It’s unlikely that this blog has any readers, and if it does it is unlikely that any of them are dyed-in-the-wool US Republicans, but just in case there are any out there, I would like to ask you a question. Can you articulate the objectives of a Republican healthcare policy? Can you describe what principles would underlie such a policy, and what methods would be used to achieve it? The new republican “alternative” to Obamacare has been released and it has attracted a lot of attacks from the right as well as the left, with many Republicans decrying it as “Obamacare lite” and complaining that it retains many of the key features of Obamacare: the mandate (now disguised as a fine), subsidies, and regulation. Some of the people attacking it (e.g. Erick Erickson at the Resurgent) seem to believe that repealing Obamacare now and working for a full replacement over the next year would be a good idea, which suggests that chaos in insurance markets is considered a small price to pay to achieve Republican objectives in healthcare policy. But what are they? A recent Vox article on the new plan suggests that it has mistaken the slogan (“repeal and replace Obamacare”) for the actual policy goal, because while the proposed plan would appear to meet the goals of the slogan it doesn’t actually offer any improvements on the actual plan. Many right-wing critics of the plan seem to agree. But none of them seem to be able to articulate what the objectives, principles and methods of a Republican healthcare policy would be. So what are they?

By way of comparison, most of the rest of the developed world and an increasing number of developing countries have achieved universal health coverage (UHC), and it is easy to identify the objectives, principles and methods of this movement. UHC has a specific objective, defined by the WHO as

ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services

This is a clear objective – you may not agree with it but you can’t fault that it is clear and definitive. If any quibbling is going to go on here (and it does) it will be over the definition of “financial hardship,” which varies from place to place and time to time, but is at least a thing that can be defined. What is the Republican equivalent of that definition? Where is the Republican equivalent of that webpage?

The movement to UHC has also defined specific principles of health coverage. There is a famous diagram that defines a nation’s health services in terms of the proportion of the country covered, the range of services covered, and the magnitude of financial coverage offered, summarized in the cube shown below.

These are the principles under which UHC is defined and changes in UHC are assessed. Typically as countries move towards UHC they will make sacrifices on one or more dimensions of this cube, but in principle they will be trying to expand the fiscal space to incorporate all of them. For example, the UK National Health Service covers all the cost of medical care and covers all the population, but doesn’t cover all services (e.g dentistry), while the Japanese system includes some co-payments (so doesn’t cover 100% of the fees), but includes dentistry in its services covered. In my opinion this cube needs a fourth dimension, timeliness, but at its basic level this cube describes the goals of the system. In addition UHC as defined by the WHO attempts to achieve equity, although that could be wrapped up in the dimensions of population covered and cost-sharing. In any case, every UHC program can be assessed in terms of how well it achieves the goals defined by the cube, and these constitute the principles of health coverage. This isn’t a perfect model (it excludes quality and timeliness, for example) but it’s a set of principles we can work with.

What is the Republican approach to defining a successful health policy, and how do you aim to assess progress towards your objectives?

Finally, UHC as it is supported by the WHO is supported by a variety of different payment and delivery mechanisms, which are well understood and frequently studied. The people working in this field understand that the goals of the UHC program can be achieved through a variety of methods, which will vary depending on the political, cultural and economic climate in which UHC is enacted. Generally we will see a mixture of general revenue, government-run services, social insurance mechanisms, private insurance mechanisms, out-of-pocket payments, and (in developing countries) NGO funding. The exact mix varies and the drawbacks of the different methods are understood. Within this framework there is a general agreement on the need for regulation and the dimensions we regulate (credentials of health care workers, financial robustness of providers, assessment of drugs and devices) and often the government intervenes to ensure that everything runs smoothly (often through price negotiations, workforce planning, and targets and rules for specific sectors or agencies). Countries select from a wide array of possible regulatory and financing frameworks but all these frameworks are understood and well studied, and as middle income nations move towards UHC they typically select a set of methods from amongst this suite of tools that they think will work best in their setting. Given that Republicans rule out some basic mechanisms – general taxation revenue, government run services, social insurance mechanisms – and a wide array of regulatory structures, what methods do Republicans propose as alternatives?

Looking at how the Republican response to Obamacare has panned out over the past six years, and reviewing the new proposed plan, it seems to me that Republicans have rejected almost all the principles and methods of UHC. They appear to have done so on the grounds of “freedom”, but have never defined what a “free” health system would be. They also haven’t defined the objectives of their healthcare policy at any stage in the debate. Given this inchoate approach to a complex and important policy issue, it’s difficult to understand why they opposed Obamacare – with no objective or principles, how can they argue for or against any policy? I know it’s a fruitless task to expect Republicans to respond to any issue seriously when all they really are is a pack of grifters and con artists, but while those epithets almost certainly are true of the party I do think a lot of its voters are serious about their beliefs. So I want to ask you – what are your objectives, principles and methods? What does a Republican healthcare plan look like and what will it ultimately achieve?

I think the Republican leadership haven’t put even a moment’s thought into these questions, and I don’t get the feeling their “intellectual” wing in the bought-and-paid-for think tanks has either. But maybe there are ordinary Republicans who can answer my questions? If so, have at it! I’ll take a lack of comments as proof you don’t have a clue, rather than evidence that this blog has no readers. So let me know! What do you want, and how are you going to get there?

