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

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

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

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

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

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

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

Table 1: The characteristics of leavers

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

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

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

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

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

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

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

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

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

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

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

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

Save

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

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

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

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

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

Madness.

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

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


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

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

An old Jedi mind trick

An old Jedi mind trick

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

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

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

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

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

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

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

What the American people have to look forward to

What the American people have to look forward to

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

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

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

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

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

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

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

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

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

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

Harder to beat than it looks

Harder to beat than it looks

I’m not going to write anything specific about what yesterday’s election results mean for America or the world, but in this post I thought I’d make a few random observations about the electoral process, polling and Democratic strategy, followed by two comments relating this election to past role-playing campaigns of mine.

  1. The US electoral process is a mess: The composition of the senate and the electoral college process are a joke that protects power for small rural states at the expense of the large and populous urban centres. That California (population 40 million) has the same number of representatives in the senate as Louisiana (population 4.5 million) is ridiculous, and ensures that Louisiana’s residents have nearly 10 times as much voting power as Californians; to a lesser extent this is replicated in the electoral college, where they have 8 compared to 55 electors. This is why we see the strange phenomenon of Republicans winning the presidency and the balance of power in the senate even though they do not win the popular vote, and cannot win significant numbers of senators in the cities. Furthermore, not only is voting not compulsory, but it is held on a Tuesday and many states don’t allow early voting or postal voting, or only have early voting in business hours. Every US election comes down to turnout, and this is a huge problem for a functioning democracy. Reform of all these aspects of the US system is desperately needed.
  2. Polls cannot predict anything while turnout is volatile: Polls consistently showed Clinton leading in the popular vote, which is what happened at the end, but they didn’t come anywhere near predicting the final result. I think this is because a) the polls don’t necessarily reflect the population of the state they’re taken in, so don’t reflect how it will vote, and b) even if they accurately estimate individual voting intentions, they need to weight this by turnout patterns in order to accurately estimate the final vote, and in the absence of accurate knowledge about who will vote, knowing how they would like to vote is irrelevant. Even guessing based on demographics won’t work, since we don’t know whether for example the white people who turn out to vote will be the Democrat voters or the Republican voters. In electoral systems with high turnout (e.g. Australia) this is not an issue, since the effect of fluctuations in turnout will be small compared to the total pool of voters, but in countries with low turnout this is a big problem. Especially since much of the result turns on subtle differences in a few states. Donald Trump would not yet have been declared victor if Pennsylvania were not his, and he won there by 1.2%. Even a small difference in turnout would flip that result. To flip that state Clinton needed just a 3% (not a 3 percent point!) increase in turnout. Note also that many states are won by such narrow margins that predicting the result would be impossible even if we had good estimates of turnout – the error margins on the turnout estimate combined with the voting intention estimates would surely swamp the margin of final victory, producing very high probabilities of error. Polling is no better than reading tea leaves in this situation. If the electoral college system were abolished this wouldn’t matter, since the law of averages combined with big margins in larger states would make polling more effective. But basically the only way to predict the result of a US election is to accurately estimate turnout using huge samples in a few swing states, and then give predictions like ‘there is a 55% chance Pennsylvania will fall to the Republican candidate’.
  3. Get out the vote strategies are not so wonderful: Trump’s ground game was famously bad, and his efforts to get turnout very poor, while Clinton was supposed to be running a well-oiled GOTV machine; yet 7 million fewer people turned out than in the last election, and Clinton got 4 million fewer votes than Obama. This tells me that Trump got better turnout than Clinton without having a ground game. This suggests that having a charismatic candidate is more important than turnout; and that a great GOTV effort is insufficient if the candidate is not well liked. From the party’s perspective this should probably be the only consideration. In four years’ time the Democrats should be asking themselves, is it better to have an inexperienced and popular candidate like Michelle Obama, or an experienced and unpopular candidate like Tim Kaine? And if they’re tempted to say “GOTV should make up for Kaine’s flaws,” they should look at yesterday’s disaster for some helpful pointers. Which brings us to …
  4. The demographic strategy is not working for the Democrats: One often reads that the Democrats are on a winning streak because the proportion of white voters is declining and the proportion of African American/Latino voters is growing, but there are two reasons why this isn’t working for them, at least in the medium term. The first is that the decline of white voters is due to ageing, and older people are more likely to be Republican, more likely to be able to vote, and more likely to be energized to vote; and the second is that fluctuations in turnout will wipe out even large demographic gains. When turnout can fluctuate by 10% between two elections (48.6% this election vs 55% in 2012, according to Wikipedia), demographic gains will be swamped by the patterns of turnout – especially if turnout is not consistent across all demographic groups. It’s also not clear to me that the growing trend in Latino/African American populations is a sustainable windfall for the Democrats, since the reason these populations are growing is that they are younger, and younger people are more likely to vote Democrat; but will this be true as these populations age? Democratic policies appeal more to young people, and the population of young people, although growing, may not be growing fast enough to offset the ageing of slightly older people into more Republican groups. If they are going to be competitive, Democrats need to appeal to older white people in rural areas, and that is very hard for them to do when those areas are completely shut off from Democratic modes of communication through Hate Radio, Fox news, and the growing echo chamber of the Republican right.
  5. Trump did not win poor people: The first exit polls I read suggested that Clinton did much better than Trump amongst people on below median income and below 50,000 US$ income. This group is disproportionately young and African American/Latino, probably also more likely to be women, and it shows that the Democrats are facing an ageing problem – this is the baby boomer dividend for the Republicans. In my experience Boomers are very vulnerable to climate change denialism, deficit terrorism, and arguments about deserving vs. undeserving poor, and this makes them easily convinced to vote for Republicans. This was an election fought along wealth lines, with a heavy leavening of racism and sexism to drive up turnout, and it’s not the case that Trump won by appealing to the poor and those “left behind” by the “neoliberal order”. He won by getting out older, wealthier people to vote against the change that their own children are pining for. This is exactly the same story as Brexit, where the people most likely to be affected by leaving the EU – young people and poor people – overwhelmingly voted to remain, while older and wealthier people voted to leave.

