UPDATE: Dr. Monnat has left a comment pointing out that I made a major error in reading her methods (I assumed she used non-standardized rates but in the methods she specifies that she did). So I have removed one criticism of her paper and modified another about regression. This doesn’t change the thrust of my argument (though if Dr. Monnat is patient enough to engage with more of my criticisms, maybe it will!)

Since late 2016 a theory has been circulating that Donald Trump’s election victory can be related to the opioid epidemic in rust belt America. Under this theory, parts of mid-West America with high levels of unemployment and economic dislocation that are experiencing high levels of opioid addiction switched votes from Democrat to Republican and elected Trump. This is part of a broader idea that America is suffering an epidemic of “deaths of despair” – deaths due to opioids, suicide and alcohol abuse – that are part of a newfound social problem primarily afflicting working class white people, and the recent rapid growth in the rate of these “deaths of despair” drove a rebellion against the Democrats, and towards Trump.

This theory is bullshit, for a lot of reasons, and in this post I want to talk about why. To be clear, it’s not just a bit wrong: it’s wrong in all of its particulars. The data doesn’t support the idea of a growing death rate amongst white working class people; the data does not support a link between “deaths of despair” and Trump voting; there is no such thing as a “death of despair”; and there is no viable explanation for why an epidemic of “deaths of despair” should drive votes for Trump. The theory is attractive to a certain kind of theorist because it enables them to pretend that the Trump phenomenon doesn’t represent a deep problem of racism in American society, but it doesn’t work. Let’s look at why.

The myth of rising white mortality

First let’s consider the central framework of this story, which is the idea that mortality rates have been rising rapidly among middle-aged whites in America over the past 20 years, popularized by two economists (Case and Deaton) in a paper in PNAS. This paper is deeply flawed because it does not adjust for age, which has been increasing rapidly among white Americans but not non-white Americans (due to differential birth and migration patterns in earlier eras). Case and Deaton studied mortality in 45-54 year old Americans, differentiating by race, but failed to adjust for age. This is important for surprising reasons, which perhaps only epidemiologists understand, and we’re only figuring this out recently and slowly: ageing is happening so fast in high-income countries that even when we look at relatively narrow age categories we need to take into account the possibility that the older parts of the age category have a lot more people than the younger parts, and this means that even the small differences in mortality between say 53 year olds and 45 year olds can make a difference to mortality rates in the age category as a whole. If this seems shocking, consider the case of Japan, where ageing is so advanced that even five year age categories (the finest band of age that most statistical organizations will present publicly) are vulnerable to differences in the population. In Japan, the difference in the size of the 84 year old population to the 80 year old population is so great that we may need to adjust for age even when looking at narrow age categories like 80-84 years. This problem is a new challenge for epidemiologists – we used to assume that if you reduce an analysis to a 10 or 15 year age category you don’t need to standardize, because the population within such a band is relatively stable, but this is no longer true.

In the case of the Case and Deaton study the effect of ageing in non-hispanic white populations is so great that failure to adjust for it completely biases their results. Andrew Gelman describes the problem  on his blog and presents age-adjusted data and data for individual years of age, showing fairly convincingly that the entire driver of the “problem” identified by Case and Deaton is age, not ill health. After adjustment it does appear that some categories of white women are seeing an increasing mortality rate, but this is a) likely due to the recent growth of smoking in this population and b) not a likely explanation for Trump’s success, since he was more popular with men than women.

White people are dying more in America because they’re getting older, not because they have a problem. I happen to think that getting older is a problem, but it’s not a problem that Trump or anyone else can fix.

The myth of “deaths of despair” and Trump voting

Case and Deaton followed up their paper on white mortality with further research on “deaths of despair” – deaths due to opioid abuse, suicide and alcohol use that are supposedly due to “despair”. This paper is a better, more exhaustive analysis of the problem but it is vulnerable to a lot of basic epidemiological errors, and the overall theory is ignorant of basic principles in drug and alcohol theory and suicide research. This new research does not properly adjust for age in narrow age groups, and it does not take into account socioeconomic influences on mortality due to these conditions. But on this topic Case and Deaton are not the main offenders – they did not posit a link between “deaths of despair” and Trump voting, which was added by a researcher called Shannon Monnat at Pennsylvania State University in late 2016. In her paper, Monnat argues for a direct link between rates of “deaths of despair” and voting for Trump at the county level, suggesting that voting for Trump was somehow a response to the specific pressures affecting white Americans. There are huge flaws in this paper, which I list here, approximately in their order of importance.

