amount of money required to properly finance high risk pools, and that it probably costs upwards of 8 billion US$ a year to do this. It also notes that – contra Paul Ryan’s assertion that pre-ACA high risk pools worked great – most of the state-based high risk pools in the pre-ACA era were hideously expensive and did not work. The article also points out that a preferred strategy of some left-wing critics of Obamacare – shifting high risk patients onto Medicare – may also not work, since Medicare is already a high risk pool and expanding it by dumping in the highest cost patients will be impossible without increased funding (the article uses the language of sustainability, about which I’m suspicious because of its origins, but it cites well-respected sources on the challenges of continuing to finance Medicare if it is treated as a high risk pool).

So given this, the only way that a private system will be able to achieve universal coverage is if everyone is enrolled in insurance, and insurance is properly financed. The article describes the systems in Singapore, Germany and Switzerland, and how each of them force all their citizens into insurance coverage. For example, about Singapore it says:

Singapore institutes compulsory contributions from employers on behalf of their employees to create medical savings accounts. Employees maintain these accounts for health care expenses such as health and disability insurance premiums, hospitalization, surgery, rehabilitation, end-of-life care, and outpatient services. Those failing to pay their premiums are subject to garnished wages and other legal actions that can force payment of back premiums, penalties, and interest. Unemployed or low-income individuals are eligible for government subsidies that enable them to pay for the premiums.

and it points out that Germans are enrolled automatically in “private” funds that take a guaranteed 7.3% of their income. It’s hard to imagine any such plan being popular in the modern US, where the individual mandate has been subjected to years of withering don’t-tread-on-me type criticism and the idea of paying an income-based premium is terrifying to the GOP’s donors. In Switzerland and Singapore, where the systems do not use tax-based payments, they have government subsidies for (according to the article) up to a quarter of their population. So these systems – which by all accounts are functioning, affordable and tolerated by their citizens – share Obamacare’s key tactics of means-tested subsidies and individual mandates.

The article also makes the point that these systems have a very healthy free market structure, with much more vibrant private markets than the USA:

Germany in 2015, for example, had 124 sickness funds and 42 private health insurance companies, and the average resident of Switzerland in 2011 could choose from 59 health insurers offering coverage, with the 5 largest insurers covering 43% of the population. By comparison, in California, a state with approximately half Germany’s population, only 7 firms covered more than 95% of privately insured individuals in 2011, with the 3 largest firms covering 75%. In Massachusetts, with a population slightly smaller than Switzerland’s, 3 insurance companies enrolled 79% of individuals with private insurance.

I think this might be pushing the comparison a little bit, because many of the “sickness funds” in Germany are likely union-run or industry-based mutual associations with very strict management criteria, non-profit structures and guaranteed membership, and they may be regionally based so not actually directly competing with each other[2]. Also, I’m very confident that all three countries studied have rigorous price regulation and strict government oversight of providers (hospitals and clinics), so that they cannot for example price gouge the insurance provider for an infamous $500 band aid as they can in the USA. It’s much easier for private insurers to compete with each other for market share when they know what the cost of the insurance payout is likely to be, and can be confident that the provider won’t charge them arbitrary amounts, and I suspect that this certainty also removes a whole layer of administrative staff at both provider and insurer, for which the US system is infamous.

Having given an overview of these systems the article draws a simple conclusion and gives a firm recommendation: Obamacare needs tougher enforcement of a more punishing individual mandate. I think this conclusion is only partially correct, missing the role of price regulation and cross-subsidization from general taxation that protects these private markets.  So I think that the article is a little strong in concluding that the USA can definitely achieve universal health coverage without at least, for example, introducing a public option to every market place (or at least the rural areas). But it does make the point that a better regulated insurance market with better subsidies and a much tougher mandate would likely encourage competition, and achieve universal health coverage (or close to it) without driving up costs. It certainly seems that the architects of Obamacare knew this and had a long term plan for its expansion and improvement, and assuming the world survives Kim Jong Il’s birthday this weekend, hopefully the Democrats will be back in power in the USA soon enough to begin taking the next steps along that road. I’m not convinced yet, but it is still possible that Obamacare could show the way to a genuinely private, free market alternative to achieving UHC without single payer. In my view, however, if Obamacare (and human civilization!) does survive the Trump presidency, it is likely to become an increasingly state-regulated and state run system, rather than a robust private market place, because introducing a public option, slowly squeezing out private provides, and then making health insurance premiums fully means-tested and tax-based, is a much more reliable way to make everyone happy.

