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

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

What was known about Asperger

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

What Asperger actually did

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

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

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

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

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

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

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

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

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

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

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

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

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

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

These ideas are still with us

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

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

And here is Charles Murray in 1994:

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

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

 


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

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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.

What the American people have to look forward to

What the American people have to look forward to

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

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

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

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

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

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

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

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

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

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

This week’s Journal of the American Medical Association features an excellent article by Barack Obama, reviewing the implementation and outcomes of the Patient Protection and Affordable Care Act (“Obamacare”). Obviously large parts of this article were likely written by someone else, since Obama is too busy with his secret Muslim conspiracies to write a full paper, but some parts – particularly the part on why and how he implemented it – do seem to be written in Obama’s voice, which is nice to see. Vox has a brief report of the article, indicating that it is the result of a six-month Whitehouse review of the legislation and focusing on the implications of one of Obama’s recommendations (for a public option). Like most non-Americans I don’t find the recommendation of a public option to be particularly controversial or striking, so I’m not interested in revisiting it here. Rather, I’d like to briefly discuss the article’s findings on Obamacare’s achievements, take a moment to rant about what a terrible statistician Obama is, and look at some of the other conclusions he draws from his success. I will quote some parts of the article and put up one figure, but I won’t go quote too much or put up too many figures because JAMA probably wouldn’t like that. I would like to say that this is a very easy-to-read article and the choice of figures and data presentation is largely very strong – Obama certainly knows how to make a case. Also note the author affiliation: “President of the United States, Washington, DC”. Classic.

Reduction in the uninsured

In Figure 1 of the paper Obama presents the long-term trend in the proportion of Americans not covered by health insurance, and shows a huge drop after the implementation of Obamacare, from 15% to below 10% of the population. That is a huge achievement, which he states corresponds with roughly 20 million Americans receiving health insurance who would not have received it if Obamacare had not been passed. This still leaves about 30 million people without health insurance in 2015, a pretty shocking number for a developed country (in contrast, Japan has about 98% coverage and the UK about 100%). In Figure 2 Obama shows that the Medicaid expansion was responsible for a major reduction in the uninsured, by comparing the percentage drop in the uninsured in states that accepted the Medicaid expansion and those that didn’t. This drop in the uninsured increases with the proportion of people who had no insurance before the implementation of Obamacare: in a state that had 20% of its population uninsured in 2013, we see a 10% drop in the uninsured rate if the state accepted Medicaid, compared to 5% if it didn’t (these are percentage point drops, too, meaning that the proportion uninsured halved in the Medicaid state!) Obama doesn’t attempt to estimate the total number of people missing out on insurance due to the recalcitrance of the 21 states that refused to accept the Medicaid expansion, but I think the implication is obvious.

Obama’s sad statistics

Figure 2 annoys me because the straight lines shown in the plot are from an ordinary least squares regression of percentage point drop in uninsured against pre-intervention proportion of the uninsured. The straight line fit for non-Medicaid states is quite poor, because of course the relationship between percentage point drops and their starting point is non-linear. Obama would have been better served to take the logit transformation of the proportional drop, fitted a straight line model to that, and then back-transformed the resulting prediction to get two pretty s-shaped curves in his figure. I guess his article wasn’t subjected to JAMA’s usual rigorous peer review standards …

(In truth this isn’t a big deal in this case because the relationship in the data is so obvious that it doesn’t really matter how you handle it. My guess is that this figure was prepared by one of the people doing the review of Obamacare, and I would like to think that the people doing that review can do higher quality work than this!)

The three dimensions of coverage

The three dimensions of coverage

Mixed results on financial protection

Insurance is only good if it covers the services you need and offers financial protection. In health financing we talk about depth, height and breadth of coverage, which are depicted graphically in the figure above that I cribbed from an LSHTM course on financing health. Reducing the number of uninsured increases the breadth of coverage (the proportion of the population covered) but if this comes at the expense of the depth of coverage (which services are covered) or the height of coverage (the proportion of financial protection people receive) the overall benefits of the plan may be limited. Obama tackles these three dimensions in his paper, though he doesn’t use the WHO framework described in the figure above. Regarding depth, he states