  • It includes suicide: Obviously a county with high suicide mortality is in a horrible situation, which should be dealt with, but there is a big problem with using suicide as a predictor of Trump voting. This problem is guns. Uniquely among rich countries, the US has a very high prevalence of gun ownership and guns account for a much larger proportion of suicides in America than elsewhere – more than half, according to reputable studies. And unfortunately for rural Americans, the single biggest determinant of whether you commit suicide by gun is owning a gun – and gun ownership rates are much higher in counties that vote Republican. In America suicide is a proxy for gun ownership, not “despair”, and because gun-related suicide depends heavily on rates of gun ownership, inclusion of this mortality rate in the study heavily biases the total mortality rate being used towards a measure of gun ownership rather than despair.
  • It uses voting changes rather than voting odds: Like most studies of voting rates, Monnat compared the percentage voting for Trump with the percentage voting for Romney in 2012. This is a big flaw, because percentages do not vary evenly across their range. In Monnat’s study a county that increased its Republican voting proportion from 1% to 2% is treated exactly the same as a county that went from 50% to 51%. In one of these counties the vote doubled and Trump didn’t get elected; in the other it increased by 2% but Trump got elected. It’s important to account for this non linearity in analysis, but Monnat did not. Which leads to another problem …
  • It did not measure Trump’s success directly: In a first past the post electoral system, who wins is more important than by how much. Monnat used an ordinary least squares model of proportions voting Trump rather than a binomial model of Trump winning or losing, which means that meaningless small gains in “blue” states[1] had the same importance as small gains in “red” states that flipped them “blue”. This might not be important except that we know Trump lost the popular vote (which differences in proportions measure) but won the electoral college (which more closely resembles binary measures of win/lose). Not analyzing binary outcomes in a binomial model suggests you don’t understand the relationship between statistics and the political system you live in, i.e. your analysis is wrong.
  • It did not incorporate turnout: A 52% win for Trump can reflect two things – a change in attitude by 2% of the voters, or a non-proportionate increase in the number of people who chose to turn out and vote. If you analyze proportions (or differences in proportions) you don’t account for this problem. In addition, you don’t adjust for the overall size of the electorate. If you analyze proportions, an electorate where 52 people voted Trump and 48 people voted Clinton is given the same weight as an electorate where 5200 people voted Clinton and 4800 people voted Trump. If you use a proper binomial model, however, the latter electorate gets more weight and is implicitly treated as more meaningful in the assessment of results. A reminder of what is fast becoming a faustusnotes rule: the cool kids do not use ordinary least squares regression to analyze probabilities, we always use logistic regression.
  • It did not present the regression results: Although Monnat reports regression results in a footnote, the main results in the text are all unadjusted, even though in at least some states the impact of economic factors appears to eliminate the relationship with mortality rates. Given that people who own guns are much much more likely to vote Republican, and the main predictor variable here incorporated suicide, adjustment for gun ownership might have eliminated the effect of “deaths of despair” entirely. But it wasn’t done as far as I can tell, and wasn’t shown.
  • It did not adjust for trends: Monnat openly states in the beginning of the paper that “deaths of despair” have been rising over time but when she conducts the analysis she uses the average rate for the period 2006-2014. This means that she does not consider the possibility that mortality has been dropping in some counties and rising in others. A mortality rate of 100 per 100,000 could reflect a decline over the period 2006-2014 from 150 to 50 (a huge decrease) or an increase from 25 to 175. We don’t know, but it seems likely that if “deaths of despair” is an issue, it will have had more influence on electoral decisions in 2016 in counties where the rate has risen over that time than where it has declined. There are lots of policy reasons why the death rate might have increased or decreased, but whether these reflect issues relevant to Republican or Democrat policy is impossible to know without seeing the distribution of trends – which Monnat did not analyze[2].