Still, for genuinely interested conservative policy-makers outside of America (whose “conservatives” have no interest in anything resembling policy), the next few years of Obamacare offers an exciting opportunity to develop new pathways to UHC. Given the complexity of movement towards UHC in some low income countries, and the very limited government finances in many of them, it would be interesting to see whether Obamacare’s roll out, expansion and improvement offers a new and more viable pathway to UHC than those currently on offer. I’m not holding my breath, but it will be interesting to see what lessons we can learn from this new and quite unique approach to one of America’s (and the developing world’s) big remaining problems.

First we have to survive the Trump presidency, though.


fn1: Caveats on the use of “non-crazy” should be inserted here, especially after Brexit

fn2: Interestingly, these sickness funds sound a lot like the non-profit mutuals that Obamacare was supposed to encourage, and which US “conservative” critics of Obamacare constantly sneer at and declare completely unviable.

By now everyone has learned the news that after 17 days of massive effort to try and force it through the legislature in the dead of night the Republicans have given up on their godawful attempt to repeal and replace Obamacare, and have accepted that Obamacare is now the “law of the land.” Having made no effort at all to reach out to Democrats, and after trying to push it through the Senate using a reconciliation process that was explicitly designed (and admitted) to negate Democrat votes, Trump’s first act of contrition for his and Paul Ryan’s failure was to blame the Democrats for not working with him. He went on to repeat the lie that Obamacare is “exploding” (it’s probably not) and openly admitted that he is going to try and hasten its collapse through executive action, following the logic that a program initiated by Democrats that is screwed into the ground by a Republican government will somehow be seen to be the Democrats’ fault.

Trump initiated this process of screwing Obamacare on his first day in office, when he passed a notoriously vague executive order that instructed all responsible departments to not comply with the details of the law to the extent they could legally get away with. A lot of people were duly concerned about this, because there are a lot of aspects of Obamacare that rely on administrative guidance that can be modified by the government in power. So this week’s New England Journal of Medicine has a short editorial by Jost and Lazarus about whether Trump can actually successfully undermine the workings of the act through administrative action alone. The two authors appear to be lawyers, one with a connection to the Constitutional Accountability Center, which supports the cause of “progressive constitutionalism” (which appears to be the idea that the Constitution is a living document whose interpretation can change over time), so presumably their understanding of constitutional law is fairly good.

The authors point out that reaction to Trump’s executive order ranged from fear to snorts of derision, and proceed to show at least one way in which it has failed bigly. One of the big fears expressed in initial response to the order was that the Inland Revenue Service (IRS) would stop collecting taxes it is required to under the “mandate”, the unpopular part of the law which punishes through the tax system anyone who does not purchase insurance. This was probably Trump’s intention in passing the executive order, but it turns out the IRS ignored him: it admitted on February 15th (a month after the order was signed) that it was still collecting mandate taxes, and that it’s sole response to the order has been to shelve a planned crackdown on tax evasion related to the mandate.

The authors point out why this should be unsurprising: government agencies are required to enforce the laws of the land, and there is a long-standing history of jurisprudence forcing them to. They point out that in fact

it is one thing to delay temporarily a legal requirement or to phase in a new law to facilitate adjustments by affected people or entities; it is quite another to refuse outright to enforce a law already in force, with the aim and effect of undermining that law. The Supreme Court has said that courts may step in to correct any such “abdication” of the executive branch’s duty to faithfully execute the law.