Save

After six weeks of waiting and watching the Republicans flail about trying to figure out a way to deliver on their campaign promise to “repeal and replace” Obamacare we have a policy! The Republicans have delivered on their promise to “simultaneously” repeal the law and replace it with something better, wisely choosing not to go down the repeal-now replace-later path that would have made them responsible for two years of madness. Instead they have decided to use the budget reconciliation process to revise the law, pushing their amendments straight into committees without giving anyone a proper chance to assess the law – including the Congressional Budget Office, whose decision on the law is essential in order for it to actually reach the committee stage. Apparently it’s a shocking piece of political cynicism when Democrats push a law through congress before anyone has a chance to read it, even after they spent months hashing out the content in public, but it’s okay for Republicans to push the law straight to the committee stage without any debate or public discussion at all …

Putting aside the dirty politics of the law, the law itself seems to be pretty dirty. Vox has an explainer, but in essence the basic details are:

  1. It repeals the mandate, a tax penalty on people who do not take out insurance, and replaces it with a fine applied to the cost of subsequent health insurance. This means that if you drop your plan and don’t take up another one within 63 days you suffer a 30% increase in the cost of your next insurance plan.
  2. It replaces Obamacare’s income-based subsidies with age-based subsidies, that are means-tested to disappear above a certain income. These credits are smaller than Obamacare’s and obviously intended to favour the wealthy and Republican voters (younger people are poorer than older people). In combination with the changes to the mandate, these subsidies will push insurance markets into a death spiral (see below) and are vastly more regressive than the Obamacare system (which was far from perfect).
  3. It doesn’t undo the Obamacare bans on discrimination against people with pre-existing conditions, but it does relax the rules on higher charges for the elderly, so that insurers can charge the elderly up to 5 times as much as the young
  4. It removes regulations on the products insurers can sell, enabling them to again offer insurance which offers no protection against financial catastrophe
  5. It retains the Medicaid expansion until 2020, after which it will stop new admissions to medicaid under the expansion rules, basically enabling the Republicans to repeal the Medicaid expansion by stealth and to put off the electoral consequences of the repeal by making sure it doesn’t affect those currently receiving medicaid. The Medicaid expansion probably increased the number of people insured by 10-20 million – this will be reversed slowly over the next 10 years
  6. It changes Medicaid funding to block grants for the states, which will mean that states give less funding to Medicaid, further restricting its effectiveness and/or driving more people off Medicaid. It also hands out money to Republican states that did not take the Medicaid expansion, to ensure they are not disadvantaged by their decision not to take the expansion over the past 6 years. Given that this decision was a political decision taken in collaboration with the federal Republican party, and that this decision directly disadvantaged state budgets, the decision to reward these states for their intransigence is breathtakingly cynical
  7. It abolishes a range of Obamacare taxes that were crucial to funding Obamacare
  8. It delays the so-called “Cadillac tax” (which all health economists agree is a really good policy) until 2025, effectively ensuring that this excellent piece of pro-equity, cost-containing legislation never happens

Aside from the decision to allow young people to stay on their parents’ insurance until the age of 26, there is essentially nothing about this health financing policy that is good. In particular, decisions 1 and 2 are very stupid decisions that will hasten the descent of insurance markets into death spirals. Consider the example of a 26 year old healthy man with no pre-existing conditions who is leaving his parents’ insurance, and is on 150% of the poverty line. This young fellow is not eligible for Medicaid (which is restricted to people earning less than 138% of the federal poverty line) but will get a $2000 subsidy under the new plan. If he does not find himself a plan within 63 days he will be charged 30% extra on the plan he chooses. The internet tells me 150% of the federal poverty line is about $18,000. The average cost of a silver plan for this man would be about $350[1]. Under Obamacare, if this chap didn’t take up insurance he would be faced with a tax penalty every month of his life for the rest of his life until he chose to purchase a plan; but his plan would be subsidized so that he would not be paying much for it, so the difference between the tax penalty and his plan cost would likely be minimal – his decision about whether to take a plan would largely come down to his personal health seeking behavior[2]. In the case of a 26 year old man we can be fairly confident he would choose not to take a plan, but that’s a story for another day. Under the Republican plan, this young man would suffer a 30% penalty on his next plan, for one year. Using Obamacare coverage costs as a guide, he would face a $110 a month penalty for one year, or $1320. Given that this man is healthy with no pre-existing conditions, and can assume that any significant health issues he faces in the next five years will be emergency issues (i.e. being shot) and best handled by free emergency care, he has no special reason to get health coverage. So from his perspective waiting four months with no coverage is no big threat to his health, and saves him more than the fine – and the longer he waits, the more he benefits. The Republican plan actively encourages young, healthy people to avoid taking insurance for as long as possible, because there is a cap on their liabilities that is determined by the price of the insurance they ultimately take. Given that no one in their 20s needs high cost coverage and salaries rise as you get older, a 30% fine is no inducement to take coverage – and the higher this fine gets, the stronger the inducement to delay purchasing coverage. This fine will encourage young people to avoid markets, except for a small group of people who hate taking risks, who will likely already be sick or at risk of getting sick. The healthy will stay away until they are old enough to need coverage – especially if the new deregulation of products enables insurers to remove maternity care from coverage, since maternity care would encourage 30-something women to take insurance.

Furthermore, while the Obamacare mandate returns the penalty for not taking insurance to the tax payer, the Republican plan returns it to the insurer – to use on covering their losses as the death spiral begins. It’s a disaster for insurers and it shows the fundamental silliness of trying to manage a universal health coverage (UHC) system through a classical private market place governed by Republican ideology – these market places rely on a large pool of low risk individuals, but Republican ideology opposes forcing anyone to spend their money in any specified way. So on the one hand you have a classical market demanding a certain pattern of expenditure that can only be guaranteed through government coercion, and a ruling party that fundamentally opposes that coercion, on both moral and practical grounds.

Madness.

It’s worth noting that a lot of right-wing commentators are angry at this new plan, calling it Obamacare lite and objecting to the subsidies and the mandate. Eric Erickson at The Resurgent opposes the mandate and sees the Republican plan as no different, giving a clear example of the fundamental conflict between modern Republicanism and basic health care policy. You can’t have a functioning health insurance system if healthy low-risk people don’t opt in, but they will never have an incentive to opt in if they aren’t forced to. Sensible systems (i.e. all the rest of the developed world) force people to opt in through the tax system, using government coercion to ensure the risk pool works; if you don’t do this you get a shrinking risk pool and sick people preferentially buying in, leading to escalating costs and a death spiral. That Republicans don’t understand this fundamental aspect of health policy makes them as stupid as their orange shitgibbon president, who just noticed that health policy is “unbelievably complicated.” They’ve had 6 years to figure this out, and they still don’t understand a single thing about one of the most crucial aspects of modern policy.