So in summary the study that found this “relationship” between “deaths of despair” and voting Trump was deeply flawed. There is no such relationship in the data[3].

There is no such thing as a “death of despair”

This study has got a fair bit of attention on the internet, as have the prior Case and Deaton studies. For example here we see a Medium report on the “Oxy electorate” that repeats all these sour talking points, and in this blog post some dude who fancies himself a spokesperson for ordinary America talks up the same issue. The latter blog post has some comments by people taking oxycontin for pain relief, who make some important points that the “deaths of despair” crew have overlooked. To quote one commenter[4]:

I too am a long time chronic pain sufferer and until I was put on opiate medications my quality of life was ZERO. I’ve heard horror stories of people actually being suicidal because they can no longer deal with the constant pain. It took me two years before I realized I could no longer work as an account manager with a major telecom company. I was making decent money but leaving work everyday in pain. I finally started going to a pain management doctor who diagnosed me with degenerative disc disease. I had to go on medical leave and now am on SSDI. My doctor prescribed me opiates in the fall of 2006 and I’ve been on them ever since. I have to say, I totally AGREE with you. I don’t know how I would be able to manage without these medications. At least I’m able to clean my house now and now without being in horrible pain. I don’t know what I would do if suddenly I was told I could no longer be prescribed opiates.
Who is someone that will champion those of us who legitametly need these medications? Do we write to our senators?? I sure hope Trump takes into consideration our cases before kicking us all to the curb!

This person (and others) make the valid point that they are taking pain medication for a reason, and that they were in despair before they got hooked on opioids, not after. Unfortunately for these commenters, we now have fairly good evidence that opioids are not the best treatment for chronic pain and that they are very, very dangerous, but regardless of whether this treatment is exactly the best one for these patients they make the valid point that it is the treatment they got and it works for them. To use an Americanism, you can take the opioids from their cold dead hands. In stark contrast to other countries, a very large proportion of America’s opioid deaths are due to prescription drugs, not heroin, reflecting an epidemic of overdose due to legally accessible painkillers. It’s my suspicion that these painkillers were prescribed to people like the above commenter because they could not afford the treatment for the underlying cause of their pain, because America’s healthcare system sucks, and these people then became addicted to a very dangerous substance – but in the absence of proper health insurance these people cannot get the specialist opioid management they deserve. America’s opioid epidemic is a consequence of poor health system access, not “despair”, and if Americans had the same health system as, say, Frenchies or Britons they would not be taking these drugs for more than 6 months, because the underlying cause of their condition would have been treated – and for that small minority of pain patients with chronic pain, in any other rich country they would have regular affordable access to a specialist who could calibrate their dose and manage their risks.

The opioid death problem in America is a problem of access to healthcare, which should have been fixed by Obamacare. Which brings us to the last issue …

There is no theory linking opioid addiction to voting Trump

What exactly is the theory by which people hooked on oxycontin are more likely to vote Trump? On its face there are only two realistic explanations for this theory: 1) the areas where oxycontin is a huge problem are facing social devastation with no solution in sight, so vote for change (even Trump!) in hopes of a solution; or 2) people who use drugs are arseholes and losers. Putting aside the obvious ecological fallacy in Monnat’s study (it could be that everyone in the area who votes for Trump is a non-opiate user, and they voted Trump in hopes of getting the druggies killed Duterte-style, but the data doesn’t tell us who voted Trump, just what proportion of each area did), there are big problems with these two explanations even at the individual level. Let’s deal with each in turn.