Coverage offered on the individual market or to small businesses must now include a core set of health care services, including maternity care and treatment for mental health and substance use disorders, services that were sometimes not covered at all previously

Which indicates that Obamacare has forced minimum standards of coverage onto organizations that offer health insurance. This is something that people living in countries with robust universal health coverage (UHC) systems take for granted, and it’s really hard to imagine having to navigate a health insurance market where this isn’t the case – at the very least setting up a core set of covered health services reduces the risk of mistakenly choosing a health insurance package that doesn’t help you with the things you’re most likely to need it for. Obama’s language here implicitly suggests that the core package of services covered under Obamacare is an expansion of those in the previous system, but he doesn’t present any evidence that this is the case for all plans, or even in general – it could be that in adhering to these core requirements insurers have dumped some other coverage from their plans. I haven’t ever seen any research on how to assess the best services to include in a plan, or how to compare two plans that have quite different and non-overlapping benefits, so I don’t know how to assess this aspect of Obamacare (or if it can be assessed), but from the point of view of consumer protection having a guaranteed core of services seems like a good idea.

Obama's Figure 3

Obama’s Figure 3

On financial protection – the height of services – Obama makes a strong case that his legislation has been very protective. Figure 3 in the article, shown above, shows the trend in the proportion of workers enrolled in an insurance scheme that has no annual upper limit on the amount of out-of-pocket payments they must make. Out of pocket payments for health care are the main source of financial risk for individuals, and typically arise when someone has no health insurance (so must pay everything from their own money) or has health insurance with very high co-payments and deductibles, a common problem in the USA before Obamacare. Obamacare required insurers to put a cap on these out of pocket payments, and the effect on the proportion of workers exposed to unlimited financial risk is obvious in this chart. Unfortunately in a later figure we see that average out of pocket expenses haven’t changed much over time, suggesting that the annual limits that insurers placed on out of pocket payments were set high enough as to not effect the majority of such payments. To properly explore this issue we need to see data on health-related financial catastrophe, distress financing, and impoverishment due to health expenses, which to the best of my knowledge have never been adequately reported for the USA. We see some hints of this in other parts of the report, where Obama notes that the proportion of people not seeking care because they can’t afford it is down, and the average size of Medicaid debts is also down, but the picture here is incomplete. My suspicion is that a lot of healthy people have picked up bronze plans that offer them financial protection in only the most extreme cases, leaving them wearing significant costs for routine care. This isn’t in itself necessarily a problem, but to properly understand the financial protection and equity effects of the law we really need to see measures of who gets screwed by very high costs and how, rather than seeing trends in average costs.

Lessons from this policy battle

Obama concludes, unsurprisingly, that his policy has been highly effective, and I agree with this conclusion. It’s definitely not the best UHC plan out there, and even before it was rewritten by the Supreme Court and repeatedly undermined by Republicans it wasn’t a great plan, but it has achieved a lot and a lot of Americans are much better off for it. He states in the conclusion that he now wants people to accept it as the law of the land and move on to ways of improving it, but first he makes this comment about the challenges of working in American politics which gives some idea of how much of an achievement even this compromised package is:

The first lesson is that any change is difficult, but it is especially difficult in the face of hyperpartisanship. Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported. For example, they supported a fully funded risk-corridor program and a public plan fallback in the Medicare drug benefit in 2003 but opposed them in the ACA. They supported the individual mandate in Massachusetts in 2006 but opposed it in the ACA. They supported the employer mandate in California in 2007 but opposed it in the ACA—and then opposed the administration’s decision to delay it. Moreover, through inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation, Republicans undermined ACA implementation efforts. We could have covered more ground more quickly with cooperation rather than obstruction. It is not obvious that this strategy has paid political dividends for Republicans, but it has clearly come at a cost for the country, most notably for the estimated 4 million Americans left uninsured because they live in GOP-led states that have yet to expand Medicaid

Here he hasn’t gone into great detail about how the Supreme Court rewrote the Medicaid expansion part of his bill, and he has notably understated the effect of obstructionism on the Republicans, but his central point is clear: this legislation could have been better if Republicans would just have supported it, or contributed in any way at all to a constructive debate on health care. Five years have passed since the bill was first introduced to Congress, and Obama has had enough time to review its effects and write a JAMA article on it, and in all that time the Republicans have tried repeatedly to repeal it yet are still to come up with an alternative health care plan. Today they released their convention platform, and as reported by Vox it doesn’t include an alternative health care plan – in an election year. This is beyond juvenile politics, and in any other democratic polity a party that cannot come up with a coherent health policy would be treated as a joke. This is the background of Obama’s legislative efforts.

