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

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

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

The myth of rising white mortality

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

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

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

The myth of “deaths of despair” and Trump voting

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

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

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

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

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

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

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

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

There is no theory linking opioid addiction to voting Trump

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

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

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

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

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


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

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

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

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

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I have just finished reading Locked In: The True Causes of Mass Incarceration and How to Achieve Real Reform, by John Pfaff. This book describes the growth of mass incarceration in the United States and describes a set of reform policies to reduce the prison population. In itself this is not unusual – the book takes as its launching point the political consensus in the USA that there is a need to “decarcerate” a large number of people – but this book presents a completely different set of causes of mass incarceration to the accepted story, and lays out a very different strategy for achieving real change. It also argues that the existing reform effort, while valuable, may actually sow the seeds of a long term failure to decarcerate, and risks normalizing a political framework that will be disastrous if crime rises again in America.

Pfaff defines the accepted causes of mass incarceration as the “Standard Story,” which argues that mass incarceration is driven primarily by three factors: the war on drugs[1], excessively long sentences, and private prisons. In the first few chapters he demolishes this story succinctly and using detailed statistics. Only 16% of all prisoners are in prison for drug crimes, and of these a large proportion probably were charged on drug crimes as an easier alternative to conviction for violent crimes; and releasing all of these prisoners would do almost nothing to shift the racial disparities in incarceration, because these disparities are universal. Indeed, since 1990 only 14% of new prison admissions were due to drug use, while 60% were for violent crimes. He then presents a wide range of evidence that prison sentences have not actually increased in length over the past 30 years in the USA: Increased prisoner numbers are due to increased admissions, not larger number of prisoners hanging around longer. Finally, Pfaff drags out the statistics on private prisons, to show that only 8% of US prisoners are in private prisons; and he argues that the lobbying efforts of private prisons are tiny compared to the lobbying efforts of prison guard associations, and from other interests that have greater influence in the zero-sum funding environment of state financing decisions in the USA (most private prison lobbying happens at the state level, where a dollar given to one interest is necessarily a dollar not given to another). In fact, throughout this book Pfaff regularly revisits the power of prison guard associations and lobby groups for prosecutors, and regularly makes the point that the USA’s mass incarceration problem is a catastrophe entirely wrought by public agencies on the public purse. Private prisons in the US might suck, and you might think it’s a bad or a weird idea, or that profiting from human misery is nasty, but they aren’t the cause of the problem.

Having demolished the “Standard Story”, Pfaff then goes on to explain what he thinks are the real causes of incarceration in the USA, which is a complex mish-mash of bad design, lack of political accountability, and public choices, against a backdrop of rapidly increasing crime rates. At the core of his story is the prosecutor. Prosecutors in the USA are the equivalent of the Crown Prosecution Service in the Westminster system, but they are radically different from the CPS. They are generally elected in county (local) elections, and funded at this level, so they are answerable to only local political forces. They have complete discretion as to who to charge, how and with what crime, and they typically are supported by a police force that is funded at the county level. Prosecutors typically are always re-elected, and no incumbent ever suffers from being too harsh on crime. But the real problem is in two aspects of the deployment of their considerable discretion: Whether to charge for misdemeanour or felony, and what plea bargain to make. If a prosecutor charges someone with a felony, that person goes to prison (not jail! The US has some kind of weird distinction!) – but prisons are funded by the state, not the county. This means that there is no financial pressure on them not to send people to prison. But it is the state that makes the laws, and at the state level there is often political pressure to create new laws and increase maximum penalties for those laws. So in recent times the prosecutor has been gifted with a wide range of potential felonies that they can threaten suspects with, that carry very large maximum penalties that are unlikely to be enacted by the judge but sound terrifying to the suspect. This means that it is very easy for prosecutors to get suspects to make plea deals for low level felonies, and there is no local pressure for them not to, but at the next election they are most likely to be judged for successfully putting felons away. This increasing freedom and power has occurred at a time when numbers of prosecutors have increased rapidly, and public defenders – the service that the government supplies to suspects – are massively underfunded and often barely have the time to meet their clients, let alone to help them defend their case. Prosecutors are also notoriously defensive about their work, there is almost no data on what they do, and their representative organizations have enormous clout. These are almost always the people whose perspective you see on shows like Law and Order, Major Crimes, etc.: they are the completely unconstrained and unmonitored heroes of the judicial system, and in the past 30 years the proportion of all cases that they decide to recommend for felony charges has doubled, at the same time as the number of prosecutors has doubled, and crime rates have risen. This, Pfaff argues, is the root cause of the growth of mass incarceration.

But beyond this, Pfaff identifies a much more challenging and much more politically challenging aspect of the growth of mass incarceration, which is going to be very difficult to reverse. Most people in US prisons are in prison for real, serious crimes: 60% of the growth in prisoner numbers since 1990 was due to people imprisoned for violent crimes, and people convicted of the most serious violent crimes (murder, manslaughter, forcible sexual assault, aggravated assault and robbery) take up a disproportionately large amount of prison space and prison time. Seriously reducing the US prison population is going to require that the US voter be comfortable with releasing these prisoners, and being less harsh on violent criminals in future. This is a very politically challenging project, and lies at the core of the reform process: If the US criminal justice system doesn’t find a way to deal differently with violent criminals, the prison population will never significantly decline. To his credit Pfaff makes a powerful and clear argument that from a human rights and a law enforcement perspective, more lenient sentences and better policing are the key to reducing crime and mass incarceration. I find his argument persuasive, but then I would, wouldn’t I? And if you don’t, then you have to accept that the US is going to have a very large number of prisoners, much larger than most other countries, and there is no solution to this problem.

Pfaff goes further, to point out that much of the rhetoric of the prison reform movement is antithetical to this ultimate goal. Many prison reform efforts are pushed as efforts to release low-level prisoners to make space for those who “truly deserve prison”, and even if this balance is not stated explicitly it is implicit in the argument that prison should be for violent crime. America is experiencing a period of declining violent crime at present, but if that should reverse then this logic of reform will be hard to reverse, and it will be hard to argue for more lenient sentences for violent criminals after years of arguing that prison is what these people deserve. Pfaff also points out that the last 10 years of prison reform efforts – which he argues have been supported by all sides of politics in the US – have shown very limited effect, and that this is primarily because they are focusing on a very small proportion of the US prison population (first time drug offenders) and that they need to move from these “low hanging fruit” to the real drivers of prison growth – and those who really suffer in this system – violent offenders.