If areas facing social devastation due to oxycontin are more likely to vote Trump, why didn’t they also vote Romney? Some of these areas were stronger Obama voters in 2012, according to Monnat’s data, but opioid use has been skyrocketing in these areas since 2006 (remember Monnat used averages from 2006-2014). The mortality data covers two election cycles where they voted Obama even though opioid deaths were rising, and suddenly they voted Trump? Why now? Why Trump and not Romney, or McCain? It’s as if there is something else about Trump …

Of course it’s possible that oxycontin users are racist arseholes – I have certainly seen this in my time working in clinics providing healthcare to injecting drug users – but even if we accept such a bleak view of drug users (and it’s not true!) the problem with this theory is that even as opioid use increases, it remains a tiny proportion of the total population of these areas. The opioid users directly cannot swing the election – it has to be their neighbours, friends and family. Now it’s possible that a high prevalence of opioid use and suicide drives people seeing this phenomenon to vote Trump but this is a strange outcome – in general people vote for Democrats/Labour in times of social catastrophe, which is why they voted Obama to start with – because he promised to fix the financial crisis and health care. There has to be some other explanation for why non-opioid using people switched vote in droves to Trump but not Romney. I wonder what it could be?

American liberals’ desperate desire to believe their country is not deeply racist

The problem is, of course, that Trump had a single distinguishing feature that no one before him in the GOP had – he was uniquely, floridly racist. Since the election this has become abundantly clear, but for Donnat writing in late 2016 I guess it still seemed vaguely plausibly deniable. But the reality is that his single distinction from all other GOP candidates was his florid racism. Lots of people in America want to believe that the country they live in – the country that just 150 years ago went to war over slavery, and just 50 years ago had explicit laws to drive black people out of the economic life of the nation – is not racist. I have even recently seen news reports that America is “losing its leadership in the movement for racial equality.” No, dudes, you never showed any leadership on that front. America is a deeply racist nation. It’s racist in a way that other countries can’t even begin to understand. The reason Trump won is that he energized a racist base, and the reason his approval remains greater than 30% despite the shitshow he is presiding over is that a large number of Americans are out-and-out fascists, for whom trolling “liberals” and crushing non-whites is a good thing. That’s why rural, gun-owning Americans voted for Trump, and if the data were analyzed properly that fact would be very clear. Lots of people in America want to believe second- or third-order causes like the rustbelt or opioids, but the reality is staring them in the face: it’s racism. Don’t blame people with chronic pain, blame people with chronic racism. And fix it, before the entire world has to pay for the vainglorious passions of a narrow swathe of white America.


fn1: I refuse to take the American use of “blue” and “red” seriously – they get scare quotes until they decide that Republicans are blue and Democrats are red. Sorry, but you guys need to sort your shit out. Get proper political colours and get rid of American Football, then you’ll be taken seriously on the world stage. Also learn to spell color with a “u”.

fn2: I’m joshing you here. Everyone knows that Republicans don’t give a flying fuck if an electorate is dying of opioid overdoses at a skyrocketing rate, and everyone knows that the idea that Republicans would offer people dying of “deaths of despair” any policy solutions to their problem except “be born rich” is a hilarious joke. The only possible policy intervention that could have helped counties seeing an increasing opioid death rate was Obamacare’s Medicaid expansion, and we know republicans rejected that in states they controlled because they’re evil.

fn3: Well, there might be, but no one has shown it with a robust method.

fn4: I’m such a cynic about everything American that I really hope this commenter isn’t a drug company plant…

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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.

The New England Journal of Medicine appears to have plunged deep into the debate on health insurance reform since Trump was elected, and in its 9th March issue has a series of articles and opinion pieces on Obamacare’s effects. This includes a piece pointing out that Obamacare expanded access to treatment for substance addiction, including opioid addiction (a big and growing problem in the US at the moment) and also a research article examining the impact of the medicaid expansion on specific health and health financing outcomes (the findings: it was broadly very positive). It also has a short research article examining the claim that the individual insurance markets have been thrown into a death spiral by the poor design of the law.

