Carving the Turkey and Medicaid

The Thanksgiving turkey wasn’t the only reason people have been sharpening their carving knives.  The national economic crisis has led the President’s Panel on the Economy chaired by Alan Simpson and Erskine Bowles to begin their own carving.  Among other steps, the Committee Chairs propose to reduce health care costs by paying doctors and other providers less for seeing patients under government programs like Medicare and Medicaid.  They also propose to expand cost-containment programs.  The Federal Medicaid program has already begun planning for cost containment. Several reports indicate that 10% of Medicaid recipients account for 72% of expenditures, mostly people with chronic health conditions (arthritis, high blood pressure, heart disease and asthma), mostly older (64+) and often receiving hospital or home health care. Other research indicates mental health disorders, including schizophrenia and addiction are among the most costly. It is likely autism service will also rank among high cost services in states mandating such services.  Among Medicaid cost containment proposals are increasing co-payments, reducing the scope of covered benefits and enhanced medical case management, which translates into close monitoring of adherence with services and their outcomes.

It’s possible the horse is already out of the barn, but it may not be too late to have some impact on how these proposed cuts play out.  As long as consumers and early intervention providers are unwilling to make distinctions among the types and intensity of services children and youth with autism spectrum disorders should receive, these changes will be made unilaterally by Medicaid and private insurers, and not necessarily based on the best available outcome evidence. It would be better if, as a field, we developed rational strategies for individualizing types and intensities of intervention.  

To contend, for example, that every four year old child with an ASD diagnosis requires 35-40 hours of Discrete Trial Intervention, whether he has Asperger disorder or Autistic disorder, whether her IQ is 55 or 115, whether he is non-verbal or speaks in short phrases, whether she is interested in other children or hides when another child is nearby, doesn’t make a great deal of sense.  Laura Schreibman and her colleagues have published several promising papers attempting to predict which children will profit most from a Pivotal Response Training strategy, a naturalistic intervention approach, which is an important step in the right direction.  

We need to develop more rational, evidence-based approaches to deciding how much and what kind of intervention strategy is most appropriate for each child with autism, which is the subject of my forthcoming book, Individualized Autism Intervention for Young Children: Blending Discrete Trial and Naturalistic Strategies (Paul H. Brookes).  You can receive an alert when the book is out by clicking on the "Keep Me Posted" link at Brookes website.     It would be wise for all of us to begin taking concrete steps to address this problem before the green eye-shaded bean counters do it for us and our kids.

Sherer, M.R., Schreibman, L., 2005. Individual behavioral profiles and predictors of treatment effectiveness for children with autism. J. Consult. Clin. Psychol. 73, 525–538.

Stahmer, AC, Schreibman, L. and Cunningham, AB (2010) Toward a technology of treatment individualization for young children with autism spectrum disorders. Brain Research. 2010 Sep 19. [Epub ahead of print]

Remembering Erich Kohnke

On this week in history, November 24, 1933 Adolf Hitler’s National Socialist Party passed a Law against Habitual and Dangerous Criminals, which allowed beggars, the homeless, alcoholics and the unemployed to be sent to concentration camps where they did forced labor until they perished from disease and malnutrition and were incinerated.  It would be another five years before Nazis ordered Jews over age 15 to apply for identity cards from the police, to be shown on demand to any police officer, similar to Jan Brewer's “Papers Please” law in Arizona for Mexicans. Without papers Jewish men were deported to concentration camps, which meant certain death.  In October 1939 the Nazis began euthanizing disabled people, such as individuals with developmental disabilities, which most likely, included those with autism, people about whom we are especially concerned today.

When I reflect on the incredibly offensive posters portraying Barrack Obama as Hitler at Tea Party rallies August 2009, I am utterly repulsed at the people carrying those signs.  They must have known absolutely nothing whatsoever about what Adolf Hitler represented. To our family, and my wife Anneke specifically, Hitler was the man who ordered her mother and father tortured and then murdered. Anneke’s father, Erich Kohnke, was born 110 years ago this week, and died at the age of 43 at Auschwitz at Hitler’s hands. We do not find the Tea Party’s portrayal of the US president as Hitler amusing or politically apt.