Within this story there is a lot of other material to consider – this book is a short and well written work with a rich vein of material to consider. It certainly changed my view of the drivers of mass incarceration in the USA and the real reforms it needs. It also shocked me with how callous the US criminal justice system is, and how shambolic. In contrast to the UK, Japan or Australia, where the prison, police and legal systems are all relatively well organized around a single structure that coordinates well, the US system is fragmented and full of perverse incentives, all corrupted by the horrors of having public servants like prosecutors elected at the county level (shudder!) Pfaff also consistently returns to a discussion of how damaging prison is for inmates, their families and the communities they are drawn from, reminding the reader regularly that prison is a destructive experience for everyone involved, and he also reminds the reader regularly of the US electorates’ appetite for punishment. But the real challenge of this book is his focus on the need to treat violent offenders differently. He even challenges the concept of “violent offenders”, arguing that we should refer to them as “people who committed violent crimes”, and argues compellingly that our attitude to violent crime is completely wrong. This struck me because although I’m generally in favour of not sending people to prison for all the reasons Pfaff describes, I am just as prone as anyone else to demanding people be locked up (e.g. that was my first response to the Grenfell Tower fire) or to thinking a sentence isn’t harsh enough (as if I, someone who has never been to prison or spent any time as a free adult anywhere I didn’t want to be, could possibly comprehend whether a three year sentence is any less harsh than a five year sentence!). And Pfaff’s argument is pretty clearly that probably I, and most of the rest of us, have got it completely wrong on prison sentences – that a suspended sentence or a year or two is probably just as good a deterrent as five or ten years, but has significantly less social and economic cost.

If I had any complaints about this book it would be that although he talks about race a little he doesn’t go into a discussion of race in depth, a problem in the American context. Also, although he repeatedly describes the lack of financial disincentives to county prosecutors sending prisoners to state prisons, Pfaff doesn’t seem to draw the obvious extra lesson here – that county prosecutors might have strong disincentives to send people to county jails, which have much less serious ramifications for their inmates than state prisons. In avoiding a full confrontation with the issue of race, and not fully drawing out all the implied pressures on prosecutors, Pfaff manages to miss the obvious possible extension argument underlying the points he makes: that a lot of prosecutors may well be cruel, racist arseholes, and that a root-and-branch reform of the entire prosecutorial system may be in order. But this is a common problem when confronting Americans’ assessments of their own problems, whether its Bernie Sanders or the gun control movement or Black Lives Matter: The American political system is rotten to its core, and it is going to take a lot more than a few piecemeal changes to parts of it to fix the huge problems lurking at its base. We’ve just passed the 4th July, so it’s probably worth reminding my American reader(s): you could ask the UK to take you back, you know. For all its flaws, the UK’s democracy is vastly superior to yours. You’ll have to give up your guns and you may have to learn to shut up occasionally, but in exchange you’ll get a functioning democracy. Think about it!

Anyway, jokes aside, this is a great book, a truly enlightening exposition of one of America’s great problems. If you are interested in drug decriminalization and have always assumed that this issue is at the heart of America’s prison problems, or if you are generally concerned about the way America needs to reform its criminal justice system to become a better country, then this book is a must read. It’s well written, well argued, dry but not exhausting, and compassionate towards the people at the core of the story: the prisoners, who by now are a large proportion of America’s population. If you care about the human rights of all people, regardless of what you might think of their worth as individuals, then this book is a compelling read. I recommend it to anyone interested in this important topic.


fn1: this is often characterized on the left and by libertarians as “the war on (some classes of people) who use (some classes of) drugs” but this book makes it very clear that the prejudice in the criminal justice system extends across the board, and that singling out one class of crimes (drug crimes) as a cause of racial disparities in incarceration won’t work, because the same racial disparities exist across all laws.

So Abram rose, and clave the wood, and went,
And took the fire with him, and a knife.
And as they sojourned both of them together,
Isaac the first-born spake and said, My Father,
Behold the preparations, fire and iron,
But where the lamb for this burnt-offering?
Then Abram bound the youth with belts and straps,
and builded parapets and trenches there,
And stretchèd forth the knife to slay his son.
When lo! an angel called him out of heaven,
Saying, Lay not thy hand upon the lad,
Neither do anything to him. Behold,
A ram, caught in a thicket by its horns;
Offer the Ram of Pride instead of him.

But the old man would not so, but slew his son,
And half the seed of Europe, one by one.
– The parable of the old man and the young, Wilfred Owen

Last weekend I watched Guardians of the Galaxy 2, the highly-rated sequel to an excellent original movie. I went with high expectations because I read some good reviews and because the first movie was so great, but I was let down by this one. It was still fun, but it suffered from some deep and fundamental flaws, including that most basic flaw that spoils so many American movies: Daddy Issues. I’m so over putting up with the blatant, sentimental moralizing of modern American movies, and this one really really laid it on thick. So here is my brief review of the many problems of this movie, followed by an analysis of one possible interpretation of the bad guy’s evil plot, and how it can be read. This review has spoilers.

The daddy issues are laid on pretty thick from the start of this movie. The fundamental plot entangles the same characters from the original story in a madman’s attempt to turn all the planets in the galaxy into a model of his home planet, probably eradicating all life on those planets in the process (this isn’t clear). Of course Quinn, the idiot dude from the first movie, is central to this plot because the bad guy is his dad, and we have the classic American trope of discovering that your dad is not the great guy you believed he was when you were five, but is actually just a dickhead with an oversized ego who will never ever listen to you because you’re his son and therefore nothing you say is important. If you go by American movies, this completely ordinary run-of-the-mill discovery is a deeply traumatic experience for American men, who then (I guess because, pace that classic Monty Python sketch, Americans just won’t shut up) have to go and make multiple movies about it. Perhaps if they didn’t fridge their mothers in every single action movie, they would have a countervailing voice to explain that there’s nothing unusual about finding out your dad is just a paunchy dude who has no power and has some sketchy views about black people.