Fortunately, this bill won’t pass – the Freedom Caucus will sink it from the right, and the Medicaid expansion states from the left. The Republicans have had 6 years to sort this shit out, and they have failed in every way. Truly, Americans are uniquely poorly served by their elected representatives!


fn1: My god American health stuff is so complex. In every other developed country you just pay a certain predetermined proportion of your income as part of your tax and get coverage. How in any way is this market-based stuff better?!

fn2: Because under Obamacare costs and subsidies depend on age, sex and location (to the nearest zip code) it’s impossible to give precise numbers to any of these issues. Suffice it to say that in Japan or Australia no one earning $18,000 would have to pay anything resembling $350 for their insurance (or even $35, I suspect). But we don’t even have free access to guns, so don’t listen to us about healthcare policy!

An old Jedi mind trick

An old Jedi mind trick

Our guardians in the press are up in arms and all a-fluster in shock that Trump’s advisor Kellyanne Conway has decided to start referring to blatant lies as “alternative facts.” She was defending the Comical Ali press conference by Trump’s spokesperson, Spicer, which apparently lit up Twitter because of its obvious stupidity, and his blatant yelling attempts to pretend that the Trump inauguration had a greater audience than the 2009 Obama inauguration was presented as “alternative facts” rather than bald-faced bullshit. Spicer even claimed that Trump’s inauguration had the most people ever or something; and this after Trump apparently attempted to get a military parade organized, with tanks and missiles. He also apparently pressured the head of the National Parks Service to find flattering photos that would confirm what he and his crew already knew to be “fact” – that he had a bigger audience than the Kenyan Socialist, even though he obviously, clearly didn’t. It’s telling that having gone looking for evidence to support their view, and having found none, instead of making excuses they simply decided to front up and lie.

The media are shocked and pearl-clutching about how blatantly Trump is rejecting reality. I’m not sure why they’re surprised. The only surprising thing about the whole sordid affair is that Conway was smart enough to come up with a new term for what the Republican party has been doing for years – making up its own facts and expecting the media to swallow them whole, or at least take them seriously. The most obvious example of this is their ongoing project of blatant climate denialism, which the media have abetted for years by allowing the liars, con-artists, grifters and spooks of the GOP denialist wing and all its “think tanks” to come on to shows discussing science and present their bullshit denialism as “balance.” Since the GOP have been coddled for years into believing that complete lies need to be given airtime for reasons of “balance,” why would they not expect the media to give Trump’s view of the inauguration just as much weight as the photographic evidence? The GOP have been denying the temperature curve for years, and sure some of them have gone for a more sophisticated “humans aren’t causing it” line but a large part of the denialism has focused around denying that temperature exists, denying that the curve is rising, slicing the curve up into small parts and claiming cooling, using a different curve (see e.g. Breitbart with its recent attempt to claim the globe is cooling), using a curve that doesn’t measure the earth’s surface, or claiming that the data is all fraudulent. These are surely just as much “alternative facts” as disputing exactly how many people are in two separate photographs of the national mall.

If the media blessed the last 15 years of abject denialist bullshit with the halo of truthiness, why would they expect the GOP to stop there? And it’s not just on matters of policy that they know the GOP lies: Paul Ryan – who the media insist on pretending is a serious policy thinker – has been caught out lying flagrantly about his own marathon times, no doubt in order to burnish his manly credentials for his far right base and to keep the media hanging onto his strange, blank-eyed granny-starving charm so they can keep pretending he’s not just another shallow tax fetishist. The GOP were also pretty good at pretending that the national debt Clinton inherited was not Bush’s fault, and that the national debt Obama inherited was not Bush’s fault – and the media pretty much let them have that as well. Which has also enabled the GOP to keep up their image as the party of serious deficit reduction and concern about “inter-generational equity” when in fact they are the biggest culprits for the ballooning federal debt, and only ever take deficits seriously when a Democrat is in charge. And wasn’t it the PNAC that said that the only limits to American power were their imagination, just before they fucked up and invaded Iraq?

The GOP and the rarified “thinkers” in “think” tanks like the Heritage foundation associated with this clan of grifters have pushed a whole bunch of other lies and deceptions over the years that are easily just as blatant as Spicer’s recent “alternative facts”: more guns means less crime, the Clean Air Act didn’t work, Barack Obama was born in Kenya, the Laffer curve, abstinence only sex education works, the Empire were the good guys (seriously there is a dude at National Review who runs with this particular shtick). They also peddle in a sideline of hypocrisy that would get a Democrat sunk in a moment – most obviously the wide array of “family values” candidates like Gingrich and Trump who’re onto their third marriage, and the rogue’s gallery of anti-gay lawmakers who have been caught adopting a “wide stance” in public toilets. They’ve been able to get away with this mixture of blatant denialism, straight-up lies, prevarications and half truths, and rank hypocrisy for the past 30 years because the media have been noticable lax about confronting them on the obvious con they’re running. Now the media have a president who really genuinely hates them and they’re suddenly starting to notice that taking facts seriously matters. But they’ve done the GOP’s work for them, allowing every single important issue of the past 30 years to be turned into a matter of opinion and “balance”, making every single basic fact underlying public policy into a debatable issue, and now Trump and his team of rich ingrates have decided they don’t need to pay lip service to the truth anymore. Having shown themselves to be willing enablers of GOP lies for 30 years, it’s going to be a little difficult for the media to back away and start pretending that facts matter.