Finally, Obama makes the point that people working in health financing understand well: that UHC is about a pragmatic pathway to financial protection for everyone, not about an ideological commitment to a specific means of getting there. He says:

The third lesson is the importance of pragmatism in both legislation and implementation. Simpler approaches to addressing our health care problems exist at both ends of the political spectrum: the single-payer model vs government vouchers for all. Yet the nation typically reaches its greatest heights when we find common ground between the public and private good and adjust along the way. That was my approach with the ACA. We engaged with Congress to identify the combination of proven health reform ideas that could pass and have continued to adapt them since. This includes abandoning parts that do not work, like the voluntary long-term care program included in the law

and in this respect I also agree with him. I suspect that if the Republican party were a real political party and not a clown car, they would have recognized the importance of reform and accepted Obamacare as a practical model that protects the free market nature of the existing health system. For those Bernie dead-enders who refuse to accept compromise, nothing except a full single-payer public plan will do, and while this worked completely fine in Australia, Canada and the UK it just won’t make it in the USA, which is probably why those Berniebros find themselves in their current cul-de-sac. Obamacare is an artful example of the importance of compromise in making good health policy, and the value of practical planning over ideology. Shamefully for the Republicans and unfortunately for the country, it hasn’t been able (yet) to achieve its full promise. Obama made a few suggestions for how it can, but ultimately his particular recommendations are less important than the simple need for a return to rational policy-making by the Republicans. Whoever the next president is, she is going to want to begin tinkering with Obamacare to make it better, and hopefully the Republicans will by then have recognized that it is their responsibility to contribute positively to that process, for the good of all Americans.

I don’t see that happening, but like Obama, I can always hope …

Must hear and obey!!

Must hear and obey!!

This week I stumbled upon another one of many articles in the Guardian complaining about fat-shaming, which is apparently something society does unsuccessfully to try and force everyone to be skinny. In an interesting parallel, this week Rabbett Run has an article digging through the role of Big Tobacco in funding libertarians to talk up smoker-shaming. This “assault on smokers” is a common complaint of the Clarksons and Telegraph-letter-writers of the world: sure, smoking is bad for your health but the anti-tobacco movement has “gone too far” and now it shames and ostracizes smokers and treats them like second-class citizens (in the words of Rabbett Run’s libertarian scholar, they are parallel to the treatment of Jews in Germany!)

An interesting similarity of language exists between the anti-fat shamers and the anti- anti smokers. There is a lot of public debate about how to handle obesity, and a lot of it is denialism of varying forms:

  • Straight-up denialism, such as this book from one of the Lawyers, Guns and Money bloggers, which claims obesity is not harmful for health, the scientific research is wrong and there is nothing to fear. This crosses the political spectrum, but is usually also associated with suspicions about the diet and weight-loss industry and/or an ideology of personal health choices
  • Politically-motivated rejectionism, often feminist, which associates obesity concerns with body-normative biases and society’s obsession with controlling women’s appearance. An example of this is Fat is a Feminist Issue by Susie Orbach, which associates campaigns against overweight with historical attempts to control women’s appearance. These campaigners may deny the role of obesity in poor health (such as the Healthy at Every Size movement) or they may accept the increased risks and fall back on a logic of personal choice, but in either case these rejectionists are politically-motivated: their first concern is the ideological impact of scientific research on and public health campaigns against overweight, and this motivates their stance
  • Adaptationists, who think that it is too late to reverse trends to obesity, and/or that they are built into our society now, and so we are better off learning to adapt to these trends than try to undo them. In the medical field this manifests in a belief that we should find pharmaceutical solutions to the health challenges of obesity, rather than behavioral campaigns. This stream of thought is also common amongst anti-fat shamers and the Healthy at Every Size movement
  • First world shamers, who believe it is shameful of rich westerners to worry about eating too much when so many people in the world are starving. These deniers want us to accept that fatness is a sign of a stable and functioning society and something the world should (implicitly, usually) aspire to – similar to how some AGW denialists think that burning fossil fuels is an inevitable and necessary part of economic growth and something we should encourage the world to do, rather than trying to find alternative development paths. These first world shamers also usually ignore the fact that overweight and obesity is a heavily class-biased phenomenon in rich countries, and increasingly a problem of the poor only
  • Free choicers, who think that we should all be able to take any health risks we want if they don’t affect others, and who see obesity purely as a personal decision (i.e. fat people eat too much). Some of the adaptationists also take this view of fat as an entirely personal decision, and sadly so do a lot of public health policy-makers who want to fix the problem. Seeing obesity as a consequence of personal behavior inevitably means that public efforts to reduce prevalence of overweight will be seen as intrusive and restrictive of civil liberties, and enables these free-choicers to reframe the debate in terms of personal choices and freedom rather than the structural and social changes that are actually needed to reduce overweight. This argument is more potent when deployed in the obesity debate because it is much easier to claim that obesity doesn’t harm others
  • Skinny-shamers, the kind of hippy punchers of the anti-fat shaming movement, who see thinness as disgusting or at least present themselves in opposition to it. This fat and proud movement is distinctly political, though not necessarily associated with any party, and it is embedded in a broader cultural movement in the anglosphere towards rejecting any form of attention to appearance at all. This movement sometimes has an influence on the fashion world, especially in its attempts to redefine very thin and small models as wrong – it sometimes engages in its own form of shaming, attacking the skinny and small as wrong or ill
  • Anorexia bait-and-switchers, perhaps a subset of the fat-proud and feminist denialists, who associate campaigns against overweight with anorexia, and suggest that body-normative ideas drive young women to anorexia. In fact anorexia is a serious mental health problem not caused by social pressure or women’s magazines, and this link is spurious but it has a strong hold in popular culture, and is a powerful rhetorical device. Note that it also often relies on its own form of body-shaming, treating anorexic bodies as disgusting and accepting that they are deeply unhealthy, and often the spectrum of this body-shaming extends to women who are not unhealthy, just thin

Many of these types of obesity denialism seem to be similar in ideological composition to anti-vaccination or anti-AGW thinking. In AGW denial circles it’s common to read conspiracy theories about how the whole scare has been made up to transfer money and power to a clique; how it is cheaper and more effective to adapt than prevent; how attempts to mitigate AGW will lead to (and/or be driven by) restrictions on personal freedom. AGW denialists also often see AGW mitigation in terms of direct attacks on their personal choices rather than structural and cultural changes, for example in which they will lose individual direct choice over light bulbs and car makes, rather than seeing it in terms of industrial and community-level decisions such as changes in power generation or land use practices that no one individual can control. Arguments based on intervention in personal decision-making rather than group practices are much more amenable to conspiracy theories and assignment of nasty political motivations, and the obesity denial movement does have a fair share of such thinking.

In reality the battle against overweight and obesity cannot be won with individual changes: overweight and obesity arises only partially from personal choices, and a lot of it is driven by structural and social factors that individuals cannot change. You can’t make a decision to walk to work if your work is far away and there is no public transport; you can’t make a decision to eat healthily if there are no decent sources of fresh fruit and vegetables near your house, or if almost all the food you buy is poorly labelled and full of sugar. It’s also much much harder to stay thin if your job involves sitting for 8 hours a day, and personal decisions to do something personal to offset a structural factor are much harder to make than personal decisions that go along with that structural factor. Furthermore, cultural practices are insidious and hard to change: ideas about wasting food that come from a poorer time, types of food and eating practices are not easy to change by the time one is an adult steeped in a certain food culture. But because public health policy-makers cannot change broad structural factors outside of their discipline, like public transport and town planning, they have to focus on the things they can touch: personal behavior. This is easily construed as preaching or trying to restrict freedoms.

Of course fat shaming does happen in our societies but it’s not driven by health concerns: it’s another manifestation of a long-lasting and deeply-entrenched sexism in our society. It’s also a reflection of the fact that traditionally aesthetic values were of great importance, and people who deviated from certain aesthetic norms have been shamed for that. Compared to the way people with tattoos or men with long hair used to be treated, for example, fat shaming is nothing: no one obese ever got refused entry to Disneyland for being fat, for example. Public health campaigns do not, generally, utilize fat shaming as part of their repertoire, and the association of fat shaming with public health concerns about obesity is another example of denialism at work – and a very effective way to dampen the debate about what to do about this growing problem.