The paradox, of course, is that the behavior of agitators who carryied those signs, who were paid to disrupt the 2009 Congressional Town Hall meetings, was very similar to Hitler’s SA Brown Shirts who shouted, threatened and carried guns into politcal meetings, designed to intimidate, not only Jews but ordinary German citizens. It worked in the 1930s and it worked again in 2009. this time it intimidated ordinary Americans.  By remembering the horrors of the past, perhaps we can avoid repeating them, though it is looking increasingly less clear that is so. 

The Armistice Day Blizzard of 1940 and the Present Storm

As I look out on the remaining green grass and mostly bare branches of elm, oak and maple trees beyond my study window on a sunny 50 degree afternoon, it is difficult to imagine the Armistice Day Blizzard which began on this day 70 years ago. That winter tempest was a living part our history for those us who grew up in that era.  The humongous storm covered an area from Kansas to Michigan and included Iowa, Wisconsin and Minnesota.  At its peak, winds gusted to 80 mph and snowdrifts in some areas were 20 feet high. Many people froze to death because they were unable to navigate their way to shelter.  As I was growing up, along about this time of the year my parents retold their story, with hour-by-hour accounts of that remarkable conflagration, and survival, which had seemed doubtful at times. Snow drifts reached onto the roof of houses as the wind howled like an enraged, injured animal

In her recent book, All Facts Considered, NPR’s Kee Malesky retells the legend The Piasa, as told by the Illini Chief Ouatoga.  The Native American story is of a huge bird with scales, horns like deer and a human-like face with fangs, that darkens the sky and brings thunder and lightening, devouring humans below in its path, hence the name Thunderbird, which is common among various native communities.  Though there was no thunder and lightening associated with the Armistice Day Blizzard, rain and sleet during the early hours of the story preceded an enormously heavy, wet snowfall driven by strong winds, creating a deadly combination.

One wonders what stories will be told to children who had grown up in early days of the 21^st century, about the devastating economic storm that overtook America.  The Piasa that darkened the sky and descended upon and devoured middle class people that triggered the Great Recession of 2009, was outsourcing of American manufacturing jobs, the collapse of the housing market due to vast numbers of irresponsible home loans, and gambling by financial firms with stock holders’ money.  Children will hear stories about draconian measures that followed, further undermining the middle class in America.  People will look back upon an era in which the United States was still a land of opportunity for average Americans.  

At least that is the way the economic storm has shaped up thus far.  Whether a realistic, balanced, long term approach to undoing the damage that has been done by two unfunded wars, tax cuts for the wealthiest people, and uncontrolled and unfunded health care costs, remains to be seen.  Cuts in spending alone will not solve the problem.  The storm can only be brought under control with a balanced approach in which the wealthiest Americans, including corporations, carry an equitable share of the resource burden and discretionary military spending is stopped. 

Pavlovian Propaganda and the Midterm Election

No doubt, poor employment figures played a major role in the mid-term election outcome, but voting occurred in a context created by Tea Party Republicans activists and their right wing financial supporters beginning in August 2009.  As a psychologist, I find it noteworthy that the Tea Party Republicans used Pavlovian conditioning techniques to turn voters’ support for President Obama in November 2008 into distrust or disdain. Their attacks on President Obama were taken directly from Joseph Goebbel’s propaganda manual from 1933.  Goebbels was “Reich Minister of Propaganda and Public Enlightenment” for Hitler’s Nazi Party. http://www.psywarrior.com/Goebbels.html  Goebbels wrote:

“The receptive powers of the masses are very restricted, and their understanding is feeble. On the other hand, they quickly forget. Such being the case, all effective propaganda must be confined to a few bare essentials and those must be expressed as far as possible in stereotyped formulas…..If you tell a lie big enough and keep repeating it, people will eventually come to believe it…. These slogans should be persistently repeated until the very last individual has come to grasp the idea that has been put forward….Propaganda must reinforce anxiety…. (and) must facilitate the displacement of aggression by specifying the targets for hatred.”

