It's personal

Syrian doctor studying in U.S. stuck abroad, while his pregnant wife is here in Providence. Specifically, he's Khaled Almilaji, who is a student in our School of Public Health of which I am a faculty member.

He says the United States is enriched by many cultures and that would be a sad thing to lose. The 35-year-old Almilaji received a scholarship to earn a master’s degree in public health at Brown University. He moved to Providence in August on a student visa with his wife. Almilaji coordinated a campaign that vaccinated 1.4 million Syrian children and provided medical care during Syria’s civil war.

Thank God we're safe from him.

There's more to the ACA than health insurance

It's amusing to watch the Republicans continue to flail as they try to figure out how to screw millions of people out of health care without getting blamed for it. But they can do a lot to make health care in the U.S. worse without it being so obvious.

For example, the ACA includes funding for the Center for Medicare and Medicaid innovation, which supports demonstration projects to find way of delivering better care at lower cost. If you read this blog, you know that we pay a lot more for health care than other wealthy countries -- yeah, the ones who cover everybody because of socialism -- and we get worse results. Because freedom. CMMI is trying to bend the cost curve down while getting better results. But of course you have to spend money to do that, so socialism.

The ACA also established a fund for public health programs to prevent chronic diseases. Oh yeah -- it goes to the states. But that costs money too, so socialism.

Then there is the Patient Centered Outcomes Research Institute (which, full disclosure, has funded some of my research). PCORI compares treatments to learn which are better. Of course, that also costs money, which comes form a tax on insurance premiums, so socialism.

If they repeal all this, it will just make us less healthy in the first place, we'll pay more for health care, and we'll get worse results. But that's better than socialism. Oh wait, I mean it's better than making rich people pay taxes.

Repealing the Enlightenment

PZ Myers reviews the "president's" war on science. Go ahead and read it. Here's my personal stake:

The lunatics who have taken over the country seem to want to undo the Enlightenment. That isn’t actually possible but they can cause horrible carnage. I’m an NIH-funded researcher and our entire school of public health largely depends on federal funding — and a lot of it is stuff that Republicans don’t like. They don’t want to know about social determinants of health, inequities, health of people they don’t like such as gay men and drug addicts, marketing of drugs for useless or unsafe purposes, hospitals raking in money for useless procedures, and a whole lot else. So yeah, I’m worried.

Objectively Evil

I don't know if you remember, but the popular vote loser in the recent presidential campaign promised repeatedly that he would not cut social security, Medicare, or Medicaid. Purportedly that helped him get votes from people who don't normally vote for Republicans.

Uh huh. His nominee for secretary of HHS wants to cut Medicare and Medicaid spending, by a lot, and in his confirmation hearing he refused to say that he would honor Trump's promise. No surprise, Trump's flunky KellyAnne Conway now says yup, he wants to convert Medicaid to a block grant, which is just a path to cutting it.

If you're like most people, you probably think that Medicaid spends all its money on welfare queens in Cadillacs trading food stamps for vodka. Actually 21% is spent on elderly people (much of that going to people in long-term care in nursing homes who have exhausted their assets); 42% on people with disabilities; and 21% on children.

When the money goes away, what happens? I'll bet you can figure it out.

System and Lifeworld

That's the subtitle of the second volume of The Theory of Communicative Action, by Jurgen Habermas. It's very heavy going so I don't necessarily recommend that you try to read it. But it seemed like a good title for this post.

Our modern, complex society is nothing like the kind of societies in which humans evolved. People lived in bands in which everybody knew everybody else, in fact they had varying degrees of kinship, and they communicated face-to-face. Many people are still part of communities like that, to some degree, although for most of us they are more diffuse. We're mobile, we don't see most of our kin regularly. Most of our daily interactions are in the form of narrow role relationships -- worker and boss, customer and server, teacher and student, colleague. And of course there is a vast system of mass communication that is our only window into a world far wider than the village or band, that affects us in ways that are often mysterious, in the face of which we feel largely helpless.

People's brains aren't really built for this. It's not hard to understand why people who are frustrated about the conditions of their lives would have mistaken ideas about what is causing their problems and what to do about it. It's perhaps a bit less obvious, but I hope it is now that I point it out, that messages may come through the system that people perceive as slights, or offend their sense of propriety. But in the old days any such message would come from a person you could have a conversation with. You could tell them how you felt, hopefully work out an understanding, or choose to avoid that person in the future. But people can't talk back to their televisions.