And make no mistake, it is a big problem. The continuing growth of overweight and obesity is going to have huge costs for health systems, and people who are proud to be fat now are not going to be so pleased with their personal health decisions when the musculoskeletal and cardiovascular problems start to bite in later life (when reversing the process is hardest). With the decline of smoking in the developed world, obesity is becoming the next big risk factor that will bring a wave of disease with it. Worse still, in many low- and middle-income countries overweight and obesity rates are also skyrocketing, but these countries have fragile health systems with weak financing that are not ready to manage a huge growth of chronic illness. This is a global problem, and denying it will delay the necessary steps to resolve it, leaving many countries facing an unexpected cost and health problems they aren’t prepared to deal with. Sound familiar?

I don’t think that obesity denialism is a product of Big Tobacco or Big Sugar, as was the anti-anti smoking lobby or AGW denialism. It also lacks a dimension of harm that the anti-vaccination movement carries with it (since fat kids can’t accidentally infect and kill other fat kids the way unvaccinated children can). But it has similarities with both, in terms of its scientific ignorance, the rhetorical tactics it deploys, and its blithe ignorance – or even celebration – of the problems it causes. The linked Guardian article is suggesting a need to add fat-shaming to the list of discriminatory activities that should be outlawed in Britain, which makes me think of the inclusion of “political” objections to vaccination in vaccination laws. Perhaps it’s time to start treating obesity denialism a little more seriously, before it gets a serious grip on our legislative and public health processes, making it harder for our societies to move out of a path that is ultimately not going to be good for us …

Vaccination policy through Republican eyes

Vaccination policy through Republican eyes

The recent outbreak of measles in the USA has brought on an epidemic of Republican anti-science blathering, this time focused on vaccination. First we had Chris Christie saying measles vaccination should be optional, then Rand Paul putting his libertarian principles where his mouth is and declaring all Americans should be free to give each other smallpox; now the National Review Online has stepped into the fray with the rather contradictory policy advice that vaccination obviously works but should be voluntary (and thus, in the case of measles, almost certainly be rendered useless).

Vaccination policy is one of those areas that is ripe for Republican chaos. As the National Review observes, it involves “elites” (a perjorative deployed in this case to describe doctors) making decisions about what parents should do, and pushing for strong laws to ensure that everyone does what they’re supposed to. Like public education, it is only of value if the overwhelming majority of people do what the “elites” want. In this case, we can calculate mathematically what proportion of the population need to do what they’re told in order to prevent the spread of disease and, unfortunately for libertarians everywhere, the required proportion for measles and whooping cough is so high as to require even strict religious types and conspiracy theorists to obey if we want to prevent everyone getting the disease. This article from the Bulletin of the WHO makes the case for herd immunity, which in the case of measles requires greater than 95% of the population be vaccinated. Allowing parental opt-outs is going to rapidly get the proportion of children vaccinated below this threshold, especially in a society where many people can’t afford medical care. This is particularly likely for measles, mumps and rubella, since the Andrew Wakefield scandal has put the fear of God (well, autism) into parents in the UK and the USA, leading to precipitous falls in vaccination rates for these conditions. Indeed, the UK is now experiencing endemic measles after a long period of only having imported cases, and recent epidemics can almost certainly be traced to the cohort of children who were not vaccinated in the years after the Wakefield scandal. Elimination of these diseases requires strong pressure for all parents to vaccinate their children, and in rare cases these children will experience usually minor side effects. We all literally have to take one for the team, because those black-helicopter “elites” at the WHO tell us to. It’s a Republican’s nightmare.

But Republicans never used to be so fragile about science. This rash of equivocal statements from potential presidential contenders and their lackeys in the media is a new phenomenon. I have a feeling that the Republicans are lurching slowly towards a new orthodoxy of denialism, to add to their creationism and global warming denialism: anti-vaccination ideology. I hope I’m wrong, but I have a suspicion that this next denialist lurch is going to be inevitable given three potent forces driving modern Republican political ideology: populist anti-government rhetoric, potent sexual morals, and a virulent anti-science culture.

