The Republican War on Reality, continued

Two essays in the new NEJM worth your attention. R.A. Charo discusses the anti-science of the anti-abortion movement. Some of this is a bit complicated, and I suggest you read it rather than relying on my summary. But the starting point for much of it is the fact that about half of all blastocysts fail to implant. If life begins at conception, that means that God murders 50% of all babies who are ever conceived. When this happens, the woman never even knows that she was, in the terms of the anti-abortion movement, "pregnant." She just has a normal menstrual period.

Ergo, if you believe that a blastocyst is a human being with all the rights of a person, that the death of an embryo is morally indistinguishable from the death of a baby, and that destroying embryos is murder, you are compelled to believe that the spontaneous death of 50% of all embryos is the greatest public health crisis conceivable (sic). You are compelled to believe that it should be the highest national imperative to pour money into research and interventions to stop this holocaust. But you don't believe that, because you don't really believe that embryos are the moral equivalent of babies. Your movement must be about something else.

Now we have Henry Aaron and colleagues. (No, not Hammering Hank, rather the health care economist.) Why have some health insurers pulled out of the ACA exchanges, why do a few rural counties have no participating insurers, and why have some requested substantial premium increases? Republicans claim it's because the ACA is "failing" due to inherent flaws in design, but this is not, you know, true.

Some insurers did initially set premiums too low because they didn't know enough about the characteristics of what would become the newly insured. When they subsequently raised premiums this was an adjustment, to be sure, but it did not result in sharp enrollment declines, and markets were set to stabilize in 2017. But as soon as the new president took office, he immediately set out to undermine the ACA.

On his first day in office, Trump signed an executive order directing his administration to be as permissive as possible in providing exemptions from ACA provisions, including the individual mandate. Then the House of Representatives passed the American Health Care Act, which would repeal the individual mandate retroactive to plan year 2016. The Congressional Budget Office estimates that the resulting exodus of healthier enrollees from the individual market would drive a 20% increase in individual market premiums for 2018.3The President has also sown doubt about whether the federal government will continue to reimburse insurers for cost-sharing subsidies that they are legally required to provide to most marketplace enrollees. . . .

The Kaiser Family Foundation estimates that ending the payments would require insurers to raise premiums for “silver” plans by 19% on average across states using the HealthCare.gov enrollment platform.4 These steps have been all the more damaging because they appear to be part of a deliberate strategy to undermine the ACA. President Trump has noted that withholding cost-sharing reduction payments could seriously damage the individual market and that market turmoil increases his leverage in seeking repeal of the ACA. To that end, the administration reportedly opposed adding language to recent appropriations legislation giving it clear legal authority to continue the cost-sharing reduction payments.

Faced with these risks, some insurers are abandoning the individual market. Anthem, one of the country’s largest insurers, cited policy uncertainty, especially regarding cost-sharing reduction payments, as a major factor in its decision to leave Ohio’s market.

Now, about that individual mandate and "freedom." This is very simple. If insurers are required to cover people with pre-existing conditions, then people who are healthy can just not buy insurance until they get sick. This makes insurance more expensive,  so people who are just a little bit sick won't buy it, so it gets even more expensive and so it goes until nobody can buy insurance. The whole point of insurance is that you buy it in case you will need it. You are not allowed to wait until your house is on fire to buy homeowner's insurance which will cover you for said fire, and you are not allowed to wait until you wreck your car to buy auto insurance which will cover you for said car wreck.

Duhh. 

And, regarding my last post, Here's Michael Jeffries in The Boston Globe:

Most Americans have no quibble with Obamacare itself, but for Republicans, repealing it is and always has always been a way to repudiate former president Barack Obama. Since taking office, President Trump has done several things that he previously chastised Obama for, but these contradictions have had little impact on his party or their supporters. This is largely because GOP voters’ disdain for Obama and support for Trump cannot be separated from findings about racism. Studies conducted after the election confirm that racial resentment directed toward people of color predicted both overall support for Trump and voters’ propensity to switch from Obama to Trump.
GOP voters know they don’t like Obama, but they do not know Obama’s legislative record, whether it pertains to the economic recovery or health care legislation. A December 2016 poll showed that 67 percent of Trump voters believed that unemployment had risen during Obama’s tenure, even though it dramatically declined. A February 2017 poll found that one third of all Americans did not even know that Obamacare and the Affordable Care Act were the same thing. Over half of the Republicans in that poll did not know whether Medicaid would be impacted by repealing Obamacare. Medicaid will be gutted by the new bill.

So the naked truth is that racial resentment directed toward Obama set off a chain of events that will likely cause 20 million people to lose their health insurance and ignite a public health crisis of unimaginable consequence. Some time ago, I wrote about one of the myths of white supremacy: the idea that its ill effects are limited to targeted groups. I explained, “What white supremacy does, eventually, is normalize and spread the abuse, trauma, and destruction initially prescribed for targeted groups.” The damage prescribed by hateful ideologies is most severe within targeted groups, but it is never contained. 

Sorry for my absence . . .