This claim has been going around for about a year now, and is generally based around the fact that some insurers have left some markets, and in some cases blamed Obamacare for their decision. For example, Zero Hedge made this claim in 2015, and the National Review took it up in July 2016. Articles discussing the alleged failings of the exchanges typically point to the withdrawal of big companies such as Aetna from some exchanges, suggesting that these companies are withdrawing because the fundamental dynamic of the exchanges prevents them from making a profit. This is important in the US context because for people earning above 138% of the federal poverty line who do not have employer-based insurance, the best and most efficient way for them to get insurance coverage is through a marketplace called an exchange, which is a special clearinghouse for selecting Obamacare-compliant insurance plans that is set up either by your state or by the federal government if your state refused to cooperate with the law. (An example of a generally well-liked exchange in a Republican-run state is Kentucky’s Kynect exchange). Obamacare’s defenders have pointed out that some consolidation is natural in markets when they change, and that new entrants or changing business practices will naturally force some businesses to fail or leave – that’s capitalism! Under this defense, the exchanges are working as intended and there’s nothing to worry about, except that in some smaller states this process may lead to a collapse of competition as only one or two insurers remain – a problem Clinton intended to fix by introducing a public provider in all markets if she won the presidential election.

The new article in the NEJM explores this issue in detail, by collecting data on all the plans that operated in exchanges from 2016 – 2017 and comparing those that left with those that remained. The authors make the particular point that once the exchanges opened the marketplace itself changed, and this had implications for insurers. They say:

In particular, the ACA’s insurance-market reforms required firms to develop and market new products that were attractive to low-income Americans who faced few access and pricing restrictions based on their underlying health status.

This means that organizations that are unfamiliar with these market conditions might struggle. They explain this as follows:

Anecdotal evidence supports the argument that the skills of particular insurers may not have been well suited to these marketplaces. Many of the exiting firms, such as UnitedHealth, have primarily covered enrollees in the self-insured–employer market, in which insurers provide administrative services and are not primarily responsible for bearing actuarial risk or for developing products targeting low-income consumers. In addition, many of the assets that have proven quite valuable in the self-insured market — such as a large national footprint that is attractive to multistate employers — may not be particularly useful in state-based individual insurance marketplaces.

They then present the results of their detailed assessment of the properties of those businesses that entered or left the market place, which they summarize in a table, reproduced as Table 1 below.

Table 1: The characteristics of leavers

This table makes clear that the insurers who left the marketplace in 2016 were offering more expensive plans with narrower networks and lower levels of behavioral health coverage; they were also much more likely to be bigger actors in the market for fully-insured people and much less likely to have experience in Medicaid markets. Overall this suggests that these companies left the exchanges not because the exchanges were flawed, but because these companies were not experienced in targeting low-income Americans who make up a large share of the individual insurance market, and having made a play at the individual market decided to get out when they were out-competed by organizations with more experience in the marketplace. The authors further note that actually a lot of the insurers active in the exchange markets are making a profit and are aggressively targeting new marketplaces – but these insurers tend to be smaller organizations with experience in Medicaid services, and don’t attract the same attention as the big employer-market insurers who failed.

This study isn’t definitive and has some limitations – for example it did not compare leavers in 2016 with historical leavers before Obamacare was implemented, and it only compared silver plans (which are the most popular but not necessarily the most profitable, I guess). Nonetheless, it gives the lie to the claim that Obamacare’s exchanges are not working, or at least suggests that they are working well enough to warrant tweaks and improvements rather than complete abolition. Once again the NEJM has shown that Obamacare’s opponents are long on rhetoric and short on facts, and that although this health care law is not perfect, it is doing okay and is certainly a significant improvement on the status quo. Let’s hope that whatever reforms proceed over the next two years will lead to improvements in the areas that are not working, and not wholesale destruction of America’s best chance at universal health coverage in half a century.

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?

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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!

Lynsey Hanley’s Respectable: The Experience of Class is a book that, in many respects, is about me. Hanley was born on a working class housing estate in Northern England in 1976, which makes her three years younger than me, and unlike most of her peers she left her working class origins to become middle class, by dint of getting a university education and a middle class job – just like me. In this book, Hanley describes the challenges of getting from there (the working class housing estate in 1980s Britain) to here (her current middle class position and lifestyle), and the challenges of living middle class when your upbringing was working class. Both aspects of this story are very important to me: escaping the bonds of working class life is a kind of cultural version of getting into orbit, requiring a huge personal effort and risk to get a single shot at hitting escape velocity, but the journey doesn’t end there. Getting into a new class, whether stolid middle class or some internationalist transcendental state, is not necessarily enough to free you from the old bonds of working class culture, and you can spend a long time – for me, perhaps a decade or more – feeling like a stranger in a new land, and even after you become to some extent familiar with the rules of your new world, you still feel like a fraud, and you still are stalked by this fear that it can all be taken away from you in an instant, that you’re just there on sufferance.

