The Affordable Care Act has been in place for a while now, and after the initial teething problems it is beginning to settle down into something resembling a functioning system, and serious health policy researchers are beginning to report on its progress. The New England Journal of Medicine (NEJM) reported in July on a series of measures of progress under Obamacare, and the results were generally positive.
The NEJM article covers some of the more controversial aspects of Obamacare, and also shows how hard it is to understand health financing policy (and outcomes of that policy) in the USA. It notes that 7.8 million young Americans are now covered under their parents’ health insurance where previously they wouldn’t have been, and also notes that this policy has been one of the most popular aspects of Obamacare. In calculating coverage more generally it has to consider the conflicting effects of the medicaid expansion and the newly-affordable bronze plans on the one hand, and cancellations of existing plans on the other. In total, the article concludes
Taking all existing coverage expansions together, we estimate that 20 million Americans have gained coverage as of May 1 under the ACA.We do not know yet exactly how many of these people were previously uninsured, but it seems certain that many were. Recent national surveys seem to confirm this presumption. The CBO projects that the law will decrease the number of uninsured people by 12 million this year and by 26 million by 2017. Early polling data from Gallup, RAND, and the Urban Institute indicate that the number of uninsured people may have already declined by 5 million to 9 million and that the proportion of U.S. adults lacking insurance has fallen from 18% in the third quarter of 2013 to 13.4% in May 2014.
On the one hand this appears to be a huge gain (though it depends on your perspective; see below). On the other hand, coverage of health insurance remains at 87% after the ACA (including so-called bronze plans); in comparison, China has 90% coverage of health insurance, and most of the rest of the OECD is up around 98-100%. It may not seem fair to compare America with countries as advanced in health financing as the Europeans, but consider this: Ghana has 65% coverage of its National Health Insurance Scheme, though private payments still make up 66% of total health expenditure, and Ghana is planning on gradually increasing this figure. I don’t mean to belittle Ghanaians by comparing them with a country as disfunctional as the USA, but given the relative wealth disparities it seems that the USA could do better than 87% coverage. Especially when you consider the political cost to the government of implementing this law.
On the topic of canceled policies, the NEJM can’t provide figures (the studies are not available), but it does point out that many of these policies would not have been canceled if the Republicans hadn’t stymied introduction of the law[1]. The grandfathering clause applied to policies extant when the law was signed in March 2010, but no one expected it to take 3.5 years to implement the law, and had it sailed smoothly through congress presumably most people would have been able to retain their (sub-standard) plans. The NEJM also points out that turnover in health insurance markets is huge, and in the absence of the ACA most of the people whose plans were canceled would likely have changed their plans anyway:
Health-policy expert Benjamin Sommers and colleagues point out that there was significant turnover in the individual market before the ACA went into effect: between 2008 and 2011, only 42% of people who started out with such coverage still had it after 1 year[2].
It’s also worth remembering that the reason these plans were forcibly canceled is that they didn’t meet minimum standards – and it’s worth bearing in mind that the ACA’s minimum standards would be considered reprehensible in any other OECD country. I have reported before on the NEJM’s findings about the poor performance of ACA-rated “bronze” plans, but the canceled policies were canceled because they didn’t live up to the standards of these highly flawed bronze plans. Complaining about having your insurance plan canceled even though it is basically an exercise in extortion seems counter-productive to me …
The other big issue for Obamacare is the risk pool. Obamacare included a “mandate,” a set of rules intended to punish young adults who did not sign on to health insurance before a certain date, with the intention of increasing the number of healthy people paying into the health insurance pools. This is done to ensure that people at low risk of illness are basically subsidizing the sick and elderly, a problem solved in other countries by simply providing financing for health through taxation. The big challenge of market-based systems is that young people won’t pay for insurance they don’t really need, but under a market-based system there is no way to make them. Obamacare is meant to close this loophole and the “moral hazard” associated with it, but it appears that it hasn’t been hugely successful. The NEJM reports that
enrollment among 18-to-34-year-olds surged as the March 31 deadline approached, climbing from 27% of total enrollment in February to 31% in the month of March. It is widely agreed that there is no single desired rate of young-adult participation. What really matters is whether the observed rate turns out to be consistent with the projections of insurance companies for any period — that is, whether the 31% participation is about what the companies expected for 2014. If young-adult participation fell short of expectations, this could prompt rate increases in 2015. However, even if participation in the pools skews to an older age than companies predicted, an analysis by the Kaiser Family Foundation showed that 2015 premiums might increase by only 1 to 2% to offset higher-than-expected costs. This modest projected effect of an older pool reflects the fact that under the law, health plans can still charge an older person a higher premium than a younger person.