NPR has devoted about half of its news content of late to interviews with Donald Trump supporters. I can't even listen any more, I turn off the radio during my commute whenever they do this. It's just too disturbing to realize that we wound up with a malignant narcissist, authoritarian blithering idiot as president because these people are so deeply incapable of critical thinking. But as Chauncey DeVega explains, perhaps with a subtext less sympathetic than I would like, the shit will hit the lifeworld.

No, they won't get well-paying jobs bolting cars together or mining coal. If the Mexicans all get shipped back to Michoacan, their food will get more expensive. In fact, more of it will be imported and a lot of the local farms will go out of business. If we throw up high tariffs, everything in WalMart will cost more and our export industries will decline. If they repeal the affordable care act, a lot of them will lose their health care and it will get more expensive for the rest of them. And those are just the promises Trump made that they thought they liked. He's going to trash their public schools, make them breathe toxic fumes, cut their social security benefits, and oh yeah, their taxes will go up even as their wages go down.

The dirty secret is that federal taxpayer funds flow from states with liberal electorates to Republican states. As DeVega writes:

As philosopher Henry Girioux has repeatedly warned, the “dead zone of capitalism” will only be expanded by Donald Trump and the Republican Party’s obsessive advancement of predatory capitalism and austerity. “Red State” America is already economically unproductive and parasitic, largely dependent on the taxes and economic activity generated in “Blue State” America. As such, Trump’s policies will disproportionately punish his greatest supporters.

So what will happen when they look around in a couple of years and find themselves worse off? We'll find out.

The dog who caught the car

It's actually amusing watching the Republicans in congress flailing around trying to figure out how to repeal Obamacare. It turns out they didn't actually understand what it does and have no idea of what to do instead. Here's Sen. Schatz (D-HI) telling the amusing tale of Republicans begging him for help because they don't want to own what they are about to do.

"They want to be able to claim this is part of a good faith negotiation, but it's simply not.They have no idea what comes next so they want some bipartisan cover for their nonsense behavior," Schatz said.

He also said Republicans were looking for Democratic cooperation so that they can share the blame."They're really worried because anyone who pays any attention to health care knows exactly what is about to happen to the system, to the market and to individuals, and they don't want to be blamed for it so they're trying to see if they can take us off the cliff with them and we aren't going to abide by it," Schatz said.

They've been spending the last seven years telling people they're supposed to hate the Affordable Care Act, but they never got around to explaining why they are supposed to hate it. The fact is, the only way to extend affordable coverage to the population is to do what the ACA does: get everybody into the pool, require community rating (i.e. don't charge more to sick people), and provide subsidies for low income people and families. There's no other way. The ACA is something of a Rube Goldberg contraption, but that's because Congress is unwilling to pass the right solution, which is:

Universal, comprehensive, single payer national health care.

UPDATE: I commend to your attention Kevin Drum, who also asks why Republicans hate Obamacare. He notes that when polled, people like all the individual pieces of it; they also like it much better if it's called Kynect or the Affordable Care Act. Quoth Mr. Drum:

So why the continued rabid opposition to Obamacare? It's not because the government has taken over the health care market. On the contrary, Obamacare affects only a tiny part of the health insurance market and mostly relies on taking advantage of existing market forces. It's not because the benefits are too stingy. That's because Democrats kept funding at modest levels, something Republicans approve of. It's not because premiums are out of control. Republicans know perfectly well that premiums have simply caught up to CBO projections this year—and federal subsidies protect most people from increases anyway. It's not because everyone hates what Obamacare does. Even Republicans mostly like it. The GOP leadership in Congress could pass a virtually identical bill under a different name and it would be wildly popular. In the end, somehow, this really seems to be the answer:

Republicans hate the idea that we're spending money on the working class and the poor. They hate the idea that Barack Obama is responsible for a pretty successful program. They hate the idea that taxes on the wealthy went up a bit. They hate the idea that a social welfare program can do a lot of good for a lot of people at a fairly modest price.
What kind of person hates all these things?

Words of Wisdom

As I've been struggling to understand how so many voters -- not the majority,  we need to keep repeating -- but a lot, could have possibly thought it was in their interest or the world's to make a malignant narcissist, raging idiot and bigot president of the United States, along comes George Lakoff to remind us of how electoral politics really works.