Hanley describes the social, cultural and spiritual challenges of both stages of this journey in rich and stunning detail in this book. She does not just describe the general challenges, though, but pinpoints specific, stunningly accurate details about the process that speak so powerfully to me of my own experience that it feels as if she has reached out from the pages into my own memory, and crafted an explanation for feelings and memories that I couldn’t pin down and understand until she shaped them. In both the general issues and in these details, she captures the essence of Britain’s class problems brilliantly.

On generalities, she describes the social and cultural barriers to a proper education for working class people in Britain, both those imposed on the class from outside (such as sub-standard schooling, economic barriers to progress, the difficulty of getting into grammar school for working class people) and those imposed on the working class by the working class – things like the way that working class children punish any of their own who show too much interest in school, the way that working class families don’t push their children to achieve or don’t consider the possibility of sending them to better educational opportunities (like grammar school) outside of their own experience, and the punishing assumptions they have about their own limited futures. For example, in describing the general atmosphere of working class culture in Britain in the 1980s, Hanley writes

Casual violence – symbolic, domestic and public – was endemic in the place and times in which I grew up. Casual racism was part of the fabric of daily conversation. Casual cynicism pervaded: a consequence of casual exploitation and casual displacement, which fed into people’s souls and manifested in their treating everything like one great frigging joke, because that’s how they felt they’d been treated their entire lives.

She follows this with a discussion of one of the motivating factors underlying this atmosphere, loss:

You may wonder what led to this collective conviction that there was no point. It might be argued that another primary aspect of working-class experience, a feeling which most defines a certain way of being in the world, is loss. Loss is everywhere: the loss of optimism as experience victory-laps hope; the loss of loved ones too soon to war, workplace accidents or to ill-health; the loss of a sense of home, going back generations as families move repeatedly in search of relief from poverty; the loss of close ties as families are broken up in a similar way by moves down south, to America, Canada, Australia; and the loss of a sense of place as families attempt to remain rooted in a changing environment, such as when a local works that once employed just about everyone in the area closes down.

This really struck at my own understanding of growing up poor in Britain – we were always moving looking for a better job or opportunities, then our family ties were broken by moving to New Zealand (and then Australia), and finally my older brother was taken from us by the state because of his continued involvement in crime, no doubt partly because his constant sense of dislocation stopped him having any sense of responsibility to the community he was victimizing. Hanley’s description of the economic, cultural and educational environment of England in the 1980s is exactly how I remember it, and her piercing insight into working class culture of that era really closely mirrors my own.

On the details, Hanley has a remarkable ability to isolate small incidents and moments that bring to life the challenges of trying to grow out of working class culture, and trying to get an education that will matter in an environment that is so inimically opposed to anyone standing out, as well as so committed to its own failings. For example, she describes a simple moment in her day like this:

While working in the library I go downstairs to Greggs to get a cup of tea … In the time takes to reach the bottom of the staircase I overhear a total of two sentences: one, by a woman speaking into a phone, is ‘FUCK OFF about your rizlas, I don’t wanna hear it,’ and the other, from a young man to a young woman, is ‘I can’t hear a FUCKing thing you’re saying with you walking ahead of me.’ My bones turn to glass again and I remember that often things do seem terrible just because of where you are. I’m thrown back into a world of ignorance and everyday violence – and if that sounds extreme, you needed to hear the way in which those ‘fucks’ were said: the desperation and life-fatigue of the first and the casual aggression of the second.