This suggests (though not very clearly) that the mandate has served its purpose, but has only increased the proportion of total enrolment by young people by about 15%, and no one knows if this is enough[3]. I wouldn’t take this small increase as a sign of great success, and it suggests that in the future insurance premiums will rise, even though one goal of Obamacare was cost containment. It’s also worth noting that there is a large pool of young Americans with pre-existing conditions who were not previously eligible for health insurance (or not at reasonable prices) and some proportion of the increase under Obamacare is likely to be people with pre-existing conditions grabbing the chance to sign on[4]. These people are not going to lower the cost of insurance. But the ACA seems to have included a subtle get-out-of-jail clause for the insurers:
Carriers with higher-than-expected claims will receive reinsurance payments, for example. This factor alone reduced premiums by 10% in 2014 and will continue to play an important role in limiting premium increases in 2015.
So, the insurers are protected against the worst effects of signing up a bunch of sick people and failing to recruit young and healthy people. All these premiums, tax breaks, cross-subsidies and protections seem incredibly complicated, and it really does seem like it would be simpler just to introduce a single payer and let them slowly take over the health landscape. But that would be … anti-freedom, or something. Because reasons. So here we are …
… Which brings us to the question of the future of Obamacare. The NEJM is treating it as a fait-accompli, and is now beginning to publish articles on healthcare policy in the Obamacare world[5], though their articles seem to be predicated on the assumption that Obamacare is fundamentally flawed (they say “major ACA provisions don’t work”, which is surely medical-journal-speak for “you really screwed the pooch”), but they do seem to be accepting the new health financing landscape. My opinion is that the ACA is here to stay, and it seems to be surviving most of the legal challenges. This doesn’t surprise me, because it doesn’t seem to me that Americans have any stomach for genuinely radical (to them) healthcare reform, and it tells me that health policy makers in the USA – on both sides of the political spectrum – are going to have to accept the ACA as the new political landscape, and work within it to reform it rather than trying to overturn it, whether their goal is to overturn it for free-market or single-payer reasons. I don’t think the ACA will ever be as successful as more rational programs in other countries, but if reasonable politicians work within its framework they can continue to improve insurance coverage and, if they can make the cost containment elements work, they can probably improve quality of insurance too. Unfortunately the ACA is complex, works across multiple sectors of the private and public health system, and depends on a lot of goodwill, so it will be very easy for the Tea Party Tendency to undermine it from within government…
Fortunately, however, the ACA contains the key to its own success. If the NEJM is right, something like 20 million people have gained health insurance where previously they were either unable to pass the hurdles, or unable to afford it. That is 20 million potential Democrat voters at the next election, and I really don’t think one can underestimate the power of security in health care as a voting incentive. These people will be looking at a revolutionary change to their own lives, and the Republicans are going to campaign in the next election on a direct promise to revoke that revolution. On top of that, a lot of big American companies are desperate for healthcare financing reform, and the ACA has proven to those companies without a shadow of doubt that only one party in the US system is serious about delivering healthcare reform. This, plus the demographic slide slowly eating the Republicans, and their lack of talented presidential candidates, suggests to me that the next elections are going to be Democrat victories, and the ACA will be locked in as the health financing policy for the USA for the foreseeable future. In my opinion this is not the best outcome for Americans, but it is certainly a vast improvement on the past. Let’s hope the Tea Party and their apparatchiks in the popular media don’t wreck this chance for ordinary Americans to finally achieve security in healthcare, one of the fundamental goals of modern developed nations.