I’ve been saying for a long time now that the GOP cannot behave like a serious political party while it denies global warming, and that the effort required to deny global warming has corrupted the entire intellectual structure of American conservatism. This is why now the GOP has become the home of vaccine denialism, with Trump considering appointing an open denialist to the vaccine safety committee, and why the GOP cannot come up with a health care policy or a strategy to contain gun violence: The effort of denying the facts of global warming has required such a complete and overwhelming rejection of the basic tenets of modern intellectual activity that they have had to walk away from reality to manage it. Just as the torturer in 1984 forced Winston to lie about the most basic things in order to rebuild his ideology, so the GOP have developed in themselves the ability to lie to themselves about anything, no matter how obvious and simple, and now it’s easy for them to believe anything they want to believe. To convince a Republican of the wrongness of vaccination policy or the fact that homeopathy can cure AIDS you don’t need to sell them on pseudo-scientific waffle – you just need to show them how it matches their ideology, and they’ll automatically believe the rest. This is what happened with anti-vaccination ideology, and it happens by default with any environmental issue. In time it will happen with everything else, because the GOP is intellectually rudderless, has built an entire intellectual structure on no foundations.

Over the term of this presidency that means that the president, all his sycophants, and most of the GOP congress are going to present us a range of ridiculous ideas that are clearly wrong, and yet believe them wholeheartedly: Trump will be “ever more popular” even as his popularity plummets; their Obamacare replacement will be enormously successful even though it is a dismal failure; crime will plummet even if it goes up; the economy will be going great even as inflation and unemployment rise. They have finally and completely severed themselves from reality and even though the rest of us have seen this coming for 30 years, their compliant operatives in the media have just noticed just how far gone the whole screaming mad mob are. But by the time they try to start dealing with it, Trump will have cut them off completely and withdrawn into his Fox news bubble. After all, once you completely reject all facts, you don’t need the media to report anything, do you? You can just make proclamations of the truth, and the more pesky fact-checkers you cut out of the process the easier it is to promulgate the truth.

This day has been coming for 30 years, and we scientists have been warning of it for a long time. I fear it is going to be a long time before America can drag itself back from this state, and that it will do a lot of damage to itself and the rest of the world before it finally recovers. Let’s hope the damage isn’t fatal …

What the American people have to look forward to

What the American people have to look forward to

We’re a week away from the inauguration of the 45th President, but the Senate and House seats have changed so that the Republicans now control both houses of Congress, and one of their first actions has been to begin repealing Obamacare. They’ve been salivating over this prospect for six years and making a big fuss about it, as have all their adjutants in think tanks and conservative media, so you would think they would be ready to roll with a coherent plan. Unfortunately it appears that they don’t, and the first week of their attempts to begin the process have been rather shambolic. Since they don’t control 60 Senate votes they are trying to enact the repeal through some arcane process called reconciliation, but that is just the start of the rolling drama that is coming; Vox has an explainer about the whole process, and is running a fairly good series of articles watching as the Republicans attempt to wreck Obama’s signature achievement.

The Republicans’ first plan seemed to be “repeal and replace”, in which they would unravel all the key parts of Obamacare now but put some kind of deadline on when they would take effect, then begin working on a replacement plan in the meantime. Unfortunately this was patent madness, that they were warned about for months, which would tip many insurance markets into a death spiral and create chaos for both insurance companies and millions of insurance holders. Trump stepped on this with the announcement that repeal and replacement would happen simultaneously and soon, which is something of a problem for the Republicans since they don’t have a plan and working one up in a couple of weeks is going to be kind of challenging (Obamacare took about 15 months to happen, I think). Even more challenging for the Republicans is their lack of a filibuster-proof majority in the Senate – they can repeal the law’s components with 51 votes, but they can only put in place a replacement with 60 votes. If the Democrats decide to act in exactly the same way that the Republicans have for the past 6 years, they will prevent any replacement plan for the next two years, and unless the Republicans can hold them responsible in the mid-terms, potentially kill any future replacement. This would be a disaster for the Republicans, since they would create an insurance death-spiral with no ability to legislate a repair, and go to the mid-terms with several million people suddenly losing their insurance. Given this their choices all seem very unpleasant.

This is incredibly irresponsible politics. Health care reform has been a Democratic party priority – and part of national debate – since the 1990s, and Obamacare was passed in 2010. The Republicans have had 25 years to think about this stuff, and have tried more than 50 times to repeal Obamacare while they were in opposition, yet over that whole time they haven’t come up with a single plan that will do anything to improve health insurance coverage. One Republican even admitted that the plans they have tried to pass during Obama’s administration were only pushed because they knew they wouldn’t get passed – they aren’t serious plans. Paul Ryan has been saying the Republicans will release a plan “soon” for years, and although there are a couple of different ideas floating around out there none of them is near the level of a properly designed plan – and none were pushed during the election. The Heritage Foundation was able to scour the whole country looking for complainants in a Supreme Court case – and fight that case – to gut one part of Obamacare, but didn’t appear to have time to come up with an alternative plan that was worth putting to Congress. The Republicans have known this day is coming for at least six years and they have nothing coherent to offer the American people. We all know the reason for this, of course – Republican political ideology simply cannot produce a reform of the American healthcare system that will give more people affordable coverage, because the Republicans’ fundamental position is that government should not be interfering in healthcare markets, and it is impossible to make healthcare affordable and accessible without extensive government interference in markets.

As if that were not bad enough, their president-elect campaigned on a promise not to cut medicare or medicaid, and recently his spokesperson said that no one would lose their existing plan (a promise that has been held against Obama by Republicans for six years!) Trump has also said he likes Obamacare’s provisions on pre-existing conditions. So now the Republicans have to come up with a free market plan that somehow keeps Medicaid in place, doesn’t take away anyone’s insurance, and forces insurance companies to cover pre-existing conditions, while bringing prices down and giving individuals greater choice (the latter two points being raised by Paul Ryan recently as part of what he described as a “rescue mission” to make health care more affordable than it is under Obamacare). And if they follow Trump’s timeline they have to do it in a few weeks or months.

It’s not clear what colour everyone’s unicorn will be, but we know it will be a free market unicorn.

So what can we expect this plan to contain? It’s not clear, because there have been multiple Republican “plans” or “policies” in the past couple of years, but based on the major ones that have floated around and some of the major policy discussions we have seen, the plan will likely include some or all of the following.