This is such a perfect, crystal clear description of an ordinary moment in the working class world that it might have been grabbed straight from my own everyday life. And it’s a reminder of how hard it is to operate in a different world – a world where people only swear when they’re surprised or angry, and never with the same venom – that you didn’t grow up in and have no familiarity with. Somehow you have to negotiate an entirely new set of manners and norms you don’t know anything about, at the same time as you’re still traumatized by and accustomed to an entirely different set of behavior that marks you out as trouble to everyone else.

This switch in background and norms is hard to adjust to, but it’s made even harder by the discovery of how much you were being held back from, and how much your own class is despised. Early in the book Hanley observes

The interesting thing about entering the middle class is that everything you have known is turned on its head. You go from being invisible to society, and yet at the same time the object of constant scrutiny and mistrust, to being at once anonymous and in possession of a voice. You are trusted to get on with things, and encouraged to go on endlessly about the way in which you do them

Everything about this sentence speaks so clearly to my own experience of growing up a working class boy and then stepping out to middle class life, and the different assumptions and expectations that are made about and of you when you are in one group compared to another. These changes can be like a slap in the face sometimes, in those moments when you realize just how much you were being denied. For example, when I first attended university – my big chance to step out of my class, though I didn’t realize it then – I was surrounded primarily by the children of the wealthy middle class in Adelaide, and I was shocked at the casual wealth of their lives and their casual assumptions about their rights and what they could and couldn’t do in public. These same middle class children refused to believe my achievements in high school, which were far superior to any of theirs, simply because my presentation as a poor kid from the country did not match their stereotypes. These children who had sailed through high school to an assumed berth in university, with the minimum of effort because their high quality schools ensured they got a good education and they had been groomed for progression from birth, were unable to comprehend that in my struggle to escape a terrible school I had worked hard every day and as a result got vastly better marks than them and won coveted awards – simply because of where I was from and what the signifiers of social class attached to me said about my potential. Eventually, of course, as I became more comfortable with the middle class world, I stopped wearing my working class history on my sleeve – changed my clothes, moderated my accent, dropped the swearing and rough language – and people stopped assuming limits to my achievement based on where I was from. Once I became more comfortable navigating the particular landscape of middle class life, people started assuming I was one of them, and a new world of opportunities and possibilities opened up to me.

But as comfortable as you become, you never truly forget or overcome that upbringing, and in discussing this Hanley brings up a recurring image that I think very well describes the crippling limitations the working class places on itself: the wall in the head. This is the barrier you build inside your own soul that stops you properly appreciating, and properly navigating, the middle class world you have entered. It can manifest in little ways, like an unwillingness to spend more than a certain amount of money on certain things, or in big ways like a fear of debt or an inability to manage money the way rich people do. It can also stop you grabbing opportunities that your peers take for granted, because it holds back your confidence and makes you timid about your own possibilities, and I think (Hanley doesn’t say this) in some ways it acts as a kind of PTSD, making you subject to a kind of existential fight-or-flight syndrome that makes you fearful of change and easily cowed into not taking risks. This is also part of the second trait of people who have moved up, which Hanley identifies: a fear that it will all be taken away from you in a moment and that you are living in your new, freer world on borrowed time. I think I still carry this fear inside me now, and I think most who have risen out of poverty to the middle class carry this feeling inside them. It can be a positive reminder of how far you have come, but it can also be a whip that strikes to stop you taking risks, or doing things that other middle class people do, because of a fear that you might be pushing your luck. This, for example, is why I did not travel in most of my 20s, even though most of my middle class peers had. Too risky!

