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

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

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

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

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

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

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Yesterday a group of US politicians who cannot control guns threatened to regulate Facebook.

During his testimony, representatives showed Mark Zuckerberg a picture of one of the fake news items that had been circulated on Facebook during the election, and asked him what he was going to do to stop this kind of material being circulated. Now, I may be a little wet behind the ears but I had always been led to believe that America valued free speech – that the country even had some kind of thing in its constitution protecting free speech – but apparently this idea goes out of the window where Facebook is concerned.

Organizations that have not yet been held accountable in the way Facebook was yesterday include Twitter, Fox News, Sinclair Broadcasting, or the New York Times. And somehow the leaders of Cambridge Analytica have also escaped harsh questioning by these sudden defenders of democracy. Why only Facebook? Presumably if Rupert Murdoch took the stand he could be shown a picture of some of the bullshit his channel broadcasts daily, and asked what he was going to do to stop it. Alex Jones, obviously, constantly broadcasts bullshit and yet hasn’t been told to stop it or face regulation. So why Facebook?

Facebook is at its heart a form of content provider that enables ordinary citizens to present their opinions to all their friends and associates at once, without anyone outside those groups being able to see or know. Twitter, Fox News, the Young Turks, all these organizations are publicly viewable, so that if they say something bad about someone or broadcast lies everyone sees it. But with Facebook, only your friends and the people you choose to address get to see it. Sure Mark Zuckerberg and his evil wizards see it but they don’t care. One important group of people who do not get to see it are our political representatives and leaders. They don’t know what’s going on out there in the wilds of Facebook, they can’t monitor it. Sure, they can pay a company like Cambridge Analytica to use that to their advantage but fundamentally Facebook removes content provision and debate from the grip of organizations like Fox News, CNN, or any organizations connected to any political donors. In the 2016 election it may have helped Republicans (and Russia), but there’s no guarantee that it will always be a powerful tool just for evil. And there’s no guarantee that only Russia will stay out of future elections. What if China decides to weigh in on the Democratic side in the next elections? Facebook is a wild card precisely because it liberates our voices from mass media. It also offers another powerful tool that scares governments – the power of spontaneous organization. This power is already being deployed by left wing organizations in America, and it’s not something that politicians will ever be comfortable.

China has a version of Facebook called Wechat, and the Chinese government is terrified of it. They maintain tight controls over it – one could say they regulate it, to use a term that America’s representatives understand – to ensure it can’t be used for wildcat demonstrations, to spread dissent, or to provide information the government doesn’t control. Of course the Chinese government got in at the development stage and now see it as a useful tool for monitoring public dissent and keeping track of public opinion, but they also keep a careful eye on everything that goes on there, because they don’t want it being used in the way that Facebook could be – to spread information the government can’t see and can’t address.

It’s probably a safe rule for life that if Republicans decide they want to regulate something, they’re not doing it in the best interests of ordinary people. Seeing these politicians rounding on Zuckerberg, you have to think that they aren’t attacking Facebook because they’re concerned about our privacy, but because they realize this tool is out of their control, and they’re scared of its huge potential to break the stranglehold of a few rich donors on the dissemination of information in America. Yes, Facebook needs to tighten up its privacy rules and be more responsible about how it handles data. But the election wasn’t stolen by Facebook alone, and censorship and regulation of Facebook is not the solution to this problem. It’s a rare occasion when a politician wants to censor things out of a genuine sense of social responsibility – they have too much skin in the game. What we saw yesterday was not a group of brave politicians taking on a huge monopoly to protect our privacy. It was a bunch of tyrants who want to shut down our freedom to disseminate information in an uncontrolled and unmonitored way.

Don’t let them!

The media this week are exploding with news that a company called Cambridge Analytica used shadily-obtained Facebook data to influence the US elections. The data was harvested by some other shady company using an app that legally exploited Facebook’s privacy rules at the time, and then handed over to Cambridge Analytica, who then used the data to micro-target adverts over Facebook during the election, mostly aimed at getting Trump elected. The news is still growing, and it appears that Cambridge Analytica was up to a bunch of other shady stuff too – swinging elections in developing countries through fraud and honey-traps, getting Facebook data from other sources and possibly colluding illegally with the Trump campaign against campaign funding laws – and it certainly looks like a lot of trouble is deservedly coming their way.