So then the group of heroes have to spend an inordinately long period of time trying to kill Quinn’s dad, which is cute because this movie combines daddy issues with patricide, which is actually a really pretty seedy basic structure for a movie: Dad had a bad idea, so instead of reasoning him out of it and coming to a better plan, you murder him. Although his bad idea involved serial infanticide, so make no bones about it (there are a lot of bones), he really did deserve to die. Credit where it is due, this movie strips back all the bullshit about daddy issues and gets back to basics: You gotta kill papa before he kills you.

Outside of the toxic daddy issues the movie is fun, packed with the same slapstick and chaotic banter as the first movie. The opening 10 minutes is a joyous rampage, worth paying for even if the rest of the movie lets you down, and some of the characters really live up to the high expectations they set in the first movie – especially Rocket, Draxx and Yondoo (as in the first movie Quinn is just a boring jock). The movie also introduces a girl called Mantis, who is well placed right in the uncanny valley, as well as being gloriously stupid and honest and sweet, so she’s a great new cast member. Unfortunately these great characters are merely support to the two boring white dudes fighting their existential battle. The key bad guy – Quinn’s dad – has a plot to destroy the galaxy which has depended on him womanizing his way around it, then consuming all the by-blows of his unions with many different aliens in a desperate attempt to destroy the galaxy. Quinn’s dad is a kind of a god so killing him is tough, and the second half of the movie involves an inordinate amount of flying and fighting and dodging and trying to blow him up. This is unfortunate because both Quinn’s dad himself and all attempts to kill him are just boring. This means that every time the main bad guy is on screen you just want him to go away, he’s so boring, and you just don’t have anything invested in the team’s efforts to beat him. He’s just some philandering idiot with a big ego and you can’t bring yourself to care. This bad guy is no Magua, no Imortan Joe. It’s like if Homer and Bart Simpson were in a fight to the death over who gets to destroy the galaxy. You want to care – your life depends on it – but really? Really? Is this how it ends?!

Which brings me to Trump, and Imperialism. It strikes me as not much of a coincidence that this particular variant of daddy issues – a daddy who is so stupid and dangerous you have to kill him to save the galaxy – comes up now, when America is ruled by the ultimate useless dad. Over the past year of being subjected to daddy issues movies and seeing the way that Americans respond to their presidential candidates, I have started to think that the US president is a kind of embodiment of the same cultural daddy issues that Americans are so obviously desperately expressing through their bloated action movies. I don’t know what is going on in US culture but the entire nation is obviously on a desperate quest to find a decent daddy, and the President is the ultimate embodiment of that. This time around they got a gaslighting, domestic abusing dickhead for a daddy, or as one Facebook meme had it, “It’s like our cool dad left and mum has taken up with a jock driving a trans am” or something similar. This president beats his (metaphorical) kids and is letting the house go to ruin, and the kids are having a huge argument about whether to leave or kick him out or kill him and bury the body under the floorboards, while the neighbours look on in horror. And so it is that this movie comes out that is about a dude who finds out his dad is a murderous arsehole whose plans involve sacrificing his own son to take over the world. Right! No coincidence at all.

Furthermore we learn that this daddy – just like Trump – is a womanizing fool, who has been running around the galaxy impregnating as many women as possible, then luring the offspring back to his home and destroying them in an attempt to take over the world. This is such a transparent play on male sexual insecurities that it’s hard to believe it’s not deliberate, but then Quinn is such a silly useless character that it’s possible to believe that the writers really didn’t get where they were taking this. On another level it could be that this is actually some kind of deep, devious critique of imperialism, because a classic feminist critique of modern imperialist politics is that it consumes the flower of its own male youth to ensure that the older men get to rule over a wasteland. Under this critique the young men are also victims of Imperialism, though some lucky few of them from specific classes get to rise up and rule the roost later, if they can survive the slaughter. The first half of this critique was expressed often by the world war 1 war poets, who saw the destructive half of this sexist order up close in the trenches of the Somme and Ypres. In this movie our hero completely rejects the imperialist order, killing his cruel and destructive dad and destroying the means of domination then disappearing into the horizon with a rat[1] and a foreign woman. Revolution, man! Did the writers intend this as a super-subtle critique of Trump and the general republican politics of wars of choice and infanticidal consumption of their own children that has come to dominate US politics since world war 2? Or did their own overwrought daddy issues lead them to this allegory by accident, as a side effect of their desperate attempts to slay their own useless dad in a movie?

That was a rhetorical question: I don’t care. I just wish these people would get their daddy issues out of otherwise perfectly good movies, and find a better way to humourously critique the current order. Avatar provided a critical analysis of colonialism without daddy issues; Mad Max 3 managed to offer up a perfect piece of savage ecofeminism without any daddy issues. Why do we need to resort to such cheap and boring plot devices as “ooh daddy hates me” or “oooh daddy disappointed me” (or both) in American action movies. Please, please stop it. This could have been a great movie, but it was let down by a boring bad guy in a boring, hackneyed emotional dynamic with a callow main character. It’s still worth watching, but only so you can watch the supporting cast shine. That’s poor movie making, and it’s an insult to me the viewer that I once again have to sit through the same emotional baggage every time I watch an American action movie. It’s not even original emotional baggage.

American movie makers need to grow up. But despite that, go and see this movie for the first half. You won’t miss much if you walk out once Quinn meets his dad, but it’s probably worth sticking out to the end. Unless you get even madder than me at being forced to swallow this horrible medicine just to make the sugar go down, in which case I recommend rewatching the first one.


fn1: Sorry, not a rat. A trash bear.

Who doesn’t want to be this guy?!