I can’t see an easy way back from this for the Democrats, not because they can’t win elections – Obama showed they can, and resoundingly – but because the Republicans will use their time in power to further drive down the ability of poor and young people to vote, and further attack the social organizations – like unions – that support activism in support of these groups.

I had a bet with two Aussie friends that the Republicans would be out of power for a generation, and I think my position was based on a misunderstanding of the importance of points 2 – 4, and now as a result I have to post an expensive 1.8L bottle of nihonshu (sake) to Australia. Which just goes to show the importance of understanding demographics, and also that this election has been a great tragedy for me, and Americans should apologize to me for my loss.

To bring this post back to RPG-related issues:

  1. A few years ago I played in a World of Darkness campaign that was set in a dystopic near-future, in which an inscrutable and ineffable evil force was working to reduce all the universe to its whims, using America as its primary point of access to the mortal world. Of course it was manipulating US politics through the Republican party, and so America had become a proto-fascist hellzone ruled by President … McCain. We thought this was hilariously cynical at the time, but now I think we were showing a remarkable lack of imagination. Shame on us.
  2. My character in the Cyberpunk campaign I recently played in was fond of saying that Asia was where the future was, and comparing shattered, collapsed America and failing Europe to the vibrant and optimistic megalopolises and future civilizations of Asia. This election shows the truth of her view: with Trump likely to sink all forms of action on climate change, China will become the global leader on response to warming; if Trump can repeal Obamacare the US will again be well behind many Asian nations in progress towards universal health coverage; and in comparison to the lunatic electoral decisions of the UK and US, the one-party administrative states of Asian states like Japan and Singapore are looking decidedly responsible and stable. I’ve said before that China is going to present a genuine alternative model to capitalist democracy if it can weather its economic and environmental problems without instability, and certainly the Chinese press have been presenting this US election as an example of why democracy is an ugly thing. As my Cyberpunk character was fond of saying (if her vocabulary extended to it), it’s time moribund European and anglosphere states started looking more seriously to Asia for ideas on politics and governance, because frankly, from my perspective, they seem to be flat out of ideas.

These are my first and probably last thoughts on the US election. I’ll be tracking Trump’s impact on Obamacare and writing about it as it happens, but the rest of this is too depressing for me to want to take on. Just the sight of a qualified woman being beaten to an important job by an incompetent, unqualified man with a history of workplace sexual harrassment allegations leaves me so cold I couldn’t watch her concession speech, and I certainly want to minimize my exposure to Trump before he forces himself onto us from the oval office. So I think I’ll be avoiding further posts about US politics for the foreseeable future … Godspeed America, I think you’re in for a rough and probably tragic ride.

How it was

How it was

Edgar Evans is an eighth generation kindred character in the new Vampire The Masquerade short campaign my group has started. The campaign is intended to involve not just the vampire characters, but also their elders (6th generation legends) and also one ghoul in the service of the ancilla. Edgar Evans is a rich man with a business empire, and he also has a small domain, and it is in this domain that his ghoul, Tia Nero, can be found. This post is the description of his domain and an introduction to Tia Nero, but in order to understand this domain, it is necessary to understand the politics of supernaturals in the second decade of the new millenium, as the humans they had long ignored, scorned or fed upon begin to build a world that is closing in on the supernaturals, and crushing them.