In response to this a lot of people have been discussing Facebook itself as if it is responsible for this problem, is itself a shady operator, or somehow represents a new and unique problem in the relationship between citizens, the media and politics. Elon Musk has deleted his company’s Facebook accounts, there is a #deleteFacebook campaign running around, and lots of people are suggesting that the Facebook model of social networking is fundamentally bad (see e.g. this Vox article about how Facebook is simply a bad idea).

I think a lot of this reaction against Facebook is misguided, does not see the real problem, and falls into the standard mistake of thinking a new technology must necessarily come with new and unique threats. I think it misses the real problem underlying Cambridge Analytica’s use of Facebook data to micro-target ads during the election and to manipulate public opinion: the people reading the ads.

We use Facebook precisely because of the unique benefits of its social and sharing model. We want to see our friends’ lives and opinions shared amongst ourselves, we want to be able to share along things we like or approve of, and we want to be able to engage with what our friends are thinking and saying. Some people using Facebook may do so as I do, carefully curating content providers we allow on our feed to ensure they aren’t offensive or upsetting, and avoiding allowing any political opinions we disagree with; others may use it for the opposite purpose, to engage with our friends’ opinions, see how they are thinking, and openly debate and disagree about a wide range of topics in a social forum. Many of us treat it as an aggregator for cat videos and cute viral shit; some of us only use it to keep track of friends. But in all cases the ability of the platform to share and engage is why we use it. It’s the one thing that separates it from traditional mass consumption media. This is its revolutionary aspect.

But what we engage with on Facebook is still media. If your friend shares a Fox and Friends video of John Bolton claiming that Hilary Clinton is actually a lizard person, when you watch that video you are engaging with it just as if you were engaging with Fox and Friends itself. The fact that it’s on Facebook instead of TV doesn’t suddenly exonerate you of the responsibility and the ability to identify that John Bolton is full of shit. If Cambridge Analytica micro target you with an ad that features John Bolton claiming that Hilary Clinton is a lizard person, that means Cambridge Analytica have evidence that you are susceptible to that line of reasoning, but the fundamental problem here remains that you are susceptible to that line of reasoning. Their ad doesn’t become extra brain-washy because it was on Facebook. Yes, it’s possible that your friend shared it and we all know that people trust their friends’ judgment. But if your friends think that shit is reasonable, and you still trust your friend’s judgement, then you and your friend have a problem. That’s not Facebook’s problem, it’s yours.

This problem existed before Facebook, and it exists now outside of Facebook. Something like 40% of American adults think that Fox News is a reliable and trustworthy source of news, and many of those people think that anything outside of Fox News is lying and untrustworthy “liberal media”. The US President apparently spends a lot of his “executive time” watching Fox and Friends and live tweeting his rage spasms. No one forces him to watch Fox and Friends, he has a remote control and fingers, he could choose to watch the BBC. It’s not Facebook’s fault, or even Fox News’s fault, that the president is a dimwit who believes anything John Bolton says.

This is a much bigger problem than Facebook, and it’s a problem in the American electorate and population. Sure, we could all be more media savvy, we could all benefit from better understanding how Facebook abuses privacy settings, shares our data for profit, and enables micro-targeting. But once that media gets to you it’s still media and you still have a responsibility to see if it’s true or not, to assess it against other independent sources of media, to engage intellectually with it in a way that ensures you don’t just believe any old junk. If you trust your friends’ views on vaccinations or organic food or Seth Rich’s death more than you trust a doctor or a police prosecutor then you have a problem. Sure, Facebook might improve the reach of people wanting to take advantage of that problem, but let’s not overdo it here: In the 1990s you would have been at a bbq party or a bar, nodding along as your friend told you that vaccines cause autism and believing every word of it. The problem then was you, and the problem now is you. In fact it is much easier now for you to not be the problem. Back in the 1990s at that bbq you couldn’t have surreptitiously whipped our your iPhone and googled “Andrew Wakefield” and discovered that he’s a fraud who has been disbarred by the GMA. Now you can, and if you choose not to because you think everything your paranoid conspiracy theorist friend says is true, the problem is you. If you’re watching some bullshit Cambridge Analytica ad about how Hilary Clinton killed Seth Rich, you’re on the internet, so you have the ability to cross reference that information and find out what the truth might actually be. If you didn’t do that, you’re lazy or you already believe it or you don’t care or you’re deeply stupid. It’s not Facebook’s fault, or Cambridge Analytica’s fault. It’s yours.