Trigger warning: Long rant; gender and racial theory; I may use the qualifier “cis-” in a non-ironic way[1]; Since saying “male genitalia” or “female genitalia” is apparently bad, I may use the words “cunt” and “cock” to refer to the things they refer to; Aussie pride; excessive footnotes[2]; dead naming of dead dudes[3]; anti-Americanism; as always, sex positivity, along with a healthy dose of trans positivity (I hope, though maybe 800 people will judge me a bastard) and my usual disdain for radical feminism; insufficient or excessive trigger warnings

TLDR: WTF is going on with feminist philosophy?! Also, if you think that transgender people are serious and real and should be given full rights and respect, you probably also need to accept that transracialism is cool; but unless you’re American you probably already did, without even thinking that it was A Thing.

I just discovered a horrific conflagration overtaking the world of feminist philosophy, which has got me thinking about a concept that I didn’t even really know existed, but which is apparently A Thing: Transracialism. Transracialism is the practice of people of one race adopting the identity of another and living that identity even if they hadn’t been born into or raised with that identity, so superficially it has this transition process in common with being transgender. I’ve obviously been out of touch with left wing radical social ideals for a while, because I didn’t know that transracialism was A Thing, and that it is Bad while being transgender[4] is Good. In this post I want to talk about transracialism and the stultifying consequence of Americans hogging the debate about sex and race, and also about the disastrous state of modern leftist discourse[5] about so many things.

The controversy concerns an interesting paper in the philosophy journal Hypatia, discussing some of the logical consequences of accepting transgender as a real and serious issue[6]. The article, In Defense of Transracialism, examined the similarities between transitioning to a new gender and transitioning to a new race, and argued that logically if you accept one you really run onto rocky ground if you don’t accept the other. For case studies (and not, apparently, as the fundamental logical basis of the argument) the paper presented the case of Caitlyn Jenner as a transgender, and Rachel Dolezal as a transracial person (“transracer”?) As we know, Jenner got widespread public acceptance for her decision, while Dolezal received widespread public scorn. The article argues in what, to me at least, appears to be a quite tightly reasoned and accessible style, that it’s hard logically to accept one and reject the other, and maybe that means transracialism is actually okay.

The paper was published in March but recently a bunch of Associate Editors connected to the journal published an open letter demanding that the paper be retracted because its publication caused many “harms” to transgender people, and because it was academically poor. The outline of the case, and a solid takedown of the public letter, can be read at this New York Magazine post. It should be noted that the author of the paper is a non-tenured Assistant Professor, a woman, who is therefore quite vulnerable in a highly competitive field dominated by men, and that some of the signatories to the open letter were on the author’s dissertation assessment committee, which makes their signing the letter an extremely vicious act of treachery, from an academic standpoint. For more background on the viciousness of the letter and its implications for the author’s career and for the concept of academic freedom, see Leiter Reports, a well known philosophy blog (e.g. here) or the Daily Nous (e.g. here). It appears that the author has a strong case for defamation, and that many of the leading lights of feminist philosophy have really made themselves look very bad in this affair. (In case you haven’t gathered, I am fully supportive of the author’s right to publish this article and I think the open letter, demand for retraction, and pile-on by senior academics to an Assistant Professor near the beginning of her career is a vicious over-reaction of which they should all be deeply ashamed).

Beyond the obvious bullying and the ridiculous grandstanding and academic dishonesty involved in this attack on the author[7], I am disappointed in this whole issue because it is such a clear example of how Americans can dominate feminist (and broader social justice) debate in a really toxic way. I’ve discussed this before in regards to the issue of sex work and radical feminism, and I think it needs to be said again and again: American influence on left wing social debates is toxic, and needs to be contained. Just look at the list of signatories to this attack on this junior academic – they’re almost all American, and this is yet another example of how America’s conservatism, it’s religious puritanism, its lust for power, and its distorted republican politics, combined with its huge cultural output, is a negative influence on left wing politics globally.

I’m also really interested in this paper because I think it shows not just that transracialism may actually be an okay idea, but when I thought about the implications, I realized that I think most people on the planet already accept transracialism, and if Rachel Dolezal had occurred in any other country we would probably just have shrugged and got on with our lives. So in this post I’d like to discuss what Americans can learn from other countries’ approach to race.

Transracialism in Australia

Just to clarify, I was born in New Zealand to British parents and moved to Australia aged 13, taking Australian citizenship when I was 21. My grandfather was a Spanish war hero, a proud soldier in the losing side of the civil war and a man who spent nine years fighting fascism, and I was raised by him and my (deeply racist, white) British grandmother for two years as a child. So actually I’m a quarter Spanish, and so in theory I could have been raised Spanish but wasn’t, and don’t know anything about my birth race, which at various times in history has been defined as a separate race or just a culture. This makes me probably really normal in Australia, because Australia is a nation of immigrants making a new life in a land swept clean by genocide. It’s my guess that if you grew up in Australia you know a lot of mixed-race people, and if you paid any attention to the discussion of the Stolen Generations in the 2000s you’re aware that race is a very contested and contestable concept, and that Australian government policy has always assumed that race is a mutable concept subsidiary to culture. I think it’s likely that if you grew up in Australia you will know at least one of the following stereotypes:

  • An Aboriginal person who doesn’t “look” Aboriginal, and who maybe has no connection to their Aboriginal culture; you may even not be sure if they are Aboriginal, suspect they are but don’t know how to ask
  • A young Asian Australian who looks completely Asian, acts in ways that are stereotypically associated with Asian Australians (e.g. the guy holds his girlfriends bag for her, the girl is a complete flake in a very Asian Australian way) but is in every other way completely and utterly unconnected from their Asian heritage and is thoroughly through-and-through “whitebread” Australian
  • A completely Australian guy who speaks fluent Greek and goes back to Greece to “be with his family” every year
  • A person who has discovered that they have an ethnic heritage of some kind and is trying to recover that heritage in some way that might inform them about their own past, even though they are effectively completely disconnected from it, but they are clearly serious about rediscovering their heritage and all their friends and family support this apparent madness
  • A black or dark-skinned Australian who literally knows nothing about the culture of whatever race gave them their skin colour