  • Abolishing the mandate: The mandate is the Obamcare rule that hits people with a tax penalty if they do not take out health insurance, in an attempt to force young and healthy people to take up insurance. This mandate is key to Obamacare, since forcing young and healthy people to take up insurance will ensure that the insurance risk pools are large enough to keep costs down and keep insurance companies viable. The mandate hasn’t been as successful as its planners envisaged, probably because the plans young people are likely to choose to take up are “Bronze” plans with very poor benefits, and many young people probably don’t think they’re worth the effort of filling in forms, given the size of the tax penalty. Republicans hate the mandate and want to get rid of it but of course don’t have an alternative method for forcing people to take up health care. If you abolish the mandate but force insurance companies to cover people with pre-existing conditions then they have to raise prices for everyone else – which means the care won’t be affordable, a key goal of Ryan’s “rescue mission.”
  • Deregulating insurance markets: Trump was big on allowing insurers to operate across state lines, and most Republican plans want to see some kind of reduction of conditions on insurers. In the repeal of Obamacare this will likely involve removing the restrictions placed on plans that can be marketed on exchanges – when Obamacare was introduced, a set of minimum standards was established for insurance plans which guaranteed people buying them would get a certain minimum level of benefits, and enabled people to choose between plans that were rated as either Bronze, Silver, Gold or Platinum. By deregulating markets and the rules on how insurers market their plans, the insurance companies will be able to return to the pre-Obamacare era of selling absolutely shonky packages at a low price – which, if they’re required to offer coverage to people with pre-existing plans, is the only way they’ll cover their costs. Many Republicans also think insurance companies should be able to compete across state lines, ostensibly because this will increase competition in smaller states and rural areas where currently only one insurer operates, and also to allow more mergers. This is unlikely to encourage competition in the long-term, but will lead to large insurers merging and creating multi-state monopolies – monopoly pricing being another way to cover costs. There is no universal health coverage system in the world which operates successfully with a deregulated private market, and it’s not going to magically happen in the USA.
  • Reforming subsidies: Another aspect of some Republican plans has been to change subsidies so that they are not income-based. Currently under Obamacare anyone with income below a certain level receives a subsidy towards the cost of their health insurance, with the subsidy growing as income decreases, to ensure the plan remains affordable. This is the natural compensation for the mandate, and is one of the pillars of Obamacare. Republicans like Tom Price have proposed replacing these income-based subsidies with age-based subsidies, which means Bill Gates gets the same subsidy as a minimum-wage 61 year old labourer in Louisiana. This policy is part of a new rhetoric the Republicans are developing based on “equality of access” rather than equality of coverage. The natural consequence of this will be that poor people will decline to take up insurance, since the subsidy won’t be enough for them – especially in a deregulated market with no mandates.
  • Block-granting medicaid: As part of Obamacare the Medicaid program was expanded, with states being offered financial support to extend Medicaid to a larger pool of people (Medicaid is the USA’s free health coverage for very poor people). Republicans hate this because it’s straight-up welfarism, and the Heritage Foundation ran a successful challenge in the Supreme Court that enabled states to refuse the expansion. Unfortunately for the Republicans a lot of states – including some Republican-ruled swing states – took the expansion, and about 5-12 million people gained health coverage through it (estimates vary). If the Republicans take away this expansion they will piss off a lot of people, including people in Republican swing states that could damage them in future elections, so they need to find a way to take away the Medicaid expansion from safe Democrat and safe Republican states, and enable swing Republican states to keep it. Their answer is block-grants, in which the money for Medicaid is granted to the states but not earmarked for Medicaid only. Since some deep Republican states like Kansas and Louisiana are in big financial trouble, they can then use the Medicaid money to bail out their failing state finances, and pare back Medicaid in their states; while swing states can keep using the money for Medicaid and avoid creating a large pool of angry voters. Even then it is likely that the block grants will be smaller than the funds currently available so all states will have to cut Medicaid coverage or reduce the quality of care offered – but the Republicans don’t care because Medicaid is for poor people, so just need to make sure they don’t cut it away from so many people that it swings an election.

Any single one of these reforms in isolation would probably be enough to radically roll back recent gains in insurance coverage in the USA, but it’s likely that whatever misbegotten, evil plan the Republicans come up will have all of these reforms to some extent. This is why Republicans have started talking about equality of access rather than coverage, because if everyone theoretically has a subsidy and the right to purchase healthcare, then you can blame them if they decide they can’t afford it. In this rhetorical model they will force insurers to cover people with pre-existing conditions, abolish the mandate, deregulate the market in such a way that insurance companies can offer absolutely shonky products at inflated prices, cut subsidies so that no one takes them, and then blame poor people for “choosing” not to take up the healthcare they had “equal access” to.

It remains to be seen whether the Republicans will be able to get away with this – either because Trump takes a personal interest in a reform that actually works, and vetoes anything they offer, or because the Democrats drag out the replacement strategy until they can again win control of Congress. In any case it’s going to be fascinating to watch the Republicans try to behave like responsible adults now that they have the levers of power, even though for the past six years they have shown themselves pathologically incapable of dealing with the contradictions and challenges their ideology has thrown up.

Of course, what’s “fascinating” to those of us who live in countries with sane governments and universal health coverage, is going to be very terrifying to a very large number of poor and chronically ill people in America. Good luck to all of you!

(This review is a little pointless because the exhibition closes tomorrow).

Yesterday I visited the Mori Art Museum in Roppongi Hills to see the Universe and Art exhibition. This exhibition attempts to show the relationship between artists’ and scientists’ attempts to explain the cosmos and the human relationship with the stars. It incorporates artistic visions of the cosmic order, scientific explanations of space over time, and artistic interpretations of science, from many different cultural perspectives. To do this it displays a wide array of art, items, scientific objects, film and video art. These objects have been drawn from many different cultures – Indian, Asian, Europe and the Americas – over several thousand years, with a particular emphasis on Japanese material from the past and the present. They include mandalas from India and Japan, star charts from China and Japan, and early stories about space from Japan and Europe. It also includes film, photos and objects from the space programs of several nations, science fiction art and stories inspired by these programs, and visual art that either glorifies or critiques or reinterprets them. Some highlights that I particularly enjoyed are listed below.