A brief history of supernatural failure

For aeons the main supernaturals ignored human development. Sure, the vampires fed on them and the Fae remained intertwined with them, but these relationships were not symbiotic or cooperative – humans lived in fear of the unknown, crouched in the dark and looked to superstition to rescue them from their night terrors. Over all the millennia of this unpleasant coexistence the supernaturals achieved nothing, made no mark on the world except, perhaps, to score fear in the human soul.

But then human science overcame human superstition, and those fear-scars became just a cultural memory. It wasn’t just that there were too many humans for the supernaturals to scare directly – it wasn’t just the thronging mass of these stinking, short-lived, frail and useless cattle. Science overcame fear, and then slowly science overwhelmed the natural world. For millenia humans and supernaturals had lived side by side, and nothing really changed – and then in one century humans changed the whole world. The supernaturals looked on in horror as humans harnessed the power of the sun to destroy cities, and tried to come to terms with the ability of humans to vanish darkness and fear with cold logic and simple technology. They dismissed all that – sure humans could build big things, but they were still just frail and weak cattle. What’s to fear?

But then the anthropocene began, and the supernaturals felt fear of their cattle for the first time. Every summer the werewolves would find new settlements, would get into fights over lost land, would find their wild reaches slowly stripped back and reduced, and though they might fight an individual farmer successfully, soon enough the hordes would arrive and they would need to fall back to a new redoubt. The mages discovered that it was harder to do their dingier works. It wasn’t just the new laws about child exploitation, or the sudden desire of humans to catalogue every one of their pathetic number, so they could never be lost. It wasn’t even the new laws on ownership and cruelty that made it so much harder to conduct animal sacrifices, or the sudden loss of empty urban space that mages would use for their less savoury experiments. The mages really noticed when they found they could no longer obtain the magical reagents they needed, because the mere existence of millions of Chinese using traditional Chinese medicine drained their reagents dry. There were so many of these pestilential creatures, consuming, consuming, always taking and taking and needing more … The vampires noticed that the dark and secret places of the old cities had disappeared, been replaced with warehouse apartments and subways and underground parking zones and all the paraphernalia of a civilization that increasingly was ignoring them – until it started making bad movies and games about them. In the space of a century they went from an object of fear to a kitsch joke, laughed at by the new science.

Nobody asked the mummies what they thought. Who would dare?

But the supernaturals that noticed it most were the Fae. Intimately connected to the patterns and cycles of nature, their supernatural home’s fate intertwined with the physical world, they noticed very quickly as the planet started to warm. As the summers lengthened and the ice began to retreat, the balance of power of the courts of Winter and Summer changed, and Summer began to rise. They watched the behavior of humans and they realized – disgusted at the potency of human science – that humans identified the changes a scant 50 years after they did. And worse still, humans identified the cause – humans were the cause. The Fae began to panic.

Most vampires did not care about the Fae, although a few had their connections; even after the Fae’s warnings began to spread, most vampires cared little for the threat of global warming. They were creatures of the night, and CO2 was not going to change the earth’s orbit. Some reacted against it with the same kind of visceral wariness that many humans show towards nuclear power, simply because of its association with nuclear weapons: Vampires have always feared the sun, and anything which enhances its effects fills many of them with a kind of unwary, superstitious dread. Others saw in global warming an opportunity – after floods and storms people go missing, and the chaos engendered by these catastrophes opens up an easy hunting ground for their kind, free of the increasing risk of reprisals that had made the Masquerade so important in modern life. For them, global warming was a chance to enjoy chaos.

But some thinkers amongst the Fae and the Vampire recognized the real philosophical threat. In a scant 100 years humans had gone from cowering, sniveling prey to a vast hive mind that could change the climate of the entire planet. They had become a horde, swarming over the planet in such numbers and building their greedy edifices in such abundance that they had not only destroyed the earth’s natural beauty, they had changed the weather, and now they were harnessing the sun and the power of the sun. The balance had been disturbed, and it was clear that its restoration would require extreme measures. A movement arose in kindred society, a movement popular among the Brujah and some of the darker sects and alliances – a demand for a cull, a real cull, before this horde overwhelmed all the dark spaces of the earth with their lust for things and their increasingly loving relationship with the sun. What if they found a cure for vampirism, some asked? What if they discovered the kindred’s society, and decided to purge it, or discovered a vaccine against the creation of new vampires? Many laughed at such fears, but the chuckling died down when the thinkers observed that humanity had eliminated smallpox in a mere 30 years, that there were societies where almost no child died, that in modern society it was impossible for a child to go missing without thousands of people descending on the scene of the calamity. They always found their murderers, and the time it took them to find a solution to a problem was growing shorter and shorter. From the discovery of smallpox to its vaccine took thousands of years. From the discovery of HIV to its treatment took 20. How long would it take them to purge the world of vampires if they found them? And as they swarmed over the earth, defiling it and investigating it and laying bare its dwindling cache of secrets, how could they not find the kindred?