If you’re a little older, like me, or know a wide range of older Australians, you may also have encountered an Aboriginal Australian who was stolen from their family at an early age and raised white but is on a bittersweet quest to recover the heritage they never had – and may have found that that heritage was extinguished before they could be led back to it. When I was 20 I was paid to provide maths tutoring to a bunch of 50-something women who were training to be Aboriginal Teaching Assistants – a kind of auxiliary teacher who will assist fully qualified teachers in remote Aboriginal communities – and some of them couldn’t even do fractions. When I asked how they missed such an early stage of education they told me they were taken to “the mission” when they were young, and didn’t get a proper education. I was young and this kind of issue wasn’t discussed then but now I understand that they were from the Stolen Generation, and were at various stages of understanding of their own racial heritage. They were going back to help their community, and recovering their own heritage, not just to settle the question of their own background but also to right wrongs done and change society[8]. These kinds of people are a normal thing in Australian cultural life. But can you look at that list of archetypes and say they aren’t all in their own way transracial? Indeed the underlying philosophy of the Stolen Generations was that you can eliminate racial traits of Aboriginality in half-Aboriginal people simply by raising them white; and the underlying principle of Multiculturalism is that culture transcends race, and we can all get along. Also in Australia there is a lot of tacit recognition of the problems second and third generation migrant children go through as they “transition” from the cultural heritage of their parents to that of their born country, where although racially they’re distinct from the majority they are clearly culturally more similar to the majority than to their parents. In the 1990s this was happening with Greek and Italian kids, in the 2000s with Vietnamese kids, and in the 2010s with Lebanese kids. Everyone in Australia knows that this happens, which surely means that everyone in Australia sees transracialism as a common pattern of multiculturalism.

Since I’ve moved to Japan I’ve seen this confirmed in many ways, but the best I can think of is a child I knew in a rural country town. His parents were both white New Zealanders but he had been brought to Japan at the age of 3 and raised in rural Japan, and when I met him at 17 he was thoroughly and completely Japanese. He didn’t speak English, communicating with his parents in a mixture of Japanese, really really bad English, and typical adolescent boy grunts. He hadn’t experienced much racism in Japan and had been sheltered in a very nice and welcoming rural environment, had a good group of close Japanese friends, communicated in the (ridiculously incomprehensible) local dialect, and was a typical cloistered Japanese boy. But he was also a big, white lump in his Japanese world, standing out like dogs balls. His race was irrelevant to his cultural background, except that he knew he was “white” and that therefore every Japanese person who ever meets him will engage in a boring conversation about why he is so. Fucking. Japanese. How is this not transracialism? Sure, a lot of transracial experience is not a choice per se, but whether it is a choice is surely irrelevant to the fact that it is completely possible and that for some of us – probably only a small proportion – changing “race” is a choice we feel compelled to make. I.e. not a choice. Rachel Dolezal might be a bad example, but whatever her motives might be, is her ability to do it under question? I would suggest that from an average Australian perspective, it is a completely ordinary concept. The only thing at issue is “why?” But since most well-meaning people don’t impugn the motives of strangers, who gives a fuck?

Race is a social construct

The possibility of transracialism becomes even clearer when you recognize that race is a social construct. This doesn’t mean race doesn’t exist – it clearly does – but that it is an invention of humanity structured around clear physical lines, not a real thing. While there is a clear difference between black and white people, there is no boundary at which this difference can be defined, and no genetic markers that clearly distinguish between one and the other. This isn’t some weird fringe idea popular only amongst Black Panthers, but a fundamental plank of modern science, reasonably well accepted at least in the biological sciences and anthropology. When we talk about races what we really are referring to is distinct cultural identities that can be mostly distinguished by noticeable visual cues (e.g. Nigerians are black, and stress the first syllable of every word in a cool way). This also means that race has very little influence on the culture you can actually adopt, which is why although I’m a quarter Spanish I’m completely white, while there are Aboriginal or Maori people who are one quarter Aboriginal but completely wedded to the culture of that quarter.

In comparison, sex is an absolute category that is definable and distinct. It has a chromosomal origin, and multiple definable, distinct characteristics. It is also clear across cultures that men and women tend to be different in many physical and personality characteristics, though these aren’t always the same in every culture and there can be lots of differences between people of a single sex between and within cultures. But sex is a clear, binary concept that, for all its massive cultural baggage, is not independent of its biological underpinnings. This, by the way, is not an idea anathematic to feminism – lots of feminists accept that the sexes are fundamentally different, and although there may be argument about to what extent these differences are biological vs. cultural, there is a large body of feminist work that assumes these differences are real and important.

And yet still people can want to change sex. Really want to change sex! And this phenomenon is common across almost every culture, though it receives higher levels of acceptance in some cultures (e.g. some Asian and Indigenous cultures) than others (e.g. modern USA). It’s also clear that you can’t force someone to change sex the way you can race. You might be able to “breed out the colour” of “half-caste” Aboriginal people by stealing them from their parents and raising them in a white family, but you can’t breed out the pink by forcing a girl to grow up as a boy – she’ll still know that she’s a girl. The same is true of sexuality of course – most people can define their sexuality clearly by the gender of the people they fuck, but we have no evidence that you can change that, no matter how hard you try. We know in fact that down that road lies tragedy. And so most of us take people’s sexuality – and the right to express it freely – very seriously. Yet most of us also accept that the right to change sex, to express a desire to be the opposite sex to our birth sex or even to be a third sex, very seriously as well.

So why not race? It’s way more fluid than gender, it has no biological basis, and we have huge amounts of evidence that people do it by accident all the time. Yet when Rachel Dolezal was outed as white she attracted general derision across the political spectrum; and Trump trades on the Pocahontas slur for Elizabeth Warren, whose sole crime apparently is to have been raised thinking she might have Native American heritage. There’s clearly something wrong with this picture, especially if like me you grew up in a race-fluid environment. Why is it so wrong to be transracial?