The meteoric iron katana

Blade of coolness +5

Blade of coolness +5

What can I say? Apparently Okayoshi Kunimune made two swords from meteoric iron, which took three weeks to craft and required several trips to the local shrine for prayer. One of these is on display, and it is quite impressive. It has all the fine lines of a classically-forged katana, but the metal is kind of darker and less shiny, more sinister-looking. Also the scabbard has “Meteor sword” written on it, which just says it all really. This blade was forged the old-fashioned way in 1898, which was after the samurai era, but was forged in the traditional way, which means that it has that slight rippling pattern in the metal around the blade. Viewed end on it looks wicked sharp. The photo I took is just a snap and overstates how dark the blade is, but I do think it is darker than a normal blade (I haven’t seen many of these artifact blades so I don’t know how dark an original samurai blade is). One of these blades ended up in the possession of the Taisho Emperor, which means that he was decked out in a sword made from a meteorite. I think that makes this a kind of unique artifact and it genuinely is very cool, just sits their heavy with its own sense of foreboding awesomeness. Everyone was impressed by this sword.

Bjorn Dahlem’s Black Hole (M-Spheres)

Space!

Space!

This installation is large and imposing and when viewed in detail kind of naff – it’s just a bunch of fluorescent lights stuck onto some wood – but viewed from afar with that kind of disfocused gaze that you have to take with certain kinds of art it suddenly becomes much more imposing and abstract. In the centre is supposed to be a black hole, with what I guess are galaxies or some kind of star tracks circling around it. A single sphere of black metal somewhere in the middle is, I guess, the black hole that it all is meant to be built around. It’s surprisingly cool (though the windows at the far end of the room give a view of Tokyo from the 52nd floor of this building and are kind of more awesome in their own way). It doesn’t move or anything, unlike …

The God Machine

It watches and waits ...

It watches and waits …

This monstrosity is set up in its own room, and is basically just a series of robust metal arms circling slowly in rings of different size and speed, with brilliant lights on the arms. The lights themselves move in simple planar orbits but the whole structure is set at an angle to the floor surrounded by walls of white, and the motions of the shadows of the arms on the wall are complex, occasionally threatening, and frustratingly close to predictable. The size, clarity, depth and position of the shadows changes as the arms complete their loops, and depending on the direction you look you see a very different system of shadows interacting. A single spike sticking up from the floor casts a complex pattern of shifting triple shadows on the floor. The whole thing is a simple set of ordered moving parts, but it carries this sense of immensity and brooding threat that makes it really cool. I think it’s by Wolfgang Tillmans, who contributed a few beautiful images as well. His website gives a sense of some of his other art, which is quite striking.

The great books

Original history

Original history

The exhibition also featured first editions of Newton’s Principia, Darwin’s The Origin of the Species, and the first works of Copernicus and Kepler. Kepler and Copernicus’s books are open at centre pages so you can see the quality of their work, while the Principia is open to the frontispiece.

On the shoulders of giants ...

On the shoulders of giants …

I studied physics in my undergraduate years, and then statistics, and so for me even just the frontispiece of Newton’s original work (shown above) carries an enormous weight and power – this is truly a book of vast importance in the history of science, and to stand in front of a work that is so close to the original hand of one of science’s greatest and most influential minds is really a great privilege. This book is over 300 years old, heavy and worn with the weight of history, and everything in my career and everything I love about the science I do is built on what is in its thick and fragile pages. So it was really great to stand looking at that frontispiece and revel in the significance of of those three words: Naturalis Principia Mathematica. I imagine if one were an evolutionary biologist one would get the same feeling from Darwin’s Origin of the Species, which was also on display, but for me as someone trained in physics this book is a great treasure and it was the first (and I guess, the last) time I will be in the presence of this original piece of history.

The exhibition had other contributions from the scientists of that era, including an excerpt from da Vinci’s Codex Atlanticus that described the movement of the planets (his handwriting is incredibly beautiful, every letter a work of art), armillary spheres and beautiful navigational tools made in intricate and beautiful detail out of brass, and a replica of Gallileo’s original telescope (also, his Sedereus Nuncius and his sketches of the moon, that he made with that incredibly primitive telescope). It’s really humbling to stand in the presence of so many of the original moments of modern science, and to think that almost everything we do now depends on the work these men put into these humble books, or that once people had to find their way to Tokyo using nothing more than one of those brass navigational instruments. It’s quite incredible to see them and realize just how primitive it all was – these scientists really were fumbling around the universe, making guesses on the basis of almost nothing, when you think about what we can do today. And almost everything we can do today depends on their fumbling efforts … So it was quite amazing to see all this stuff in one exhibition, and also to see some of the wild, amusing and speculative ways in which artists of that time and since have speculated on the implications of those scientific endeavours. It’s also obvious when you see that early work that there is no barrier between science and art – those scientists were technicians but they approached their work with a religious zeal and an obvious sense of aesthetics, a joy in the beauty of maths and physics as well as in the discovery of the unknown. For all the challenges of that era, for these men it must have been a very exciting time to be alive.

The Crows and the Insects in Amber

Some of the video installations weren’t so great but there were two amazing works. The first was a high resolution high magnification video exploration of a piece of amber with insects trapped inside it. Set to eery backing music, it moved through the amber filming different parts of it in such a way that it produces spacescapes and scenes like starscapes, nebulae or distant galaxies. In between these strange galactic visuals it zoomed in or out on the insects themselves, so that they loomed in the camera like Cthulhoid monsters, alien horrors, or strange planetary landscapes. This installation was probably 4-5 minutes long (or at least the part I saw was) but it was a fascinating way to turn a piece of something ancient, terrestrial and tiny into something vast, timeless and cosmic. A brilliant idea.