It wasn’t exactly a panic, but a kind of paralysis set in amongst the supernaturals. They watched as the dark places, the wild places, the sacred places were first torn away from them, then paved over or turned into tourist spots, young couples taking selfies by the dozen in places that a hundred years ago they would have been terrified to walk within a day’s march of. What could they do about this? In their slow and sinister way the vampires schemed, and assumed that they would always be able to hide amongst the flesh folk, always be able to make some new scheme.

For the Fae, though, the philosophical debate quickly became a real battle for power, as it always does amongst the Fae. After the Court of Winter’s amateurish attempt to start a nuclear war in Cuba a fragile political truce was born – no more direct interference in human affairs, by any of the Courts, and everyone expected them all to honour it. But nobody counted on the Changeling, whose numbers grew as the human population swelled. Changeling were like sleeper cells for their courts, a kind of Super PAC of faerie power, who could act on behalf of their Courts without breaching the fragile agreement the Courts had made after the Winter Court’s foolish attempt to produce a nuclear winter. They manoeuvred their changelings like pieces on a chess board, infiltrating human business and politics to try and get their way. By the early 1990s everyone in the supernatural world knew the score: Winter and Spring were with the Democrats, and Summer and Autumn with the Republicans, because all of Fae meddling had shaken out along one deadly axis – global warming. By the early 1990s nothing else mattered, because every Court knew that Summer and Autumn would be forever ascendant if humanity failed to tackle the causes. All of the Fae realms had realized their fate was now tied to that of humanity, and they bent all their will to changing it.

Naturally they sowed the ranks of business and politics with changelings. One such changeling emerged in the 1980s in business, and began to grow in power and influence. He was aging but still robust, an orange-faced caricature of a rapacious businessman, making his money in dodgy real estate and casino deals, tied to the mob and bribing politicans wherever he needed to, playing fast and loose with every standard of business and human decency – a classic progeny of the Summer Court. This man was a crass, larger-than-life bully boy, a carnival barker with tiny hands and huge insecurities, the kind of narcissist who makes it big in Fae life, and by the end of the 1980s he had begun to reap the rewards of that narcissism in mortal life, with ghost-written books and tasteless TV shows. And in the early 1990s he began to make hints about turning his popularity to political advantage – he began to talk about moving into politics.

This was too much for one Vampire, Johnny Falco[1]. Johnny Falco had an irrational hatred of the Fae and their machinations[2], and the thought of a Summer Court Changeling taking control of American politics filled him with disgust – especially this repulsive, orange-faced ignoramus with his trashy tastes and his terrible architecture and his shallow opinions on everything. This was exactly the kind of person who really irritated Johnny Falco, and who made his grandsire despair of the cattle. So one day in 1996 while at one of his casinos in Atlantic City this businessman was murdered, horribly, with a trenching shovel and a gold-plated scale model of one of his own towers. No one saw the person who did it, no one understood how the perpetrator could have gotten into the businessman’s inner sanctum, or how he had managed to remove his face and leave it on a Ronald McDonald statue a stone’s throw away from the tower, in full view of a whole cluster of cctv cameras, but there it was the next day, leering bloodily at a small group of terrified Japanese tourists.

The mystery was never solved, and the businessman’s empire fell into ruin – and nowhere more so than his Atlantic City casino properties.

The Domain

Johnny Falco didn’t just kill the businessman – he also killed his property. The Atlantic City casino properties were bleeding money, but after the murder the authorities discovered an elaborate system of shell companies that covered up for … nothing. They couldn’t find where the money came from or who was responsible for the properties, as if the dead businessman had been a mere figurehead. The casinos sat empty as investigations continued, but even years later no trace of the original investors could be found, or their money. Occasionally a city authority or some rival business would set up a scheme to buy the properties but always at the last moment someone would get cold feet, or the key figure in the investment program would disappear or die, or suddenly their business would be bankrupted overnight by some strange market play. The business world gave up on them and they fell into disrepair, crumbling in the centre of Atlantic City’s glitzy gambling zone. But buildings like that don’t just decay – they poison. Their rot spread out from them like a cancer, infecting the businesses around them and slowly paralyzing the entire zone. Investors saw easier pickings in native reservations and the effervescent Vegas economy, and slowly they pulled their money out. By the turn of the century the collapse of the casinos had spread outward to infect a large part of the Atlantic City seafront, which became a low-rent junkyard of pawn shops, bounty hunters, gunshops and cheap liquor stores. A section of the city 10 blocks long became a wilderness of malfunctioning neon and broken lives, a self-governing conclave of the poor and the destitute.