The crisis we face is simultaneously so terrifying and so bizarre that I haven't been able to respond properly. Writing about the quotidian issues that interest me seems inadequate, while others who have a much larger audience are saying what I might say about our larger problems. But I've decided I'll keep on blogging, for my own sake if not for yours.

So, the Senate Majority Leader is insisting that his members vote tomorrow on a bill that will radically re-make 15% of the U.S. economy, without telling them anything about what's in it. Does that seem strange? Here's former Republican Senator David Durenberger, who thinks, yes that is rather odd:

This week, the Senate once again is set to vote on a health care bill that will radically change how people get coverage and who can afford their care. But unlike normal times, Senators, you are being asked to approve a Motion to Proceed to a vote:

• Without knowing what will be in the bill you would vote on.

• Without knowing what the non-partisan Congressional Budget Office will say about the impact of major amendments and the final bill on coverage and premiums.
• With full knowledge that the Senate parliamentarian, who rules on what can and can't be allowed in a budget bill, has said that the Senate must remove provisions intended to prevent an insurance market death spiral of sicker patients driving up costs.
• Without knowing the details of the secret state Medicaid waivers the Trump administration insists will make the bill work.
• Without knowing how your own state budget will be impacted.
• Without knowing how you will defend the provisions you will only learn about later, including the payoffs and other things that will be sneaked into the bill at the last minute.
• Without even knowing which bill you are being asked to vote on, what the defining amendments will be and how much time you will have when being pressed for a final vote you’ll be stuck with. Forever.

So why is McConnell doing this? For the past seven years, the Republican party has been obsessively demanding the repeal of the Affordable Care Act. They told their voters they were supposed to hate it, without explaining why they were supposed to hate it. (No, there aren't any death panels and the government didn't take over health care.) As it turns out, the only reason to hate it was that it was signed by a president with an African father. There actually isn't any way to repeal it without hurting tens of millions of people, but the Republican leadership is determined to do it anyway because if they don't, they'll face challenges in the next primary. So they have to keep what they are doing a secret for as long as they can.  Call your Senators' offices. Demand that they vote NO.

Not again . . . .

There seems to be a flavor of the month the past couple of years of universities covering up for grotesque behavior by prestigious professors -- in this case the dean of the USC Keck School of Medicine. It's kind of hard to believe he had time for it, given what is presumably a demanding job, but he was spending his off hours doing meth and smack with prostitutes and drug dealers. His kept woman OD'd in a hotel room, and the police happily covered it up. The university obviously found out about what was going on and let him quietly resign with an excuse that he was taking another job, but allowed him to continue to rep the school of medicine for fundraising purposes. Oh yeah -- he had been accused of sexual harassment in an earlier job at Tufts -- disposition of the case covered up --  and assaulting a colleague at a later job, outcome also kept secret.

Now, as far as I'm concerned if he was effective at his job I don't personally care what he was doing in his free time -- that's between him and his wife, mostly. However, they obviously would have responded very differently in the case of any ordinary faculty member. The knee jerk response for these big shots is that they are allowed to get away with just about anything. The ruling class within the university sticks together, even in cases where it really matters to the mission including academic fraud and sexual harassment. It just doesn't seem to change.

But really, check out the article. It's just a blockbuster investigation, great journalistic work.

Ignorance is bliss?

A majority of Republicans now tell Pew Research pollsters that colleges and universities have a negative impact on the U.S. That's a big change from just two years ago, and it's most pronounced among people who identify themselves as conservative.

Now why would they think that? What is the negative impact we purportedly have? I suppose the place to start in trying to figure that out is what we actually do.

First, obviously, we educate young people. What does "educate" mean? It actually has several components, which I will get to.

Second, we do research. We work to increase human understanding of the universe, including humans and human society. We do this based on standards for observation and inference, upon which there is a substantial area of broad agreement but considerable disputation around the edges. These vary somewhat among disciplines, some of which allow for a substantial values component in their discourse, others of which at least pretend to have little or none.

Our standards for observation and inference have a lot to do with the nature of the education we provide. Students do memorize facts. They also learn methods of inference and critical thinking. They learn how to distinguish categories -- what is, what ought to be, what is beautiful -- and to talk about each of these in the manner proper to its nature. They learn skills for learning. They learn logic, critical reading, methods of discourse and argumentation. Colleges and universities produce people with the knowledge and skills to expand scientific knowledge, manage enterprises, develop technology, solve problems. Without colleges and universities, we would be living like people in the 15th Century. We wouldn't have modern medicine, or telecommunications. Colleges and universities also train actors, musicians, film makers, chefs, architects, public policy makers, and engineers.

So what is bad about them? Let's go back to those categories -- the true, the good, the beautiful.

Being a conservative Republican nowadays requires believing some things that are objectively not true. Most notably, it requires believing that human activity is not causing the climate to change. It is people working in universities who are determining that yes, that is really happening. (Also, there's that little question of evolution and the history of the universe.) People in universities, including in schools of public health such as where I work, also figure out that people can be harmed or helped by features of their physical and social environment, which provides the rationale for policies such as pollution control, early childhood education, expanded health care access, and yes, gun safety policies. Note that conservatives have literally forbidden federal funding of research in the latter field -- truth that is contrary to ideology is not to be discovered.