The second was a video work by teamlab, Crows are Chased and the Chasing Crows are Destined to be Chased as well, Blossoming on Collision–Light in Space. For this you enter a large dark room and stand in a specific spot in the centre of the room, then the entire room begins to shift and move as the video covers all the walls, floor and ceiling. From your central spot you watch crows take flight and then you chase them along the lines of their flight, and then they burst over you and disappear and suddenly you’re chasing new ones. I don’ t know why crows, I don’t know why we’re chasing them, but it’s really good. It’s a kind of mixture of video game and interactive exhibit, I guess, but all through a movie. It probably wasn’t entirely suited to this exhibition – it could easily be the open sky rather than space that these crows are flying through – but it was still a splendid experience.

This exhibition finishes tomorrow so there is not really any point in recommending that you, dear reader(s), rush on down to see it, but at least now you know what you missed. This was a really interesting attempt to combine two fields of human endeavour that are often seen as at odds with each other or unconnected, and it did a really good job both of merging the two and also of introducing me to some genuinely cool modern artists working in this field. It also serves as a good reminder of how space exploration, from its earliest beginnings, has been not just an engineering and physics endeavour, but an artistic effort that expresses something about what it means to be human and what our position is in the cosmos. As we watch new and modern efforts to explore our solar system – and, possibly, to colonize it – it’s worth remembering that they are always about more than just science, which makes them simultaneously both a luxurious waste of money, and an essential attempt to understand the core of what it is to be human. I hope in the future other museums and art galleries will attempt a similar exhibition to this, so people outside of Japan can share this unique insight into how art and science have worked together over thousands of years to bring humans closer to the stars, both physically and spiritually.

She'll tear your heart out, and store up the pain for next time

She’ll tear your heart out, and store up the pain for next time

With the Spiral Confederacy campaign rolling to a close my regular gaming group is about to embark on a new campaign in a setting called Undriel, using a variant of World Of Darkness rules with Ars Magica type magical system. Undriel is high fantasy with a strong flavouring from Irish folklore. This is my character for the new campaign.

Xenobia was born the second daughter of a noble family in Garias, that rich and fated kingdom on the shores of the western isle that is rumoured to have had a long dalliance with dark magic and the Fomori. The particular name of her noble family is of no matter, because she has been cast out from them. Raised with the expectation that she would marry young, promised to a much older man in a marriage of convenience and politics, Xenobia rebelled against her gilded cage and ran away from home in her teens. Tricked by a handsome, mysterious older man from a lower-ranked family, she was lured into eloping with him with promises of adventure and love. Finding herself alone in his remote and cold mountain castle, she slowly began to lose her confidence and her happiness, as he set about systematically degrading and debasing her. Finally she discovered that all of the abuses and cruelties he visited upon her were part of a great ritual, in which he intended to break her innocence and then sacrifice her life on a dark altar to some great evil. At the last she slew him, but the backwash of dark magical energies released in his ineffectual and incomplete ritual washed over her and cursed her, soaking into her so that she suddenly became magically endowed.

Unfortunately this magical awakening was not a pleasant one. Stillborn in a dark ritual interrupted by murder and flight, her magical powers manifested themselves as necromancy and death magic. Xenobia is cursed so that she cannot easily cast any magic that is not based on death, fear, pain and darkness[1] – she is an unwilling necromancer. She can destroy flesh, conjure the spirits of the dead to fight for her, shroud herself in shadows and drive her enemies away in fear, but in order to heal an ally or to conjure a light spell she must suffer the pain in her own flesh. Over time Xenobia came to understand this curse, and during her sojourn in the lonely tower she crafted two magic items to help in her work. One, the burnt eye socket of her cremated former lover, stores damage or essence that she drains from others, that she can use it to restore wounds or injuries in herself or her allies; the other, a battered necklace of emerald, stores the pain she causes to others as a flash of light inside the gem, which she can then call upon the next time she casts a non-necromantic spell. By unleashing this stored pain she can, for that one spell, avoid the penalty of her curse. But if she does not harm others, she cannot store their pain, and must instead suffer that pain herself.

Xenobia has long since been cut off from her family, but she has retained the resources her dead lover had hoarded to himself, including his tower in the remote mountains of Garias. She carries herself still as a noblewoman, dressing elegantly and in the latest fashions and always acting with the etiquette and formality her status demands of her. Those who spend time in her company might notice that she lacks some of the airs and accomplishments of her fellow noble ladies, having missed finishing school and the finer lessons of court life while she wrestled with her curse and the awakening of her powers. Xenobia is also scarred, one side of her face permanently damaged by fire; every moon she casts a spell to renew the perfection of her appearance, and uses make up in the latest courtly fashions to ensure she remains perfect in form. When she casts her dark magics that scar briefly shows through the transformed flesh, revealing the ugliness beneath her courtly demeanour. However, aside from those times when she must hide away to recast the spell, Xenobia is to all outward appearance a normal minor noblewoman. She is pretty, young, slim and small, physically unopposing and apparently mostly harmless. This apparent weakness enables her to insinuate herself into positions where her rougher companions might not go – and belies the ferocious, destructive and unsettling nature of the magic that she carries into battle with her.

Xenobia travels the lands of Undriel seeking a cure for her curse, and a renewed purpose to carry her life forward now that she has been cursed with magic. Will she find that purpose, or will the dark nature of her magic overwhelm her, and draw her into the same evil that consumed her ex-lover? Only the Gods can know …


fn1: Manifesting in game terms as a 3 point flaw that causes her to suffer wounds, increased difficulty or greater spell use costs if her spell does not have one of these features, with the costs growing with the essence cost of the spell.

Save

Thongor say smash!

Thongor say smash!

Late last year I ran a one-off session of Barbarians of Lemuria, a simple and stripped down sword and sorcery RPG. The session report for that adventure is here.