Apparently the highest court in the land has built up a body of precedent which requires government agencies to enforce government law, and the authors seem quite confident that if agencies don’t do this, court action would likely force them to. They go further than this, though, considering the hypothetical case in which the IRS bends the definition of “financial hardship” sufficiently to enable anyone affected by the mandate to be exempted from it on the basis of “financial hardship” (apparently some devious Republicans had considered this oily move). They write:

In a critical 2015 Supreme Court case upholding nationwide availability of ACA “premium assistance” tax credits for eligible low-income insurance purchasers, Chief Justice John Roberts held that courts and agencies must interpret and apply individual provisions of a law — indeed, of the ACA in particular — so as to further its overall “legislative plan.” Roberts concluded: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. . . . [W]e must interpret the Act in a way that is consistent with the former, and avoids the latter.”

This might seem quite reasonable to outsiders, but apparently in America the idea that government agencies must act according to the legislative intention of the law of the land is novel and requires clarification from the Supreme Court.

(Also note that this statement was made by justice John Roberts, a conservative judge appointment by Bush Senior, not one of those quisling liberals who think all toilets should be unisex because they’re radical feminists!)

In conclusion the authors are unconvinced that Obamacare can be undone by administrative action alone, though they concede it could become less generous and function less smoothly as a result of meddling. But the Republicans need to be careful here, since administrative overreach in this regard is likely to be punished by the courts, stacking further humiliations on Trump’s already woeful record of mistakes and inactions. Worse still, there is a big and growing split in the Republican movement over Obamacare, and signs that some of the 19 states that resisted the Medicaid expansion are going to cave, further entrenching Obamacare’s role. In particular Kansas, whose economy has been completely wrecked by Republican Crazy Caucus economic ideals, is desperate for money and is very close to taking the Medicaid expansion because balancing the budget will require the extra money. Virginia’s governor is also trying to get that state covered, and activists are using failure to take the expansion and its associated funds as a stick to beat Republicans locally. With Trump’s popularity nosediving, the collapse of the American Health Care Act showing the impossibility of reform through Congress, and many of the areas that voted for Trump most vulnerable to executive action, it is unlikely that vulnerable Republicans are going to want to push this issue at a local level. So the conclusion of this opinion piece in the NEJM is that while Obamacare won’t work as well under Trump, it is unlikely to be seriously damaged. And the longer it continues to function, the harder it will be for Republicans to repeal it or to continue to even talk about it. My guess is that over the next two years – and especially as the mid-term elections approach and it begins to look like a wave election is going to swamp a lot of Republican congress people – we will see more states take the Medicaid expansion, and moderate Republicans begin to talk strong talk about repairing the existing law rather than destroying it. Whether any of them survive the mid-terms will be another question entirely – but if they don’t, they will be replaced by angry Democrats, raising the possibility that after a wave election in 2019 the Dems might be able to force a veto-proof bill across Trump’s desk, requiring him to sign a public option into law.

Regardless of what happens at the next election, though, it appears that there is no easy way for the Republicans to undermine Obamacare enough to destroy it, and it would be increasingly reckless of them to try. Obama’s legacy looks to on increasingly solid ground, and I think it’s now safe to say that he was one of the greatest of the modern presidents. Who would have thought a Kenyan Muslim could go so far!?

I guess Speaker of the US House of Representatives Paul Ryan (aka the Zombie-Eyed Granny Starver) must be an avid reader of this humble blog[1], for within days of me posting a heart-felt plea for someone in the Republican camp to reveal their health policy principles, the GOP’s Granny-Starver-in-Chief gave a presentation on national TV to explain them. This presentation, intended to explain the Republicans’ Obamacare repeal-and-replace strategy (the American Health Care Act, or as Townhall.com call it, “Swampcare”), involves Ryan with his jacket off, a sure sign that he’s very serious, and it even has powerpoint! A fragment of it can be viewed here, and it’s clear from this monstrosity that Paul Ryan, the great and serious policy wonk of the Republican majority, doesn’t understand how health insurance works. Or worse still, he does understand, and he thinks that insurance is A Very Bad Thing.