Facebook offers shady operatives like Robert Mercer the ability to micro-target their conspiracy theories and lies, and deeper and more effective reach of their lies through efficient use of advertising money and the multiplicative effect of the social network feature. It also gives them a little bit of a trust boost because people believe their friends are trustworthy. But in the end the people consuming the media this shady group produce are still people with an education, judgment, a sense of identity and a perspective on the world. They are still able to look at junk like this and decide that it is in fact junk. If you sat through the 2016 election campaign thinking that this con-artist oligarch was going to drain the swamp, the problem is you. If you thought that Clinton’s email practices were the worst security issue in the election, the problem is you. If you honestly believed The Young Turks or Jacobin mag when they told you Clinton was more militarist than Trump, the problem is you. If you believed Glenn Greenwald when he told you the real threat to American security was Clinton’s surveillance and security policies, the problem is you. If you believed that Trump cared more about working people than Hilary Clinton, then the problem is you. This stuff was all obvious and objectively checkable and easy to read, and you didn’t bother. The problem is not that Facebook was used by a shady right wing mob to manipulate your opinions into thinking Clinton was going to start world war 3 and hand everyone’s money to the bankers. The problem is that when this utter bullshit landed in your feed, you believed it.

Of course the problem doesn’t stop with the consumers of media but with the creators. Chris Cillizza is a journalist who hounded Clinton about her emails and her security issues before the election, and to this day continues to hound her, and he worked for reputable media organizations who thought his single-minded obsession with Clinton was responsible journalism. The NY Times was all over the email issues, and plenty of NY Times columnists like Maureen Dowd were sure Trump was less militarist than Clinton. Fox carefully curated their news feed to ensure the pussy-grabbing scandal was never covered, so more Americans knew about the emails than the pussy-grabbing. Obviously if no one is creating content about how terrible Trump is then we on Facebook are not able to share it with each other. But again the problem here is not Facebook – it’s the American media. Just this week we learn that the Atlantic, a supposedly centrist publication, is hiring Kevin D Williamson – a man who believes women who get abortions should be hanged – to provide “balance” to its opinion section. This isn’t Facebook’s fault. The utter failure of the US media to hold their government even vaguely accountable for its actions over the past 30 years, or to inquire with any depth or intelligence into the utter corruption of the Republican party, is not Facebook’s fault or ours, it’s theirs. But it is our job as citizens to look elsewhere, to try to understand the flaws in the reporting, to deploy our education to the benefit of ourselves and the civic society of which we are a part. That’s not Facebook’s job, it’s ours. Voting is a responsibility as well as a right, and when you prepare to vote you have the responsibility to understand the information available about the people you are going to vote for. If you decide that you would rather believe Clinton killed Seth Rich to cover up a paedophile scandal, rather than reading the Democratic Party platform and realizing that strategic voting for Clinton will benefit you and your class, then the problem is you. You live in a free society with free speech, and you chose to believe bullshit without checking it.

Deleting Facebook won’t solve the bigger problem, which is that many people in America are not able to tell lies from truth. The problem is not Facebook, it’s you.

 

She was right all along!

Today I discovered a really excellent article discussing how American and Soviet scientists and intelligence operatives reported on the collapse of the Soviet Economy, at the Texas National Security Review wtf. The basic thrust of the article is to understand whether researchers in the US national security complex, and associated academics, missed the collapse of the Soviet economy that began around 1966, or whether they were actually predicting the fundamental economic challenges that would eventually bring the Soviet Union to revolution and implosion. Apparently in the 1990s there was a bit of a thing where major newspapers and some politicians accused the CIA and the academics in its orbit of having completely missed the fact that the Soviet Union’s economy was failing, and having driven the US to go into debt peonage in order to achieve massive economic growth that wasn’t actually needed. The article cites a few of these critics saying basically that if the CIA had accurately predicted the trajectory of the Soviet Economy then Reagan wouldn’t have had to build up huge deficits to finance a massive military and economic expansion. Putting aside how ludicrous this is on its face – conservatives don’t care about deficits, for starters, and Reagan was building deficits for a wide range of political reasons – the article dismisses this by showing that in fact the CIA and its fellow travelers did in fact predict the collapse of the Soviet economy, in remarkable detail, and this 1990s criticism is all just silly revisionism.