The toxic American influence on sex and race debates

Of course in America race is not a simple issue, because of slavery. America has a complex, toxic and quite unique racial environment which makes it very hard for Americans to react reasonably to these debates. Just consider the “politically correct” term for black Americans – African American. How is this not a transracial identity? Africa is neither a country, nor a culture, nor a race. Being “African American” is a completely concocted identity, a race that didn’t exist until the 1970s and the advent of pan-Africanism. Nothing wrong with that per se, obviously, but it leads to strange contortions in which, for example, the previous president[9] was dismissed as not “African American” enough by some of his critics even though his dad was Kenyan. We also see unedifying moments like this, where we discover that one of Dolezal’s trenchant critics was raised in a white household from the age of 2, and has clearly made a conscious choice to be black – but rejects Dolezal’s choice on clearly spurious racial grounds.

I think the problem here is simply that Americans need to come to terms with their own racist history, and simultaneously with their role as centre of empire and cultural hegemon. It’s not just that white Americans are beneficiaries of a long history of slavery, or that a sizable portion of white Americans can’t even yet accept that slavery was really wrong, or that treason in defense of slavery was really bad. It’s also the case that black Americans are simultaneously deprived in their own country but hyper-privileged globally, benefiting from many of the profits of empire just as their white compatriots do. This is why, for example, in response to the water poisoning crisis in Flint, Michigan we heard so much about how this was happening “even in a developed country” – black Americans are used to certain basic things that many of the people in America’s tributary nations don’t get. Similarly, black Americans can talk about pan-Africanism while black Americans are bombing Libyans. This is a complex, messed up problem that Americans have to come to terms with before they preach to the rest of us about transracialism. Combine this with America’s well-established puritanism and religious extremism, and you have a perfect storm of stupid. It makes you wonder why they even bother doing philosophy.

It also makes me think that they don’t really have a proper grip on some of these issues. Instead of talking about their own race issues, I think a lot of American feminists could stand to look around the world and learn from others. Australia has a unique culture of multiculturalism and acceptance that, while far from perfect, offers important lessons on how to negotiate racial conflict. We also have a history of genocide and responding to genocide that is deeply entangled with old fashioned racial theories that still seem to have some influence on both the left and right of American politics. But as an Australian I think we have learnt a lot and grown a lot, both about sex and race, in ways that Americans need to learn from. Instead, however, these American philosophers seem to think that their experience of race is unique and universal. I even recently stumbled across a tweet by a “key” philosopher of transgender issues (American) who claimed that transracialism had never been practiced anywhere except by one person (Rachel Dolezal). What a joke! This shows deep ignorance of broader issues of race and culture and a kind of infantile understanding of what the rest of the world is doing. I bet right now there are huge debates going on in China in Chinese about people faking ethnic minority identity (or vice versa) that no American philosopher of race even knows about, let alone can turn into a lesson for American philosophical dialogue.

I think it’s time Americans learnt some humility. America is a nation of religious extremists with a history of slavery that just elected an orange shitgibbon for president. Some humility would be in order.

And a little less bullying too! So if, like me, you think that this article might have pointed you to a phenomenon that is more common than you think, that you didn’t even know existed, maybe you should read it. And then reconsider whatever passing judgement you might have made of Rachel Dolezal, and ask yourself how easily the media are fooled by ugly narratives, and what that says about their quality.

And then, I guess, be whatever race you want to be!


fn1: Google it!

fn2: Including but not limited to references to Aussie pride

fn3: Until today I didn’t know that this term existed, though I think that I probably tried to avoid doing what it refers to. Google it!

fn4: You’ll note that I am writing “transracialism” but not writing “transgenderism”. This is because apparently the latter term is offensive while the former is not; and this has nothing to say! Nothing at all! About how one of these processes is accepted by those who police our language in the name of social justice, while another is not.

fn5: Add “will non-ironically say ‘discourse'” to the trigger warnings! Too late!? Too bad!

fn6: Because for arbitrary and stupid reasons I can’t say “transgenderism”, every sentence where I want to refer to the process or state of being a person who is transgender is going to involve these slight awkwardnesses of English language. I’m going to stick to the politically correct phrasing here, but I hope that everyone sees how awkward this is, and how telling the acceptability of one -ism but not another -ism is.

fn7: I’m making a decision not to name the author because I suspect that if things go badly for her and the paper is retracted she is going to want her name not to be associated with the paper that she struggled over; I know that my actions won’t make a difference to the google search results, but I choose not to add to them. Nonetheless I think this is work she should be proud of and I hope she doesn’t have to retract or disavow it. Also what kind of budding philosopher wants their name turning up on a disreputable blog like this, associated with fantasy gaming and sex positivity?!

fn8: And they were being taught fractions by an ignorant white dude half their age. Can you imagine the indignity!? But they were very nice to me, and I think I did a good job of the teaching. But teaching fractions is HARD.

fn9: Please come back!

In the wake of the Republicans’ catastrophic inability to repeal Obamacare, many people have begun to accept that the Patient Protection and Affordable Care Act is the new basis on which the US health system will be built. This means that for the foreseeable future, assuming the Republicans are not able to suddenly develop a competent and coherent health financing agenda, progress towards universal health coverage (UHC) in the USA will depend upon improvements of and reform to the free market system as it is regulated by Obamacare. Obamacare is unusual among developing nation health financing systems for its heavy reliance on private insurers as the fundamental providers of risk pooling, as opposed to most other health financing systems where some form of government insurer provides the overwhelming majority of national health financing. For a lot of critics of Obama and Clinton from the left this is seen as a failure, and a sign that they are neoliberal sellouts: under this view of health financing reform, no market-based system will work and Obama sold out his own supporters when he put forward a plan that did not include single payer or a public option. For conservative policy makers in non-crazy countries – for example the UK[1] or Canada – and also in developing countries moving towards UHC, this offers an opportunity to see whether a free market approach to health financing can deliver the key goals of universal coverage and financial risk protection. The problem for conservative thinkers on health care is that there seems to be very little evidence that free market systems work, and the problem for left wing critics of Obamacare is that there is no evidence single payer could have been delivered in the modern US political environment. So for both far left critics and moderate right wing admirers of Obamacare the obvious question is: can UHC be achieved without a single payer system?