I could go on with this but the bottom line is, reality has a well-known liberal bias. We study reality, and that's bad.

But the good and the beautiful matter as well. It was not always the case, but universities nowadays strive to be inclusive and celebratory of diversity. We encourage open debate and dissent. Now, lately there have been some highly publicized controversies -- in fact they are very few and far between -- about invitations to particular speakers who some members of a university community find offensive. These happen to be people called "conservative," which in these instances means racist and/or misogynist. Whether allowing these people to speak or not is proper is a debate I will defer. The point here is that racism and other forms of bigotry and exclusion are not generally condoned in colleges and universities, but they are condoned among conservative Republicans. So we have a disagreement over the good.

Finally there is that question of the beautiful. I expect that many people who consider themselves conservatives also have a feeling that people with college educations look down on their culture. This isn't actually true, for the most part. Some well-to-do people are snobbish, of course. And there are no doubt differences in artistic, culinary or sartorial preference among people of differing levels of education. But I can assure you that working class and low income people are just as valued and respected as wealthier people, if not more so, here in the school of public health and elsewhere in the university. We really are working to make life better for everyone, especially those in most need. And please don't confuse us with politicians.

Coercive psychiatry?

Two writers in BMJ maintain that there is a global trend toward more coercion in psychiatry. Their evidence seems largely impressionistic - I'm not sure they prove the case - but it does reopen a discussion that we haven't heard much of lately.

In the bad old days mental hospitals were indeed what Erving Goffman called "total institutions." Many people were confined involuntarily, and often for life. Their lives were controlled by rules and regimentation, and many cruelties were practiced on them including shackling, solitary confinement, and destructive brain surgery. As you probably know a mental hospital was Ken Kesey's metaphor for the oppressive conformity of 1950s America in One Flew Over the Cuckoo's Nest. Yes, it was fiction, but it resonated.

As I have discussed here quite often, the de-institutionalization movement closed most mental hospitals. This was partly a response to the more liberal values of the post-1960s era, partly a response to the availability of treatments that suppress some of the worst symptoms of psychosis, which made de-institutionalization more feasible. What did not happen, however, was the promised second half of the program, that is the creation of adequately supportive community-based housing and services. So lots of people wound up homeless, and in prison. The BMJ editorial evokes incarceration to support its thesis, but that doesn't really work: police, prosecutors and prison guards aren't psychiatrists. What this really points to is a lack of psychiatry, not that psychiatry itself is more coercive.

However, they also argue that involuntary commitment and forced treatment are becoming more common, along with solitary confinement and restraint. The justification, in their telling, is "risk management." Mentally ill people are seen as dangerous. It seems to me that in part, what we are seeing is simply the regression toward the old regime when the promised new one failed to materialize. But there are also those who have argued that more inpatient psychiatric resources are needed, on the grounds that not everybody can make it on the outside after all, at least not all the time.

Unfortunately people who are held against their will, and who have underlying behavioral problems, are difficult for staff to deal with. And it is very hard to discourage staff from taking the relatively easy path of drugging and restraint. It happens in nursing homes as well. So I'm not sure that what we are seeing is a corruption of the culture of psychiatry so much as it is a reflection of insufficient resources being put toward a more humane response to mental illness.

But there's a lot of that sort of thing going around.

The Rule of Rescue

I briefly mentioned the case of Charlie Gard in my last post. Now both the Pope and some clown have weighed in. (The link is to a comment on this, which I will allow to speak for itself.) Who knows exactly what the clown meant by his tweet, but the Vatican statement included the specific assertion that the Pope prays that the parents' "wish to accompany and treat their child until the end isn’t neglected," and the statement from the Pontifical Academy of Life that

We should never act with the deliberate intention to end a human life, including the removal of nutrition and hydration. We do, sometimes, however, have to recognise the limitations of what can be done, while always acting humanely in the service of the sick person until the time of natural death occurs.

To be clear, Charlie Gard has irreversible brain damage. He cannot hear, see, swallow, cry, or breathe. It is unlikely that he has any conscious awareness, but please try to imagine what it is like if he does. He is being kept alive by a machine that breathes for him, and by another machine that pumps nutrition and hydration into his body. If the machines are turned off, natural death will occur.  Indeed, it is probably fair to say that it has already occurred, and what we are seeing is only a simulacrum of life.

Oh, by the way, it costs a great deal of money to keep the machines going. The Vatican hospital has offered to continue the exercise, presumably indefinitely. Transporting him, with his machines, would be extremely expensive. Did you know -- and does the Pope know -- that some 3 million children under five die every year from "conditions that could be prevented or treated with access to simple, affordable interventions"?

Are the Pope and Donald Trump offering to do anything at all for any single one of them?

The title of this post refers to an ethical instinct that people have to provide succor to a single, identifiable individual who is in dire circumstances. They will say that no price is too high, that human life is infinitely precious. But obviously, nobody actually believes that.