This wasn’t the part of the article that interested me though – in fact I thought the discussion about why this is important was the weakest part of the article. What I enjoyed was the detailed description of the stages of economic growth and collapse of the Soviet Union, and the description of how Soviet theorists and planners saw it coming from the 1970s onward but seemed powerless to stop it. It tells a detailed and interesting tale of an economic program that seemed so successful (to both American and Soviet observers) in the 1950s, falling into stagnation in the 1960s and then into ruin in the 1970s. It’s a detailed and well-researched description of an economic system falling apart, and it shows that actually the economic analysts of the West really had their finger on the pulse here, and their theories about how economies should work and what was wrong with the Soviet economy proved to be correct in the end. This isn’t just American triumphalism that you might expect from the Texas National Security Review wtf, because the author cites a bunch of Soviet theorists who basically saw all the same issues that the Americans saw, and were unable to come up with any solutions that could work. The story of how they failed to come up with solutions is in itself fascinating, and something I will come back to when I discuss the Chinese communist approach to the same problems these researchers identified. But first I want to ask – did Western Marxists of the 1960s to 1980s see any of these issues in the Soviet economy, and if they didn’t, what does that say about their much-vaunted economic analysis skills?

The rise and fall of the Soviet planned economy

The article divides the Soviet economy into two rough stages, the first lasting from I guess the 1930s or the end of the war up until 1959, and the second starting somewhere in the mid 1960s and running to the fall of the Berlin wall. The first period was characterized by what the author calls extensive growth[1], which appears to be the process of throwing bodies at basic problems like building roads and shit. This period was characterized by rapid growth and social engagement(?), and seems like the kind of period when central planning would be no hindrance, or possibly even beneficial to growth. This is the period of increased steel production, more coal in more burners, the kind of basic economic problems being solved by simple and robust methods. But by the 1960s the Soviet Union had solved these basic problems and had moved into a more complex economy characterized by skilled labour working on more difficult problems of distribution and production, and it could no longer function by simply investing in new plant and equipment. At this point both American and Soviet analysts of the economy noticed that it needed to move to a more mixed structure, and it required engaged and committed professionals rather than hard working industrial hands. Central planning failed at this point, and the social and cultural conditions in the Soviet Union began to hold back growth and achievement, because you can’t get skilled professionals to work for just money alone, and the other cultural and social rewards of engaging in the mixed economy just weren’t there. The economy by this point had also become much more complex and had become too complicated for proper central planners to manage, but the lack of monetarization and small scale innovation and markets prevented it from finding local and specific solutions to complex problems. Both American and Soviet theorists noticed this problem, with the Americans wondering if the Soviet leadership would make radical changes to unleash new energy and creativity, and the Soviet thinkers wondering how to do this and complaining that they weren’t able to come up with solutions to match the problems they had identified[2].

At this point the author also describes a bunch of other problems overwhelming Soviet society that were identified in the west and discussed: declining life expectancy, increasing infant mortality, rampant alcoholism, and endemic corruption. The corruption was seen as a response to the challenges of an economy that simply wasn’t working and the cultural and social barriers to progress, and the alcoholism and infant mortality were seen as signs of a deepening social malaise that simply couldn’t be solved by a planned economy. This part of the essay – which to be fair is a long way in – was powerful stuff to read. It’s a fundamental given of modern development economics that when life expectancy or infant mortality go in the wrong direction, you’re getting something very wrong. That should be a sign that you need to get off your arse now and fix whatever mess you’re facing[3].

What did Western Marxists see in all this?