From this presentation we can see two health policy principles that the Republicans appear to cleave to: That health insurance is bad and health savings accounts (HSAs) are good; and that the government should be the insurance provider of last resort for society’s sickest. Let’s look at these two principles and their implications.

Do Republicans really think health insurance is bad?

It appears from this keynote presentation of Ryan’s that they do. He makes clear that the healthy are subsidizing the sick and that this is a bad thing, and suggests that this is a bad thing and is the reason that Obamacare prices are rising. The tone of Ryan’s voice, the expression of exasperation, and the follow-up comment that “this is not working” and that the Republican plan will “fix this” are all keys to his belief that health insurance is a bad thing. The healthy, under his formulation, should not subsidize the sick. This is backed up by comments by Rep. Shimkus in the house energy and commerce committee, who when asked about requirements on insurance plans asked “What about men paying for prenatal care”, following up with the rhetorical “Should they?” (That Washington Post article also mentions similar comments from a 2013 committee, where a Republican asked why men should have to pay for maternity care). This isn’t just a glib and nasty comment, it’s a policy position. Note that Shimkus didn’t say anything along the lines of “Pregnancy is a lifestyle choice and our plan will not require insurance companies to cover lifestyle choices.” Rather, he gave an example of someone having to pay for coverage of a problem they will never themselves suffer.

But this is the entire point of insurance: Generally you buy insurance on the assumption that you will never have to use it, knowing that your insurance company will use your premiums to pay for someone who does have to use it. In the case of health insurance, since we all get sick everyone knows that their insurance is contributing to coverage for people who will suffer conditions that most of us will never suffer. Men pay for breast cancer treatment, women pay for prostate cancer treatment, people who are fated to die in a bus crash at 43 pay for alzheimers care that they themselves are doomed never to receive. That’s how insurance works. Once you start saying that people shouldn’t have to pay for things they won’t themselves experience then you are changing the entire nature of insurance. Or, you don’t understand how insurance works.

It’s clear to me from these comments that the Republicans are actually seeing insurance as a Health Savings Account. An HSA is designed so that no one can take out of it more than they have put in, and they use the money in the HSA only on care for the conditions they themselves face. With a well-run HSA the healthy don’t subsidize the sick – rather your current self subsidizes your future self. In this formulation, no one ever has to worry that their money will be used to pay for a treatment they themselves would not face, and no one can get angry about the healthy subsidizing the sick, since it’s only their own future sickness they’re subsidizing. HSAs never suffer from justice issues either – you won’t find a healthy supposed marathon-running non-smoker like Ryan being forced to use their premium payments to cover lung cancer for a sedentary smoker, because they won’t be subsidizing anyone.

So here we have Republican principle number one: Health insurance bad, Health Savings Accounts good.

Government as insurer of last resort

Paul Ryan also touted an alternative method for handling people who are rejected from health insurance plans due to pre-existing conditions, which he described as state-based insurance plans that would cover high risk people. Under this scheme the states get about $10 billion a year to run high risk insurance pools for those very sick individuals. This would enable the health insurers to reject these people, and/or would make a special form of insurance that was better able to handle these high cost cases, enabling health insurance funds to offer lower premiums to everyone else and thus to widen their risk pool. This insurer of last resort model is consistent with the idea of health insurers as a type of health savings account management company: They set a premium for people with pre-existing conditions that is prohibitively high, and then those people “choose” not to pay for the premium and instead run to the government’s high risk pool for coverage. Ryan touted the Wisconsin Health Insurance Risk Sharing Plan (HISRP) as an example of a “good high risk pool” that was shut down by Obamacare, presumably suggesting this as a model for the AHCA.

This is unfortunate for several reasons. The first is that HISRP was cross-subsidized by a tax on all insurance premiums charged in the state, meaning that in fact the healthy were subsidizing this program for the sick; the second is that doctors and hospitals charged lower prices to HSIRP recipients, i.e. they allowed the state to regulate what they were able to charge, which is anathema to Republicans. This is also not an idea that is absent in Obamacare, which offers states funds to set up high risk pools[2], so it’s not clear how this policy is an innovation compared to the current policy.