The modern Republicans are steeped in anti-science through their long association with the tobacco lobby, anti-environmentalism in the service of corporate interests, and their deep commitment to global warming denialism. US libertarian and right-wing politics is notable for its foolish fixation on DDT built on a foundation of false attacks on Rachel Carson, its hatred of the clean air act, its increasingly fantasist opposition to the science of global warming, and its strict libertarian stance on smoking. Indeed, the link between these ideological strands is hardly surprising given that big tobacco has funded the network of climate denial and anti-environmentalist organizations for years. But as this web of denialism expands, and newer activists grow up and learn their trade in a political environment that is suffused with not just the rhetoric of anti-science activism but also with a deep disrespect for scientists and the scientific process, it is hardly surprising that the Republican political world will become vulnerable to new forms of anti-scientific crusade. Many Republicans seem to be opposed to any form of scientific research, not just that which directly threatens business. How can we forget Senator McCain’s derision for a study of the DNA of bears? It’s easy to imagine that the post-tea party Republican party is easily fooled by anti-science rhetoric posing as scientific critique.

I think this toxic atmosphere turned its sights on vaccination science proper for the first time when the HPV vaccine was introduced, and vaccination got its full attention for the first time. This happened because the HPV vaccine is aimed at a sexually transmitted disease, that is only harmful to women, and in order to prevent this disease one needs to vaccinate girls before they become sexually active. Somewhat alarmingly for those in our community who want to pretend that their daughters are all good little girls, the policy therefore requires vaccination at a surprisingly young age, the implication being that good little American girls might be getting laid rather early. This immediately drew the ire of the sexually conservative wing of the Republican party and associated organizations like the Family Research Council. Initial objections were based on sexual morality, but it entered Republican politics during the primary season for the 2012 presidential election. By this time arguments against the HPV vaccine had become more nuanced, as for example in this National Review piece where the author tries to argue that HPV is different to measles because it is intentionally transmitted and rare (wrong!) and questions why only girls get it, as if this is some evidence of a sexual conspiracy by liberals (in fact this policy is followed because the science suggests it is sufficient to prevent cancer, and more cost-effective). However, in the modern world debates on health policy inevitably require some kind of scientific rhetoric, so by the time of this primary season Michele Bachman had found the spurious scientific objection that it causes mental retardation. In four years opposition to the vaccine had gone from a purely sexual-morality-based principle to a general scientific critique of the safety of the vaccine and the validity and necessity of the policy. All these “science”-based arguments are wrong, but how is a modern Republican to know? They have a kneejerk distrust of scientists and they are so negative about science that it’s hard to believe they would understand or accept any science they read. So of course people who want to object to the vaccine on principle but feel the need to cloak their opposition in scientific rhetoric are going to be willing to believe any rubbish they’re fed.

Finally, overlaid on this mixture of christian anti-sex moralizing and distrust of science we have the libertarian arguments about agency and control over one’s individual choices. For most moderns, health continues to be seen as an individual choice, and decisions about healthcare are things that we take for ourselves when we are sick. Vaccination policy is the exact opposite of this: it concerns actions taken with our bodies when we are well to protect others. It’s all too easy for libertarians to fall prey to conspiracy theories and bad science where vaccination policy is concerned because it just doesn’t sit comfortably with their ideology. So the trifecta is complete, and the entire ideological sweep of the Republican party is vulnerable to anti-vaccination claptrap.

If my theory is correct, then we should expect to see more of this kind of rhetoric as Republican primary season heats up, and we should also expect to see the typical Republican approach to undoing long-standing laws they don’t like: administrative procedures to make them too difficult to enforce, followed by court challenges rather than direct political debate. If we start to see that happen then I think we need to throw vaccination into the large and growing dustbin of sane and rational policies that have become too tough for the Republican machine to handle – along with gun control, universal health coverage, and global warming. Once they take the step to anti-vaccination denialism, what bridge connecting them to the science community is left to burn?