To their credit it appears that Soviet theorists and planners from the 1970s onward saw the writing on the wall and were at least aware of the need for change, even if the political structures of their economy prevented them from effectively implementing them. But how did western Marxists study their model society and how did they react? While we know a lot of western Marxists went their own way – especially after Hungary and Czechoslovakia – we know that many of the western communist and socialist parties continued to support the Soviet Union for a long time. One of the few remaining claims for which the people of this time get any credit is that while its political prescriptions may have failed, Marxism provided a cogent and insightful analysis of the economic problems facing capitalism, and a definitive description of how economic crises arise and are resolved. Presumably then it would have been able to analyze the problems within the Soviet Union, and presumably at least some of these Marxists would have had better access to information and data coming out of the Soviet Union than did the CIA.

So what did they do with it? Did they see the crisis the way their Soviet colleagues did? I have dug around online and can’t find anything about Marxist critiques of Soviet economic ideas at that time except for this review of a book on Marxist critiques of Soviet economics, that suggests the book is not a comprehensive review of what was said and written in that time. I certainly can’t find any evidence of a famous critical review of the problems facing Soviet industry. One would think that at least in the post-Vietnam era, perhaps in the 1970s, some of the Marxists of the New Left would have been feeling liberated enough to consider critically whether the Soviet Union was going in the right direction. At this time left wing movements in the west had started looking to national liberationist movements in Africa and latin America for inspiration, and these movements were typically less economically and ideologically hidebound than the Soviet Union, though often still dependent on it for economic and military support, so one would think western Marxists would have been able to engage more critically with Soviet economic ideas through these movements. But I can’t see much evidence that they did. What were they doing during this time? Is there a cruel irony where Soviet theorists were applying western market economics to critique Soviet economic systems, while western Marxists were applying rigid Marxist principles and missing the entire point? Were CIA academics more closely engaged with Soviet economic data than the Soviet Union’s supposed allies in the American left? I can’t find any information about this online, and I’m wondering.

How did China learn from Soviet failure?

The article also mentions that Soviet leaders tied economic growth directly to the ideological success of their project. They figured that people would be willing to make political and cultural sacrifices to the revolution provided they saw economic progress, and could look forward to a future utopia, but from 1970 on the economy was stagnating and so they were offering the people decades of austerity and asking them to commit to a political program that offered no future. This fundamental bargain – freedom in exchange for development – seems to me to be at the heart of the Chinese political program, and to have been a huge success for them: basically, so long as everyone’s economic lot continues to improve, the Chinese communist party assumes that the population will tolerate limits on expression, political activity and assembly. It’s a deal that has worked for them so far, and it seems to be at the core of their political program. But it failed in the Soviet Union, so how did Chinese leadership respond to this?

This is another topic that is very hard to assess for a non-expert just using random internet searches. How did China respond to the Soviet Union’s stagnation? Is there a body of work, in Chinese, by Chinese planners and intellectuals, interpreting the Soviet Union’s failure in terms that could be used to improve China’s economic and social performance? Did the 100 Flowers movement or the Cultural Revolution stem from some recognition that Soviet ideological strictness was stopping economic growth and interfering with the basic bargain? I found this critical text from Mao that suggests Mao understood that economic growth cannot be about just industrial development, and that commodity exchange (i.e. free markets of some kind) are essential. But it’s very hard to read – this language is like nothing from standard public health text books! – and it obviously requires a heavy knowledge of pre-existing Maoist and Stalinist theory. For example, Mao repeatedly contrasts the Chinese communist party’s attitude towards peasants with the Soviet party’s, and finds Stalinist thought lacking on this issue that doesn’t make any sense to me.