The other big problem with this high risk insurance pool idea is that it doesn’t work precisely because the people in the pool are too sick. Recent assessments of Obamacare’s state-based pools found that they were running out of money far faster than expected, and many state pools have had to go back to the government for more money. Elsewhere I have read estimates that the AHCA’s proposed funds will only cover about 400,000 high risk individuals, when America has about 2 million people who need them.

Still, this is a policy principle, and it’s not necessarily bad in and of itself – but it does require that the government be willing to offer a potentially open-ended assurance to states that these risk pools will be funded. This might be a good policy idea, but it doesn’t seem like it’s going to be compatible with either a) the Republicans’ historical antipathy for welfare programs and b) the reconciliation process’s restrictions on what funds are available for the plan. It’s the sort of thing that is easily sold as a sop to people concerned about the impact of reform on high-risk individuals, and then easily defunded in practice. If you doubt that, remember this: Paul Ryan’s nickname among his critics is “Zombie-eyed Granny Starver.” Also remember that Ryan is a confirmed liar, who lied about his marathon times to make himself sound like a champion when in fact his marathon times are really average, and you can’t trust liars when they promise to pay you back in future.

What’s wrong with confusing health insurance and health savings accounts?

Now it’s true that in and of itself favoring HSAs over health insurance as a policy tool isn’t necessarily bad. Singapore uses them as part of its health financing system, and China tried them (though I think they moved away from them to a more standard social insurance system), and they could probably theoretically be made to work. They come with obvious equity issues for people born without money, and also they have their own free-rider issues when dealing with people who don’t pay into them but then become sick, but they can probably be made to work. But to make an HSA system work will almost certainly require that they be mandatory (as I think they are in Singapore) and government-subsidized for the young poor. They suffer from many the same problems as private superannuation plans, in that the people who should be paying the most into them – young people – are simultaneously the people with least need of them and the least money to do so, so typically the best way to implement them is mandatorily and by stealth. Of course the Republicans hate mandating anything (except unwanted pregnancies), so they won’t be fond of forcing people onto HSAs; but it is true that HSAs are consistent with general Republican ideas about personal responsibility, no free lunches, etc.

The problem though is that to make HSAs a centerpiece of American health policy requires a root-and-branch reform of how the private markets work. The new Republican bill doesn’t do this, and continues to leave the private markets in the hands of traditional health insurance companies. But it’s clear that the Republican policy-makers are thinking of health insurers as administrators of a kind of HSA program, while the health insurers think of themselves as (and actually are) traditional health insurance companies. This is a big problem, because the policy requirements of HSAs and health insurers are completely different, and confusing one for the other is a disaster. This means that health insurance companies are setting premiums on the basis of an assumption that the government will work to expand the risk pool, or at least not to impede its expansion, while republican policy makers are thinking that insurance companies are setting premiums on the basis of the future underwriting risk each enrollee’s individual future health risk profile presents. So the Republicans have no interest in setting policies that will encourage the healthy (i.e., poor young people) into the market, and may even be trying to find ways to encourage sick people to enrol and pay more (such as through the first-year penalty on insurance for people who let coverage lapse). For example, if they could set policy legislatively rather than through reconciliation, Republicans might pass a law that allows health insurers to set premiums based on each person’s individual future risk profile (so e.g. young women pay more than young men because they will get pregnant), but the insurance companies would prefer to set premiums on the basis of actuarial risk and the size of the risk pool, which is a more instantaneous calculation. This could create policy conflicts that prevent insurers from properly setting prices while simultaneously discouraging young people from entering the risk pool.

Health policy in America for the past 100 years has been built around health insurance markets, not HSA markets. The republicans, by thinking of health insurance as a type of HSA, risk making policies to encourage a market that doesn’t really exist, while the health insurance market struggles to function without proper government subsidies. A good example of this is the way the subsidy design in the Republican plan does not vary by state. Republicans seem to be completely ignorant of the fact that premium prices vary by state, since they depend on the size of the risk pool in each state and the relative balance of healthy and unhealthy, old and young, and also the cost of health services in each state. So Alaska is much more expensive than California. Lawmakers who understood health insurance as a risk pool mechanism would get this, but policy makers who think that health insurance premiums are set as if they were HSA fees will not – HSA fees depend on the future health risks faced by an individual, so may not vary much by state, while health insurance premiums depend on the instantaneous balance of healthy and high-risk individuals in a geographic area, so vary a lot by state.