This week’s issue of the Journal of the American Medical Association has published an opinion piece addressing this issue. Entitled Achieving universal health coverage without a single payer: Lessons from 3 countries, it gives a brief overview of how Singapore, Germany and Switzerland have achieved UHC with at least nominally non single-payer systems. It attempts to address some of the key differences between these systems and the USA, and some ways in which the health market in those countries is different. Since JAMA is behind a pay wall, I thought I would give a brief summary of a few of these points.

First the article opens with a clanger, asserting that “Universal coverage is a top priority not only for Democrats but also for President Trump,” which does lead one to wonder how critical the authors are. It then goes on to dismiss summarily one of the key ideas raised by Republicans for making private health coverage more affordable in the US: high risk pools. The intention of a high risk pool is that patients with high cost or pre-existing conditions be offered insurance from a special fund financed by the government, thus removing them from the main private insurance risk pool and enabling insurance companies to reduce the cost of mainstream health insurance products. The problem with this model is that it is enormously expensive and there is no evidence that it works. The article points out that no US government will be able to justify the amount of money required to properly finance high risk pools, and that it probably costs upwards of 8 billion US$ a year to do this. It also notes that – contra Paul Ryan’s assertion that pre-ACA high risk pools worked great – most of the state-based high risk pools in the pre-ACA era were hideously expensive and did not work. The article also points out that a preferred strategy of some left-wing critics of Obamacare – shifting high risk patients onto Medicare – may also not work, since Medicare is already a high risk pool and expanding it by dumping in the highest cost patients will be impossible without increased funding (the article uses the language of sustainability, about which I’m suspicious because of its origins, but it cites well-respected sources on the challenges of continuing to finance Medicare if it is treated as a high risk pool).

So given this, the only way that a private system will be able to achieve universal coverage is if everyone is enrolled in insurance, and insurance is properly financed. The article describes the systems in Singapore, Germany and Switzerland, and how each of them force all their citizens into insurance coverage. For example, about Singapore it says:

Singapore institutes compulsory contributions from employers on behalf of their employees to create medical savings accounts. Employees maintain these accounts for health care expenses such as health and disability insurance premiums, hospitalization, surgery, rehabilitation, end-of-life care, and outpatient services. Those failing to pay their premiums are subject to garnished wages and other legal actions that can force payment of back premiums, penalties, and interest. Unemployed or low-income individuals are eligible for government subsidies that enable them to pay for the premiums.

and it points out that Germans are enrolled automatically in “private” funds that take a guaranteed 7.3% of their income. It’s hard to imagine any such plan being popular in the modern US, where the individual mandate has been subjected to years of withering don’t-tread-on-me type criticism and the idea of paying an income-based premium is terrifying to the GOP’s donors. In Switzerland and Singapore, where the systems do not use tax-based payments, they have government subsidies for (according to the article) up to a quarter of their population. So these systems – which by all accounts are functioning, affordable and tolerated by their citizens – share Obamacare’s key tactics of means-tested subsidies and individual mandates.

The article also makes the point that these systems have a very healthy free market structure, with much more vibrant private markets than the USA:

Germany in 2015, for example, had 124 sickness funds and 42 private health insurance companies, and the average resident of Switzerland in 2011 could choose from 59 health insurers offering coverage, with the 5 largest insurers covering 43% of the population. By comparison, in California, a state with approximately half Germany’s population, only 7 firms covered more than 95% of privately insured individuals in 2011, with the 3 largest firms covering 75%. In Massachusetts, with a population slightly smaller than Switzerland’s, 3 insurance companies enrolled 79% of individuals with private insurance.

I think this might be pushing the comparison a little bit, because many of the “sickness funds” in Germany are likely union-run or industry-based mutual associations with very strict management criteria, non-profit structures and guaranteed membership, and they may be regionally based so not actually directly competing with each other[2]. Also, I’m very confident that all three countries studied have rigorous price regulation and strict government oversight of providers (hospitals and clinics), so that they cannot for example price gouge the insurance provider for an infamous $500 band aid as they can in the USA. It’s much easier for private insurers to compete with each other for market share when they know what the cost of the insurance payout is likely to be, and can be confident that the provider won’t charge them arbitrary amounts, and I suspect that this certainty also removes a whole layer of administrative staff at both provider and insurer, for which the US system is infamous.

Having given an overview of these systems the article draws a simple conclusion and gives a firm recommendation: Obamacare needs tougher enforcement of a more punishing individual mandate. I think this conclusion is only partially correct, missing the role of price regulation and cross-subsidization from general taxation that protects these private markets.  So I think that the article is a little strong in concluding that the USA can definitely achieve universal health coverage without at least, for example, introducing a public option to every market place (or at least the rural areas). But it does make the point that a better regulated insurance market with better subsidies and a much tougher mandate would likely encourage competition, and achieve universal health coverage (or close to it) without driving up costs. It certainly seems that the architects of Obamacare knew this and had a long term plan for its expansion and improvement, and assuming the world survives Kim Jong Il’s birthday this weekend, hopefully the Democrats will be back in power in the USA soon enough to begin taking the next steps along that road. I’m not convinced yet, but it is still possible that Obamacare could show the way to a genuinely private, free market alternative to achieving UHC without single payer. In my view, however, if Obamacare (and human civilization!) does survive the Trump presidency, it is likely to become an increasingly state-regulated and state run system, rather than a robust private market place, because introducing a public option, slowly squeezing out private provides, and then making health insurance premiums fully means-tested and tax-based, is a much more reliable way to make everyone happy.

Still, for genuinely interested conservative policy-makers outside of America (whose “conservatives” have no interest in anything resembling policy), the next few years of Obamacare offers an exciting opportunity to develop new pathways to UHC. Given the complexity of movement towards UHC in some low income countries, and the very limited government finances in many of them, it would be interesting to see whether Obamacare’s roll out, expansion and improvement offers a new and more viable pathway to UHC than those currently on offer. I’m not holding my breath, but it will be interesting to see what lessons we can learn from this new and quite unique approach to one of America’s (and the developing world’s) big remaining problems.