But it seems to me that the Chinese communist party must have done something right. Under Mao they also went through a period of heavy “extensive” growth, but then under Deng Xiaoping they introduced market reforms that enabled their economy to adapt to its growing complexity, and it is now generally accepted that China runs a mixed market economy that has the flexibility to respond to new economic challenges while retaining the central planning that should, I guess, ideally be able to manage potential crises and balance competing interests. China has also not seen any period of stagnation in health markers – quite the opposite! – and seems to be much better at incorporating foreign capital and foreign ideas into its market (the original article makes the point that the Soviet Union found it very hard to import new technologies, and suffered in productivity as a result). So I wonder – was Chinese communism always more open to foreign ideas and to critical reinterpretation of basic principles? Did they see what was happening in the Soviet Union and think about alternatives earlier and more aggressively? In his Critique of Stalin’s Economic Problems of Socialism in the USSR Mao repeatedly returns to the problem of commodity production, and seems to be much more open to market ideas than the Soviets (in his own words), but then at the same time I think he was presenting Stalinism as a betrayal of Marxism for being too westernized or something. So how was China interpreting Soviet struggles? China shows no signs of economic slow down or of economic failure, though of course it is increasingly vulnerable to crashes and crises of a capitalist kind, so it’s not as if it has developed a perfect mixed economy. Did Deng Xiaoping and his successors learn from the Soviet Union, and how? And if so why was their communism open to change but Soviet communism was not? For example, the article presents corruption as a fundamental and unresolved problem of the Soviet Union, possibly connected directly to its economic and political stagnation, but we know that the Chinese government has made fighting corruption an important symbol of progress and has genuinely tried to stamp out the worst of it. Why and how did they make these decisions, and to what extent were their policy ideas driven by reaction to Soviet failure, or to western criticism?

A final note

This has been a blogpost only of questions – I don’t know anything about these issues, but I find them very interesting. I think I have said before on this blog that I think China’s future progress offers a key challenge to capitalist market democracy. Until now the only real challenge to the orthodoxy of western capitalist democracy arose from the Soviet Union, and it was a dismal failure (as is its gangster successor). But if China can make one party non-democratic Chinese communism successful, then it will offer a real alternative to capitalist democracy. In the past I have said that China needs to negotiate a series of complex challenges but that if it does it may prove its system a viable alternative to capitalist democracies. I think it’s safe to say it has shown itself to be a much better alternative development model than Russian communism, which when you’re coming from the background Chinese communism was coming from is a pretty big claim to success. But now it has moved into the intensive development phase identified in the linked article at the Texas National Security Review wtf, the question is whether it will continue to adapt in the way it needs to to show that its political model can deliver the economic boons that its fundamental contract demands. This question is further complicated by the abolition of term limits and the possibility that Xi Jinping is becoming a new Mao[4], which could undo all the gains of the past 10 or 20 years and return China to a period of madness or Soviet scleroticism[5]. I guess also the lessons of Soviet history are less important to Mr. Xi than they were to Mr. Deng, and Mr. Xi faces an environment that is in some ways much less challenging (development is complete), but also much more challenging (Trump!) Are Chinese planners moving on from the lessons of Soviet failure to the lessons of capitalist failure?

I think it’s possible that we are seeing a new era of failure in American capitalist democracy, and there are many countries in Africa that are desperate for political and economic development models at a time when China is becoming increasingly assertive about the rectitude of its own model. By looking at how previous systems have learnt from their mistakes, perhaps we can see how the Chinese government will adapt to future challenges, and also how the American government will – or won’t – learn from its own litany of errors. How will this affect development in Africa, and how will it affect the response of the big economies to the fundamental environmental and economic challenges that threaten to destroy us all? I think we need to look to China for the answers to many of these questions, and in seeing how previous regimes learnt about their own and their enemies’ weaknesses – and how they failed to adapt – perhaps we can see where our current leadership are going to take us, and worse still – how they are going to fail us.

 


fn1: It’s possible that in reporting the author’s work I will significantly dumb it down, so if any descriptions of what the author wrote seem trite or simplistic please blame me, not him

fn2: These theorists were operating in the post-Stalin era, which I guess was freer, but I hadn’t realized so much self-critical work was allowed in the Soviet Union during Khruschev and Brezhnev. But it appears that there was no translation of critical thought into action, even where it was tolerated.

fn3: Modern America is facing a challenging problem along these lines, of declining life expectancy due to middle-aged mortality, increasing maternal mortality, and growing inequality in infant mortality. Is this a sign that America’s economy is going the same way as the Soviet Union?

fn4: I think he’s not, but if he does then I think this shows a fundamental and important instability in these one party systems, that they don’t just produce occasional madmen – they return to them. The madman could be the stable attractor in these systems. But if, for example, Xi goes through three terms, China continues to develop and liberalize and then he retires, what does that tell us?

fn5: Though it’s worth remembering that even under Mao China made huge progress, probably because it was in this extensive phase of development where progress is easy if you have strong central government and central planning

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…

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.