This confusion is a recipe for trouble, and a sign that despite having six years to sharpen their understanding of these issues, supposedly intelligent and committed Republicans haven’t bothered.

What does this say about the media’s love of Paul Ryan?

The media love to treat Paul Ryan as a serious Republican policy thinker, when in fact he is nothing better than a fraud and a shonkster, a hired salesperson for the policy preferences of his rich patrons. He doesn’t have any deep policy ideas, and he doesn’t care to or need to – his only legislative goal is to dismantle welfare programs and spend the money saved on tax cuts for the rich. He is also a confirmed liar and a fantasist, with no personal integrity – hardly surprising since he comes from a party that has long suffered from “family values” politicians who cheat on their wives and anti-gay politicians who solicit in bathrooms. But the media is labouring under the impression that America has two serious parties, rather than one serious party and one gang of frauds and criminals who occasionally get hold of the machinery of the state long enough to loot it for the benefit of their rich patrons. We now know that these pirates in the GOP aren’t even patriotic – they’re tools of the Russians and the Turks, and have moved from selling their domestic policy to the highest bidder, to selling their foreign policy to whatever foreign agent will help them win power. But so long as the media needs to keep pretending that the Republicans are a serious party and not a gang of wreckers and criminals, they also need to find people within that party they can treat as serious even when they’re not. Paul Ryan, with his fake sincerity and his ability to act like an idiot’s idea of a smart person, and his sleazy aura of seriousness, offers them someone to elevate to the level of “thinker”, even though he has repeatedly shown himself to be incapable of the task. Charles Pierce, who invented the term Zombie-eyed Granny Starver, summarizes Ryan:

Every time he produces a “budget,” actual economists collapse in helpless laughter and other Republicans hide behind the drapes. As a vice-presidential candidate, Joe Biden made him look like a child, and Ryan was unable even to carry his own precinct for the Republican ticket.

Since Obamacare reared its ugly head Ryan has consistently and repeatedly squibbed on the basic responsibility to produce an alternative policy, and now he has unveiled this one – and claimed it’s the best chance Republicans will get to repeal Obamacare – he has confirmed what anyone with any sense already knew: he hasn’t got a clue, and doesn’t care to make the basic effort required to have a clue. So will the media finally recognize this and give up on him – and hopefully by extension all the frauds and liars on his side of the chamber – or will they continue their love affair with him, and continue to sell the American people short? My money’s on the latter, because even though the past three months have made clearer than ever before that the Republican party is just a gang of crooks, the media will never admit their role in enabling these frauds and scoundrels over the past 30 years. They have to hit rock bottom before they can admit their problem and make amends, and I’ve no doubt that discovering their favourite policy wonk knows nothing about anything is nowhere near rock bottom for the US media.

We have a long way to go yet before the Republican party and its enablers are properly shamed for the damage they have done. Let’s hope that Obamacare repeal fails before we get there.

 


fn1: Maybe that’s why his health policy knowledge is so bad! But at least he won’t use OLS regression on count data like good ‘ole Barry

fn2: Funnily enough Ryan, a confirmed liar, didn’t mention that Obamacare set up a state-based high risk pool in Wisconsin when it closed the existing high risk pool. The new one has about 1100 enrollees – because most of the 21,000 enrollees in the previous one became eligible for Medicaid or individual insurance plans under Obamacare. This is an interesting bait-and-switch that Republican shonksters like Ryan use: at the same time as they are proposing to do away with a government entitlement and kick the poor over to the mercies of the free market, they attempt to gee up some outrage about how the Democrats unwound a government entitlement that people really liked. I guess I shouldn’t be surprised that a shameless liar like Ryan has no shame, but it still disappoints me every time I see it.

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