Update
It appears more evidence is beginning to come in from government reports and independent surveys. The blog Lawyers, Guns and Money has a post suggesting that 60% of California’s uninsured have managed to get insurance through the ACA, and that the majority of these are through medicaid, which indicates they probably were uninsured due to financial problems rather than pre-existing conditions (there’s a link to Krugman in the blog, and also some kind of conspiracy theory screed on the Naked Capitalism blog). I also found (through the same bog) a vox article showing striking changes in Kentucky’s proportion of uninsured. The chart in that article is quite powerful, and apparently Kentucky had a functioning exchange from the beginning with an aggressive campaign to get people signed up. I wonder if voters in states that chose to reject the ACA’s medicaid provisions and exchanges might start to look askance at the priorities of their current legislatures …?
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fn1: Well, it doesn’t quite say that … this is my straightforward interpretation of the language of the paragraph.
fn2: I should mention here that if you can’t read the original article due to a paywall, please don’t make the mistake of thinking that these statements aren’t referenced. I remove the references when I copy and paste text from the original article, because I can’t be bothered also copying and pasting the references.
fn3: It’s worth noting here that because most developed countries have universal health care systems based on taxation and national insurance, there are very few countries outside of America where research can be done on private insurance financing. So in addition to running a system that from the outside looks to be incredibly inefficient and low quality, the USA is also running a system that cannot benefit from the research outputs of the rest of the world.
fn4: The pre-existing condition issue has always seemed to me to be the easiest example of why the USA needs to change its system, and also the most obvious example of how inhumane and cruel the US system is. No one is responsible for their own genetics, but in the USA the market for healthcare is basically designed to exclude people with certain random background traits. That’s just mean.
fn5: For some reason they insist on calling it the “Affordable Care Act.” Weirdos.
Compromise and Conceit 
August 1, 2014 at 9:51 am
“their lack of talented presidential candidates”
Seriously? You think the Republicans have this as a relatively significant problem? The world is full of stuffed shirt political leaders incapable of expressing an opinion on whether anything more complicated than apple pie is good or bad. Other political parties do just fine putting such people up. To suggest this feeds the Republican problems is a complete tangent.
The other reasons you identify (and their high portion of complete loons) is the reason the Republicans have a problem. Those issues then feed into candidate selection so that when you look for the intersection of between the sets of “People Tea Party members would accept voting for” and “People who haven’t eaten a baby” its difficult to find any options. So yeah, their candidates tend to suck, but given what their working with I’m surprised they come up with people as good as they do.
And I say this as someone with a soft spot for the Republicans.
August 1, 2014 at 1:35 pm
I was thinking in terms of charisma and ability to run a campaign, as well as the level of organization in the campaign. My memory of the last presidential candidate primaries was that there was a woeful bunch of contenders, many of whom turned out to have either kooky views, dubious pasts or problems remembering the names of departments they were going to abolish. But I was also channelling your second paragraph when I wrote that, and probably should have added “who are acceptable to their base and the general public.” I don’t think this is a problem for the Democrats – Hilary Clinton seems to still be broadly well liked by the public on both sides of the aisle, and probably won’t alienate the base. I just don’t see the GOP having a Bush or a Reagan who can manage to be likable to a broad cross-section of the public, inspirational, and able to unite the three very distinct forces within the party itself.