Hanley manages to combine this political and economic analysis of the conditions facing the working class with an almost anthropological understanding of how these conditions manifest at a personal level to give a really engaging and powerful description of the process of social mobility, and its consequences for those who are able to climb the ladder. She combines her own insights and stories with the work of a wide array of sociologists who have studied class, in particular a book by Richard Hoggart, The Uses of Literacy, that describes the same phenomena in an earlier age, from a similar standpoint. In updating this book for the modern era she incorporates more pop culture, and I guess tells stories that are more relevant to people like me. But in weaving all this together she tells a story that is almost perfectly about me, and I guess about people like me. It is the first time I have ever seen anything about the experience of poor people taking advantage of social mobility, that combines a sensitive and genuine respect for the class she has left with a scathing criticism of that class, without blame or sneering. For that alone, this book was like an awakening for me, the first time I ever thought that my experience of fighting so hard to become a scientist was unusual or challenging or rare, and exactly what forces I had to overcome to do what I unthinkingly did when I was just 17 years old. There are, of course, some differences – she grew up in the industrial north while I grew up in the rural southwest, and she never had the good fortune to migrate to Australia, a country that determinedly set out to make sure that the economic and political barriers to social mobility were lowered considerably (at least for my generation). Australia doesn’t have the same class structure or the same rigid divisions as Britain, and it’s possible that for people who were born and raised in Australia this book has nothing to say. But for someone like me, with an experience grounded strongly in British class barriers, this book was a powerful and eye-opening attempt to describe my own life story – an amazing experience for anyone who sees their story told by someone else, in a sympathetic and detailed account of their own life that mirrors yours. It’s the first time it has ever happened to me, and I will always be grateful for it.

The book does have some flaws, and for me the main one is its poor structuring. The book as a whole and the chapters within it don’t really have a strong introduction/body/conclusion structure, so that at times it comes across more as a rambling series of anecdotes rather than a coherent story. Some chapters end abruptly without anything resembling a review or conclusion, leaving you wondering exactly what Hanley was trying to say, and then the next chapter doesn’t really flow from the previous one, starting almost on a completely separate topic without any coherent structure. For me this was not a problem, since I was reveling just in having my story told, but for someone reading from a more dispassionate or disinterested perspective it might render the book far less readable than it might otherwise have been. Also, for someone reading from outside the class – i.e from the perspective of a middle class person who might influence policy – the lack of coherence might conspire to hide any possible conclusions that can be drawn about what needs to be done. This is particularly problematic when combined with the book’s other main flaw – its lack of recommendations. I would have loved to have seen a conclusion that gives concrete ideas about what needs to be done to make social mobility easier, political and economic recommendations on the one hand for weakening the stultifying grip of Britain’s class culture , and on the other hand a kind of self-help guide for those of us who have managed to climb the ladder. I don’t know how we can climb that wall in our head (or break it down) or how to escape that cloying fear of failure that haunts us, and I wonder if Hanley does either – but if she does, I’d love for her to have shared it with me. These flaws mean that while the book may be a powerful explainer for those coming from inside the experience, and potentially a powerful guide to understanding barriers to social mobility for those in other classes who are trying to break them down, it may only provide a limited guide to what can be done, and may turn off others who aren’t already approaching the problem with a sympathetic ear. Coming from inside the story, I can’t really say how much damage these two flaws do to the book’s overall mission, and I hope that they aren’t too overwhelming for other readers.

I was recommended this book on the left wing blog Crooked Timber, in a post by Chris Bertram, who turned to it as part of his attempt to understand Brexit. I don’t know how much it would help with this but I think it definitely provides a strong insight into how people in the working class experience class, and how hard it is to escape. I have written before on this blog about how I think social mobility is not the solution to inequality that many people hope, and have instead suggested we need to make all work rewarding and dignified. Hanley seems to have absorbed the same lessons from her own experience of changing class, writing in the conclusion of the book

I hope that by using elements of my own experience I have illustrated some of the shortcomings of a political narrative that places the onus for social mobility – for ‘getting out’ of the working class and into the middle class – on to individuals, rather than making it possible for everyone, regardless of occupation, to live comfortably.

I agree with her on the importance of this, and I hope that in reading this book others – especially from those classes that actually influence policy – will see how challenging it is to be ‘socially mobile’, both in taking the chances offered and in living with the consequences, and will rethink the way British society is organized to stop people at the bottom living comfortably, and to force them to climb so high and so hard to get out of the class they’re in. It’s not exactly a manifesto for revolution or social change, but I hope if more people read this book they will come to understand through its eloquence and insight just how hard they make things when they demand that everyone in the working class be respectable, and the impossibility of making Britain a better place by social mobility alone.