Strange things are happening in Australian politics at the moment. The Federal government appears to be shooting itself in the foot with rocket launchers, and doing everything it can to become that rarest of entities, a one-term Federal government. There are many examples of the government’s reckless desire to consign itself to the dustbin of history, but most of them are beyond my ken. However, one that touches on an issue I’m vaguely familiar with – health – stands out as a particularly egregious example of policy-making stupidity, in which the government squandered a chance to implement a potentially important policy that would have improved the budget bottom line, then doubled down on an incredibly bad policy that is guaranteed to annoy essentially everyone. In an electorate with compulsory preferential voting and consistently high electoral turnout, this really is a recipe for electoral disaster – and completely avoidable.

The policy in question is the General Practice co-payment, and although it’s a politically tricky task – better governments have floundered over it – it has a sound public policy basis and with the right political guidance a new government riding high on popularity should be able to get this sort of thing introduced. That’s what first term governments in Australia do. So what went wrong?

A brief primer on Australian health financing

Very briefly, Australia’s health system is managed primarily through General Practitioners (GPs), family doctors in the USA, who are the first port of call for health concerns. In theory every time you visit you pay the GP and present the invoice to the government-run single payer health insurer, Medicare, who reimburse you a fixed rate depending on the type of service you received (this is called a rebate). Your GP can choose to charge you more than this rebate, in which case you have to wear the difference as a co-payment. Many GPs opt to provide a service called bulk billing, in which they don’t take cash from their patients but bill the government directly for only the rebate. This makes the service essentially free at the point of care for the patient, but reduces the amount of money the GP can make; it does however reduce the overhead for the GP, since they don’t need to manage a cash system in their office. GPs in Australia are essentially private health providers, claiming fees from a government single payer, and the system is deregulated sufficiently that many large international and national healthcare providers run large, multi-doctor and very modern clinics (often with allied health services attached), all charging the patient essentially nothing. Crucially for the health financing debate in Australia, hospitals are funded by State governments, while GP rebates through Medicare are funded federally. Note that Medicare is not like the US version (only for elderly people); in Australia it is the name of the universal health coverage scheme that all legally resident Australians can access.

One big problem with Medicare is that the essentially free nature of bulk billing services (and many non-bulk billing services, if GPs don’t increase their fees) is that patients are not discouraged from attending GPs for essentially irrelevant medical problems, have no incentive to wrap their problems into one visit, and have no incentive not to visit a GP for problems (like common colds) that the GP essentially can’t treat. This can lead to over-servicing, which causes congestion and reduces the efficiency of GPs as a service. It should be noted that compared to British GPs – who essentially run a poor-quality outpatient referral service – Australian GPs provide a wide range of services up to and including medical imaging, management of chronic and potentially fatal illnesses like cancer and HIV, and even minor surgery. They genuinely are the workhorses of the system, with a lot of responsibilities, and over-servicing is a serious issue. One solution often proposed for over-servicing is a mandatory co-payment that would force all patients to pay a nominal upfront fee to discourage frivolous GP attendance.

The Abbott government’s co-payment proposal and its aftermath

Into this policy issue stepped the new, first term government, run by Tony Abbott, a conservative ideologue who is probably better described as radical than conservative (as many conservatives are). Abbott won government on a platform of trust, promising “no surprises,” and certainly didn’t promise a major health financing change that I can recall (I can find no evidence either way that isn’t blatantly political, with a quick search). Immediately after the election Tony Abbott identified the classic “Budget shortfall” (every government since Fraser, except for Gillard, has done this it seems, and Gillard only didn’t do it because she was replacing her own party leader…) and started identifying “savings” that could reduce the deficit, which was in “crisis.” One proposed measure was the GP co-payment, which would be a $7 co-payment for all patients visiting a doctor. This unannounced and unsupported policy change attracted uproar, since it would fundamentally change the way that health financing worked, and no one was expecting it. After a long period of anger and clear messages from the Senate that the measure wouldn’t pass, the government relented and reduced this co-payment to $5, apparently voluntary. That’s right, the government was going to seriously go out on a limb for a policy that would give GPs the choice to become tax collectors for the government. Would you trust your doctor if they had volunteered to collect extra tax for the government?