I’m not suggesting the Tea Party is a Nazi organization, but they used the same racist techniques to create irrational fear of Barrack Obama making him their target for their venom. Goebbels recommended using public meetings as the optimal vehicle for spreading fear and propaganda.   Goebbels specifically targeted Jews, while the Tea Party expressed their hatred for African Americans and Hispanics. The Tea Party rallied against Obama brandishing firearms and carrying threatening signs.  Nevada Tea Party Senate candidate Sharron Angle said she favored “second amendment remedies,” meaning solving political differences with guns. When Tea Party activists say they want their country back, they mean they want conservative white Christian men running the country, not an articulate African American president assisted by a diverse cabinet of leaders varying in gender, race and ethnicity.  In the mid-term election, much of the support for the Tea Party came from blue-collar white men (and some women) who were conditioned to fear an African American president.  

It is paradoxical that the working class white men who were influenced by the Tea Party’s propaganda, were hoodwinked by phony displays of self-righteous outrage that were paid for by powerful insurance and pharmaceutical industries during August 2009. These counterfeit town hall meetings were not a spontaneous grass roots outpouring, but were manufactured events hosted by lobbyists opposed to Obama’s presidency, like Dick Armey’s Freedom Works. Hundreds of times per day for more than a month, televised images of Pavlovian political conditioning were re-broadcast across the country, in which images of screaming fanatical racists were paired with Obama’s name or image. Never in our nation’s history has so much racist venom been so widely and intensively disseminated. The die was cast by late 2009.

The relentless barrage of falsehoods, including images of the President as an African witch doctor, false accusations about Obama’s nationality, and false claims and gross exaggerations about the proposed health care legislation (“pulling the plug on grandma”), led some Independent and conservative Democratic voters to begin to recoil when they heard the President’s name. Like a tone preceding a shock that elicits fear, Barrack Obama’s image began to evoke anxiety among many voters who had come to associate him with outrageous claims that had gone largely unchallenged by Democratic leadership. Only former President Jimmy Carter had the courage to speak the truth about the racist nature of Tea Party’s propaganda, which fell largely on deaf ears among the public at large.

Even in the face of Obama’s remarkable legislative achievements over his first two years in office during the worst financial crisis since the Great Depression, eventually the propaganda campaign turned a sufficient number of voters against the President and Democrats in Congress to make the difference in the midterm elections.  Many voters were no longer open to hearing anything positive about the President’s accomplishments.  They could remember that his middle name was Hussein but not that 863,000 private sector jobs had been created in 2010.  Many Caucasian, blue collar voters began parroting the Tea Party’s absurd slogans about taxes and the deficit, but seemed unaware that George W. Bush created the largest deficit in US history before Obama took office,  or that the economy was actually gradually recovering under Obama’s leadership.  

President Obama refused to wallow in the mud with the Tea Party activists. But failure of the President and other Democratic leaders to forcefully confront the racist claims and vigorously refute the fabrications and exaggerations regarding his health care plan and the Troubled Asset Possessions Relief Fund (TARF) that saved the economy from collapse, led many voters to accept the unchallenged claims.  That planted the seeds for fear and hostility that was a major factor in the recent midterm election results. 

Remember how Pavlovian conditioning works… tone followed by shock.  Repeat that sequence a few thousand times and eventually when the tone sounds people are fearful and stop behaving rationally. It worked, and many American people stopped behaving rationally. The Tea Party propaganda program only needed to influence 5-10% of voters in many elections to make the difference. Ask those who voted for Tea Party candidates what their newly elected representatives will do about the deficit or which programs they will cut and the consequences of those reductions, and you will find in most cases they have absolutely no idea. All they know is that they are afraid of Barrack Obama.

If the President thinks appeasement during his last two years in office will make his position stronger with the voting public he is mistaken. It will further weaken his standing with his supporters as well as opponents, diminishing his chances of re-election  Those who say the President should turn his other cheek to John Boehner and Mitch McConnell have forgotten the lessons of history. Republicans will interpret offers of bipartisanship from Obama as appeasement. Negotiation is one thing, acquiescing is another. 

Unless Obama and Democratic Senate and House leaders stand up firmly for their values, Republicans will steam roller them, undermining everything that was accomplished over the past two years, including protecting our children so they can receive health care despite pre-existing conditions.  We survived the Bush administration debacle and voted for the President’s progressive agenda in 2008, but  may be once again without representation unless the Democrats stand up on their hind legs and show what they are made of.