First we have to survive the Trump presidency, though.


fn1: Caveats on the use of “non-crazy” should be inserted here, especially after Brexit

fn2: Interestingly, these sickness funds sound a lot like the non-profit mutuals that Obamacare was supposed to encourage, and which US “conservative” critics of Obamacare constantly sneer at and declare completely unviable.

By now everyone has learned the news that after 17 days of massive effort to try and force it through the legislature in the dead of night the Republicans have given up on their godawful attempt to repeal and replace Obamacare, and have accepted that Obamacare is now the “law of the land.” Having made no effort at all to reach out to Democrats, and after trying to push it through the Senate using a reconciliation process that was explicitly designed (and admitted) to negate Democrat votes, Trump’s first act of contrition for his and Paul Ryan’s failure was to blame the Democrats for not working with him. He went on to repeat the lie that Obamacare is “exploding” (it’s probably not) and openly admitted that he is going to try and hasten its collapse through executive action, following the logic that a program initiated by Democrats that is screwed into the ground by a Republican government will somehow be seen to be the Democrats’ fault.

Trump initiated this process of screwing Obamacare on his first day in office, when he passed a notoriously vague executive order that instructed all responsible departments to not comply with the details of the law to the extent they could legally get away with. A lot of people were duly concerned about this, because there are a lot of aspects of Obamacare that rely on administrative guidance that can be modified by the government in power. So this week’s New England Journal of Medicine has a short editorial by Jost and Lazarus about whether Trump can actually successfully undermine the workings of the act through administrative action alone. The two authors appear to be lawyers, one with a connection to the Constitutional Accountability Center, which supports the cause of “progressive constitutionalism” (which appears to be the idea that the Constitution is a living document whose interpretation can change over time), so presumably their understanding of constitutional law is fairly good.

The authors point out that reaction to Trump’s executive order ranged from fear to snorts of derision, and proceed to show at least one way in which it has failed bigly. One of the big fears expressed in initial response to the order was that the Inland Revenue Service (IRS) would stop collecting taxes it is required to under the “mandate”, the unpopular part of the law which punishes through the tax system anyone who does not purchase insurance. This was probably Trump’s intention in passing the executive order, but it turns out the IRS ignored him: it admitted on February 15th (a month after the order was signed) that it was still collecting mandate taxes, and that it’s sole response to the order has been to shelve a planned crackdown on tax evasion related to the mandate.

The authors point out why this should be unsurprising: government agencies are required to enforce the laws of the land, and there is a long-standing history of jurisprudence forcing them to. They point out that in fact

it is one thing to delay temporarily a legal requirement or to phase in a new law to facilitate adjustments by affected people or entities; it is quite another to refuse outright to enforce a law already in force, with the aim and effect of undermining that law. The Supreme Court has said that courts may step in to correct any such “abdication” of the executive branch’s duty to faithfully execute the law.

Apparently the highest court in the land has built up a body of precedent which requires government agencies to enforce government law, and the authors seem quite confident that if agencies don’t do this, court action would likely force them to. They go further than this, though, considering the hypothetical case in which the IRS bends the definition of “financial hardship” sufficiently to enable anyone affected by the mandate to be exempted from it on the basis of “financial hardship” (apparently some devious Republicans had considered this oily move). They write:

In a critical 2015 Supreme Court case upholding nationwide availability of ACA “premium assistance” tax credits for eligible low-income insurance purchasers, Chief Justice John Roberts held that courts and agencies must interpret and apply individual provisions of a law — indeed, of the ACA in particular — so as to further its overall “legislative plan.” Roberts concluded: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. . . . [W]e must interpret the Act in a way that is consistent with the former, and avoids the latter.”

This might seem quite reasonable to outsiders, but apparently in America the idea that government agencies must act according to the legislative intention of the law of the land is novel and requires clarification from the Supreme Court.

(Also note that this statement was made by justice John Roberts, a conservative judge appointment by Bush Senior, not one of those quisling liberals who think all toilets should be unisex because they’re radical feminists!)

In conclusion the authors are unconvinced that Obamacare can be undone by administrative action alone, though they concede it could become less generous and function less smoothly as a result of meddling. But the Republicans need to be careful here, since administrative overreach in this regard is likely to be punished by the courts, stacking further humiliations on Trump’s already woeful record of mistakes and inactions. Worse still, there is a big and growing split in the Republican movement over Obamacare, and signs that some of the 19 states that resisted the Medicaid expansion are going to cave, further entrenching Obamacare’s role. In particular Kansas, whose economy has been completely wrecked by Republican Crazy Caucus economic ideals, is desperate for money and is very close to taking the Medicaid expansion because balancing the budget will require the extra money. Virginia’s governor is also trying to get that state covered, and activists are using failure to take the expansion and its associated funds as a stick to beat Republicans locally. With Trump’s popularity nosediving, the collapse of the American Health Care Act showing the impossibility of reform through Congress, and many of the areas that voted for Trump most vulnerable to executive action, it is unlikely that vulnerable Republicans are going to want to push this issue at a local level. So the conclusion of this opinion piece in the NEJM is that while Obamacare won’t work as well under Trump, it is unlikely to be seriously damaged. And the longer it continues to function, the harder it will be for Republicans to repeal it or to continue to even talk about it. My guess is that over the next two years – and especially as the mid-term elections approach and it begins to look like a wave election is going to swamp a lot of Republican congress people – we will see more states take the Medicaid expansion, and moderate Republicans begin to talk strong talk about repairing the existing law rather than destroying it. Whether any of them survive the mid-terms will be another question entirely – but if they don’t, they will be replaced by angry Democrats, raising the possibility that after a wave election in 2019 the Dems might be able to force a veto-proof bill across Trump’s desk, requiring him to sign a public option into law.

Regardless of what happens at the next election, though, it appears that there is no easy way for the Republicans to undermine Obamacare enough to destroy it, and it would be increasingly reckless of them to try. Obama’s legacy looks to on increasingly solid ground, and I think it’s now safe to say that he was one of the greatest of the modern presidents. Who would have thought a Kenyan Muslim could go so far!?

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.