Once this proposal had been sufficiently ridiculed the government canned that too, and introduced a nasty and cunning administrative change that will see the rebate for a 6-10 minute doctor’s visit reduced from $37 to $17. Obviously doctor’s costs won’t change, and so for a large proportion of their consultations they will face the choice of a $20 reduction in payment, or passing on all or part of that payment to patients. This is going to represent a huge increase in cost to patients, well above the $7 co-payment. Imagine, for example, that you are seeing a decent private doctor who charges you $50 for your service. Under the old system you pay the $50 and get a $37 rebate from Medicare; you end up paying $13, a fair whack of cash but no big deal. Under the co-payment system this would have increased to $20; under the new rebate revision, unless the doctor decides to carry the extra costs, you will now only be reimbursed $17, so your new fee is $33 – a more than 100% increase! Crucially, this move doesn’t need to go through parliament, so the government can effectively charge a rebate without getting senate approval. This is a hugely unpleasant change, and without huge numbers of concessions (for e.g. the elderly and those with chronic illness) it will lead to a huge increase in GP costs. If, for example, you’re taking statins for high cholesterol, your GP is your primary source of management and your management will probably require one of these 6-10 minute sessions every three months – so your medical bills will increase by $80 a year. This is actually a lot of money to some people.

The result of this should be obvious. While the $7 co-payment would discourage needless medical visits without necessarily significantly increasing costs for patients, the huge rebate change will destroy the bulk billing system, causing many poor people to drop out of GP service and shift to Accident and Emergency (A&E) departments in hospitals. GPs will attempt not to change their cost structure, and so will double the time they spent with each patient, massively increasing waiting times – except that their poorest patients will have disappeared to the A&E. This will mean that in the end GPs will see less patients who they charge more, and A&Es will become congested with patients attending for unnecessary minor complaints. With GPs charging more per visit for less visits, total medicare revenue won’t change – but less people will be seeing their doctor on time. The budget hole will not change in the slightest, waiting times won’t change at GPs, and A&Es will see an increase in pressure.

A&Es, as I mentioned above, are funded by state governments, not the Federal government.

So the government tried to implement a potentially important but unpopular policy, and when this failed switched to implementing a completely counter productive and unpopular policy that will seriously affect everyone through increased health care costs. They showed no policy sense and no leadership. Brilliant.

What does this tell us about this government’s policy approach?

As I mentioned above, getting a co-payment through Australian politics is a tough ask, and takes political skills, but it has two major policy benefits: it raises more money for Medicare, which is generally accepted to be underfunded, and it reduces unnecessary service use, which is a major problem in free or nearly-free health systems. With Australia’s growing burden of non-communicable disease and preventable health problems it’s probably a good idea, and $5 or $7 is not horrifically punitive, though for the very poorest in Australian society it’s tough. Australians in general are wealthy though and $7 is the price of a piece of cake – it’s really not the end of the world. Nevertheless, it represents a major shift in policy approach away from the bulk billing philosophy, and steering that policy through requires a nuanced debate in which the government prepares the public, then debates with the public, then compromises. It’s also potentially the kind of policy that involves expending a lot of political capital for not much gain – the co-payment is a good idea but not necessarily the best way to solve the problems it is intended to fix, and may not be worth any government expending political capital on. Instead, this government introduced it soon after an election, in an environment where it is accused of multiple broken promises, without any preparation or debate. It even managed to anger the Australian Medical Association, historically a very pro-conservative organization (one of its ex-presidents was a Liberal leadership contender, and an ex-Liberal health minister moved on to become one of its directors, I think). But then, having angered everyone who cares, the government dropped the plan in exchange for an even more punitive and vicious policy that will obviously fail to achieve any of the stated goals of the previous policy, and probably won’t raise any extra money but will put more pressure on Australian hospitals.

Is this not the very model of political naivete? To me this is an example of a government that has no policy framework at all. They were simply looking for ways to raise money and tried to cloak them in a policy goal that they didn’t really understand or care about, and when their mistakes were pointed out to them instead of backing down and finding a better solution, they simply dropped the cloak of policy rationality and turned vindictive. And this seems to be what they have been doing for much of their policy “development” since they won office. This is no recipe for sensible government, and the GP co-payment debacle is a classic example of how mean-spirited this government is, as well as its complete lack of interest in any real policy goals.

If this is how they go about all their policy development, the sooner they become a one-term government the better.