Barbarians of Lemuria is intended to provide rules for sword and sorcery adventuring in the style of Conan, the Lankhmar series, and Thongor, in a light and easy to play style. The game comes with its own setting, the mythical land of Lemuria, which has a long tradition in fantasy writing and film and is also the name of a great southern continent that the Victorians imagined existed somewhere in the southern hemisphere. This land is mentioned in the Strange Tales fantasy magazine and is the setting for the books about the barbarian Thongor by Lin Carter. Barbarians of Lemuria expands on these vague historical and literary references with a map and setting information, so that in addition to rules for a quick and simple sword and sorcery RPG it comes with background information on a classic setting sufficient for running a whole sword and sorcery campaign.

The game is definitely light on rules and written for brevity and ease of use. In just 211 pages it manages to encompass all the usual RPG rules plus wargaming rules, setting, monsters, a brace of sample adventures, a random adventure generator, summary tables and character sheets. All the rules for task resolution and combat are squashed into 8 pages and are perfectly sufficient to cover most scenarios you need them for. Sample adventures are typically 2-3 pages including maps and background, and are really only rough sketches for a wide array of free form approaches to the general ideas laid out in them. Wherever possible the game attempts to capture the seat-of-the-pants risk taking approach to adventure from the sword and sorcery setting through loose rules and quick and dirty approaches to problems. For example, in the section on equipment they write:

… there are no rules for encumbrance. Heroes can go around with what they can carry. They live for the day. You never know what you will need on an adventure and you can’t take everything, so why bother? Use your hero points instead. That’s what they are for. If you want backpacks full of adventuring gear, a weapon for every occasion, three spare suits of armour and a pack animal to carry it around on, then play another game. If all you want is a breechclout and a sturdy blade, play on!

I think that might be the best encumbrance rules I have ever read, and it gives a good summary of how normally picky technical details like armour, healing and so on are handled in this game. It’s a game to unleash your barbarian on the world, not to fiddle with spreadsheets.

The rules are very straightforward. Your PC has four attributes and four combat attributes plus four careers, all of which are ranked from 0 – 3 at the start. Skills are resolved with 2d6+attribute+career vs. a target number of 9 with simple difficulty modifiers; combat is the same with combat attributes in place of careers. Careers are things like slave, noble, barbarian, hunter, priest etc. and offer a bonus equal to the rank of the career in attempts to perform activities that can plausibly be related to the careers. PCs also start with a boon and if they want flaws and more boons; these give a bonus or penalty die on the 2d6 roll (like advantages/disadvantages in D&D5e), and Hero Points that have a versatile range of possible uses to make your character more effective. Some of the boons are classic sword and sorcery – for example Battle Harness turns your loin cloth or chainmail bikini into medium armour without the combat penalties of medium armour, while Missing Limb is exactly that, and comes with the rule “the game master will penalize you where appropriate.” In combat weapons do d6 damage, sometimes with a penalty or bonus die, and armour absorbs a bit of that.

Those are the whole rules – now you don’t really need to buy the book. Unless you want to enjoy the full richness of the boons and flaws and the deeply entertaining magic system, which really makes this game stand out. Magic is divided into four levels: cantrips and level 1-3 spells. Wizards have about 10-14 arcane power to spend, and spells come at increasing cost, ranging from 1-2 points for cantrips up to about 15 for level 3 spells. Wizards can reduce the cost of spells by meeting requirements, such as visible technique or taking a wound. These requirements grow in seriousness as the level of the spell increases, until at level 2 they encompass things like human sacrifice and serious injury. Level 3 spells (which can include making mental slaves and causing earthquakes) require a permanent point of arcane power to be lost. The spells themselves aren’t described – they’re up to the players and GM to negotiate – but examples are given to help with deciding the appropriate level of the spell. Also different levels of spell recuperate lost power at different rates – cantrips twice a day, level 1 spells at midnight, and level 2-3 spells just once a lunar cycle. This means that a wizard can start the game with a stupendous amount of power, but can’t use it often across a campaign. In my adventure our wizard used a couple of cantrips, one level 1 spell, recovered some of those points at midnight, then burnt all remaining points on a single level 2 spell. This means that having started the adventure with 14 points of arcane power he finished it with 0 points, and would only regain 8 of them within a day – another four would take up to a month to come back, and the remaining two up to two months. He also finished the adventure with the name of a demon tatooed on his chest and arm, seriously wounded and guilty of human sacrifice – all to power a great spell that failed.

There are also similarly simple but flexible rules for alchemists (who build things) and priests (who get divine favour). It’s perfectly possible to play these classes together too, so you can be a priest of some dark god, conjure evil magics, and build fire oil all at the same time. Monster rules are simple enough that four or six monsters can be fit into a two-page spread, including pictures and descriptions, and they are super easy to grasp. This makes the game really easy to pick up and run with in a short period of time – we started at 1pm, created characters from scratch and got through the entire adventure by 5:30 pm or so, going at a leisurely pace with lots of description and fluff.

This light-hearted and concise approach to rules really forces GM improvisation and encourages players and GM alike to plunge into the heroic, fast-and-loose style of sword and sorcery adventures. With very little time devoted to calculation, dice rolling and rules-faffing (even when new to the game) there is a lot of time and space for players to describe and improvise their PCs actions, and lots of time also for them to make heroic failures, make mistakes and retry things or go on different routes through the adventure. It really is a very good rule set for sword and sorcery, and a really good example of a game in which the rules, the writing style, the graphics and the setting all work together very well. This makes it a completely useless game if you want to pick it up and use the rules for anything else – you’d need to do some significant work to make a different setting feel right – and definitely not a game for people who like lots of crunch and detail in their gaming. But if you simply want to get rolling on an adventure with a barbarian, a druid and a beastmaster, then this is the game for you. It’s a refreshing, exciting contribution to the RPG world and a great sword and sorcery game, and I definitely recommend testing out if you want to play a swashbuckling barbarian campaign in a classic setting.