I have noted that most voters have little understanding of public policy. I'm a particularly rational type of person. I try to collect information and work out the logic of problems. I study public policy the way academics do, because that's what I am. But few people have the time or inclination to do that. People live in constructed worlds, what Lakoff calls frames. Any information that doesn't fit in the frame will be ignored, disbelieved, or dismissed as anomalous.

What he is a bit less explicit about, but I believe he would agree with this formulation, is that the frames are built out of words. There are images in there as well but Lakoff focuses mostly on language. The words connect with each other in a web of presumptive causal and affinal relationships, and they have positive and negative connotations. Lakoff also says that frames contain value systems, and he sees a divide in U.S. (and possibly other countries') political culture between a system based on the view of the family as nurturant, and a contrasting view of the family as authoritarian. The family is our fundamental metaphor for the organization of society at higher levels, so these views of the family shape people's political allegiances.

Conservative political activists understand all this better than liberals because they study business and marketing in college, while we're off studying history and biology and useless stuff like that. Marketers know how to reach people, and they are totally amoral. Sell the sizzle, not the steak, the saying goes. Buy this car and you'll get a hot girlfriend. Drink this beer and you'll be a fascinating person. Vote Trump and win, win, win!

We need to learn these lessons. Elections are not machinery for turning people's self-interest into policy. If they were, the self-interest of 5% or less of the population would not continually prevail. We need to get a bit cynical, I think, and start talking to people in their own language.

Anyway, read Lakoff.

Tragedy or Farce?

It's getting to the point that I can't write anything because I don't know where to begin. The idea of Donald Trump as president was preposterous from the beginning, but nobody could quite imagine what the reality would be like. At this point it's an even bet, for me, whether the Trump presidency self-destructs in an explosion of idiocy, or whether it destroys us first.

The oppo research memo on the Russian connection is a lot of fun, but the absurd prospect of appointing RFK Jr. to head a presidential commission on vaccine safety is more telling. This will almost certainly not end up convincing people not to vaccinate their kids -- instead it will convince people that Donald Trump is a fool. If he wants funding for it he'll need legislation, which he won't get. If he tries to let Kennedy mess with the CDC in any way, the entire medical establishment will rise up in outrage. He is certain to make blunders of the same magnitude almost daily. For example, Ben Carson as secretary of HUD is similarly buffoonish, although HUD doesn't have such an influential constituency.

My thinking is that it's going to become increasingly damaging to the Republican party to continue owning him. They're going to start flailing for a way out. They are already flailing with the realization that they can't just repeal the ACA, but their president in waiting is trying to order them to do it next week. Their Chamber of Commerce constituency most definitely does not want tariffs and they don't want their low wage workers deported either. Their foreign policy establishment is going to howl like a pack of wolves with their tails on fire about buddying up with Vlad.

Public policy doesn't really matter to voters, who don't understand it anyway, but the man is a clown. The Republicans benefited enormously from Ronald Reagan's avuncular persona -- it's cast a glow over them ever since, despite Reagan's manifest incompetence. Trump, in contrast, will go down in a golden shower of ridicule. That gives me hope.

The historical moment

The historian Andrew Bacevich takes a step back from the present wailing and gnashing of teeth to look at the big picture. He should concede that there is a stochastic element to the outcome of the election, and that massive failure by the corporate media is a necessary condition for it as well. Nevertheless he has much of interest to say about the discontents that were also a necessary condition.

I am old enough to remember the existential dread of the Cold War and Mutual Assured Destruction. I saw the country torn apart by Vietnam, the Civil Rights movement and the countercultural movement(s) of what are usually called The Sixties, which actually lasted from about 1963 to 1974.  Then there were all the min-wars and interventions.

Bacevich's key point is that with the fall of the Berlin wall, followed by the collapse of the Soviet Union in 1991, U.S. elites  thought they bestrode the narrow world like a colossus.* "We" had won and now the U.S., the sole superpower, was going to lead the world into a new era of globalized  neo-liberal capitalism, and end all dispute. Instead we got one failure and disaster after another. The Clinton impeachment followed by the Supreme Court installing his witless successor. The terror attack in 2001, followed by a "mindless . . . and unsuccessful war launched on the basis of false claims and outright lies." The destruction of New Orleans. (He doesn't mention the poisoning of the Gulf of Mexico.) The crash of 2008. Meanwhile the neo-liberal revolution had made rich people richer, but left everybody else behind. And the cultural revolution that started in the 1960s was threatening and disturbing to many people.