It was here, in 1996, remarkably coincidentally with the death of the businessman, that Edgar Evans decided to set up a surf shop – right across the road from that Ronald McDonald statue. His Polaris foundation bought up an old gaming parlour and turned it into a massive surf emporium, drawing expressions of disgust and disappointment from investors across the eastern seaboard. People had had high hopes for Evans, a reformed extreme sportsman with robust business sense, but this deal made no sense at all. Sure, the entire Jersey coastline was a haven for surfers and they all had to pass through Atlantic City at some point but did he seriously think they would slum it at his surf emporium amongst the broken glass and broken dreams of this banged-out strip?

They underestimated Evans. He didn’t just sell surfboards, but rented combi vans, set up a vegan organic restaurant called 20,000 Cows, established a live venue and a cheap hostel over the surf shop. Life returned to this tiny part of the seafront, and somehow surfers from all around the world came to enjoy his hospitality. The Atlantic City surf festival was founded, and his business thrived. He expanded to the warehouse next door, turning it into a branch office of the Polaris Foundation and using it to store equipment for the Foundation’s Atlantic Coast Research Project. Once a year the Sea Shepherd ship, Polaris Quest, docked nearby and held an open day.

And above it all loomed the businessman’s abandoned, crumbling tower, his name still emblazoned across its penthouse level in tarnished gold, bragging about the long-dead icon’s fame. The building was occupied now, by squatters and homeless and crack gangs, but they seemed to have a kind of respect for the area, because they never caused any trouble for Evans or his business. Dark rumours spread about his means of enforcing his will on these local homeless, but no evidence ever came to light. He opened a boxing gym for local street kids, ploughed money into a drugs program, funded local rejuvenation projects – he was in every way a perfect local citizen. But still people wondered – how did he have such a hold over these locals.

How had he made this his domain?

The Ghoul

Of course the press came sniffing around, looking for answers, for clues to Evans’s business vitality. They always ended up meeting the same person: Tia Nero. Tia Nero was the corn-haired, blue-eyed, mesh-and-leather skater girl who managed the surf emporium. Short, slight and cheerful, always dressed in a mixture of black punk and skater style, she was the antithesis of the good business person, but she had a way – she had a certain charisma, a certain personality, that made people listen to her and trust her. She was sassy, she had a reputation on the skate scene for extreme bravery, and she was a sharp manager. She would talk to the press, show them around, introduce them to colourful characters, show them photos of her skating days, take them to enjoy the phenomenal food and atmosphere of 20,000 Cows[4], and by the time they left they were writing glowing reviews of this new social project.

In reality Tia Nero is a revenant, the illegitimate child of one of Polaris’s ghouls, sent to serve Edgar Evans in the new world. She is everything her public persona suggests, but she is also a steely agent of the night, ruthlessly enforcing a set of strict rules on the residents of the neighbouring tower and ensuring that they are always available for Evans to feed upon or call upon. She also administers this most public branch of his business empire, helping him to retain his connection to a community of surfers who still view him entirely positively, and supporting the activist credibility he needs to maintain connections with the environmental movements that he is manipulating for his own and Polaris’s ends. Evans is mostly in New York city now, and when he needs an agent he knows he can trust to operate on his behalf in the daytime, with initiative and sense, he calls on Tia. He knows she will do what he wants, and over long years of working together he has never met anyone he trusts more. There is only one aspect of their relationship that creates any friction between them.

She can surf in the sunlight.


fn1: Actually another player’s PC

fn2: He got the worst end of their behavior in our World of Darkness campaign and the player hates hates hates them

fn3: Tia Nero is a loose anti-person to Tia Blanco, a vegan surfer I have on my instagram feed

fn4: 20 years ago I had a phenomenal afternoon experience in a vegan restaurant called 20,000 cows in Byron Bay, now dead (though its Lismore branch lives on). Nothing special happened, just a wonderful atmosphere, great food and a feeling of wholeness and comfort that I have never forgotten. Here it is resurrected in Atlantic City, in the shadow of a … certain business person’s … untimely bankruptcy

Save