The Obama presidency seemed to hold promise for real change, but hopes were dashed. The wars ground on, wages stayed stagnant, politics became more bitter than ever. The elites of the Democratic party, Hillary Clinton and her associates, were blind to the extent and nature of disaffection. Yes, fake news and conspiracy theories, and failure of the corporate media to talk about public policy certainly hurt her. But she was the exact symbol of everything that fueled discontent: however belatedly she tried to reinvent herself, she was a known to be a champion of free trade and failed wars. And of course the cultural upheavals.

Bacevich thinks Trump is transitional, not transformative. He doesn't have a coherent ideology or program and his rhetoric is empty. It seems very unlikely he will survive re-election - or perhaps even last until then. There isn't really any such thing as Trumpism, he is just a vessel for rejection. If we can survive the next four years the question is what happens next. That we can see only through a glass darkly.








* Allusion is to Shakespeare's Julius Caesar.

Mistakes were made

I believe the full article is off-limits to you common riffraff, but here at least is the abstract of a recent essay in JAMA about the consequences of the mass shuttering of psychiatric hospitals that happened in the 1990s. This happened for good and just reasons: mental hospitals were inhumane totalitarian institutions, it was generally believed that antipsychotic medications would enable people with serious mental illness to function more independently, and that people had a right to an environment that was the least restrictive and most integrated into the community that they could safely live in.

You may recall that this movement coincided more or less with the movement to liberalize the prescribing of opioid analgesics, also on humanitarian grounds, and you know where that got us.

This is not entirely parallel by any means. The problem with the desintitutionalization of the mentally ill is partly that the second half of the concept -- creating community based supportive living arrangements -- didn't happen. The states saved a lot of money by closing their mental hospitals, but they never got around to spending it on an adequate community based mental health system. The result is that seriously mentally ill people now wind up in jail when they aren't on the street.

What Bastiampillai and colleagues also note is that people do sometimes actually need hospitalization for acute psychiatric episodes. Maybe this is more true than it would be if they had adequate support in the community, but given the current situation, the availability of beds in psychiatric hospitals is simply inadequate. They think this may be associated with rising suicide rates. I don't know, I don't think that's been proven. But I will say that the Affordable Care Act mandated mental health parity and of course, extended coverage to a lot of people who really needed it. It's been a boon to the mental health system. It doesn't provide people with housing and other non-medical services that they also need, however.

Obviously rather than repeal the ACA we need to expand services for people with serious and persistent mental illness, including providing co-located and coordinated mental health and medical care. (They tend to have complex physical comorbidities as well.) The group homes that were supposed to follow deinstitutionalization also need to become real. Maybe if Donald Trump were to pay taxes we could afford it.

Fear and trembling

Probably the hardest thing about this historical moment, for me, is its profound uncertainty. We really do not understand what has happened, and have only the dimmest vision of what may happen after January 20.

Hunter extensively chronicles the president-elect's cognitive deficits. He knows nothing about public policy, either can't remember or doesn't care what he said yesterday, and his only coherent ideology is narcissism. We can get a fair idea of what a Trump administration is likely to do based on the people he has nominated to cabinet positions, and it's fair to assume that he'll sign any legislation the Republican congress puts on his desk. But on the other hand his incompetence raises the possibility that some of the worst may be avoided. The congressional Democrats have an agenda that is far more popular, and they won't face a coherent president who can articulate a Republican narrative.

At the same time, his business empire is extremely vulnerable, precariously balanced on a mountain of debt and quite possibly underwater.  We've all heard that he may be in hock up to his ears to Russian oligarchs close to Putin. But as James Wimberly points out, he is definitely in hock to Deutsche Bank, which is critically illiquid and could probably ruin him by calling in their loans. And, Angela Merkel can probably force them to do this. It is also unclear what Putin's actual agenda is re his orange-haired poodle. Having the U.S. president on a leash and his buddy from Exxon as secretary of state might enable him to develop some oil fields but it's not clear how much more Russia, in economic and social decline, can gain.

Trump also has a lot of legal problems including the possibility of a fraud indictment over the Trump Foundation. That would come from the Attorney General of New York so he can't prevent it. There are likely any number of revelations that could emerge at any time that would make it very difficult for the Republicans in congress to allow him to remain in office. Not that president Pence would be much of an improvement, but the spectacle of impeachment would wipe out most of the first year of the administration and leave the party badly weakened.

None of this is grounds for optimism, don't get me wrong. The disaster has already befallen us, we just aren't sure what exact form it will take. But if we can get through the next two years and the people come to their senses . . .