If the Republicans seriously plan to run on a platform of abolishing Obamacare (and let’s hope for everyone’s sakes they don’t) then they’re going to have to find someone with enough broad appeal to somehow retain “independents” who voted Republican in the last election but now have a health plan, at the same time as somehow reassuring people who would otherwise stay home but might come out to vote in order to protect their shiny new health insurance (or their kids’!) That’s a big challenge – though not impossible – but it will take some charisma and a very good campaign. I can’t see anyone on the Republican side who has that, though I confess I haven’t been paying a lot of attention.
I don’t want this thread to be about the next US presidential election (that’s a minor part of the post, though I do think the short- and long-term political ramifications of the ACA are important), but since we’re here: who do you see on the GOP side who could pull off such a task? Assuming that the ACA will affect voting intentions and have a broadly pro-Democrat effect, obviously, since the question is moot if it doesn’t.
August 3, 2014 at 9:33 pm
“who do you see on the GOP side who could pull off such a task?”
No idea. I don’t track Republican hopefuls. But their RINO (Republican in Name Only) name calling pretty much guarantees that their extremists will always manage to spike their own wheels and impede any centralist tendencies. It’d seem that the Democrats don’t have to run as far to the left to win (based on Clinton being a real option, as I recall Obama basically outflanked her on the left).
For running to abolish Obamacare it may be worth considering a scorched earth possibility. Per your links, Obamacare seems to have improved the health metrics (and hopefully the real outcomes too) but it seems like it’ll always be half pregnant. A Republican who came in ranting about its evils and replaced it with a radically different alternative wouldn’t be the worst thing that could happen because:
a) I’d assume that some purist free market option could be made to work (lack of international examples notwithstanding) with the right approach, so moving to such a model wouldn’t be terrible; or
b) If Obamacare was just burnt to the ground, the eventual backlash as it’s loss could result in a second wave that manages to address the cost containment issues still present in the ACA
Either outcome is a stretch to imagine happening, but when faced with the banality of politics I find it best to imagine the downs as merely setting the scene for the inevitable triumph of good/righteousness/the baby eater from the other side. Too much shonen manga maybe?
August 8, 2014 at 11:52 am
I read somewhere the other day (probably Lawyers, Guns and Money) an analysis of Republican approaches to minority groups (i.e. black and latino Americans): appealing to these groups is important for winning actual elections, but saying stupid stuff that hates on these groups is essential for winning primaries. And since noone (by definition) can win an election if they haven’t won a primary, rhetoric that alienates minorities at elections is essential for getting to the elections – so that by the time any “serious” Republican contender gets to public prominence, they have a long chain of “states’ rights” and “legitimate rape” dog-whistling behind them that alienates them at the election. The RINO name-calling is what drives this weird dynamic, and I suspect it will prove the same with Obamacare: that by the time any “serious” contender for president gets up at a debate, they’ll have a long history of statements about how healthcare doesn’t need to be reformed, “death panel” bullshit, etc. which will make it impossible for people who actually benefited from Obamacare to take them seriously. Which then, even if they do actually present a serious alternative package, will hamper their ability to sell it. This might not be a problem if they had a Bush vs. Kerry scenario, but they’re likely going to be running up against Clinton, who is popular and taken seriously. When the first election debate comes around, it’s going to be Hilary Clinton vs. some poor chump who just fought their way through a bruising round of primary battles at which they had to yell trenchant anti-Obamacare criticism at every turn – and by the time of the debate Clinton is going to be able to say “20 million Americans are better off because of us.” Good luck with that, GOP.
As for a “purist free market option [that] could be made to work,” I’d also like to believe this is possible but I can’t see it in the US context: there’s too much regulatory capture by the big industrial players, there’s no depth in Republican healthcare policy advisors, and the Republicans themselves are not serious about reform. Basically what would happen here (in the practical context, I mean) is that a bunch of Republican ideologues who think the status quo is actually okay would throw the task out to some shallow AEI scholars to come up with a half-baked plan, that would be heavily influenced by the insurance companies but not by (e.g.) the New England Journal of Medicine or the Commonwealth Fund, and which would not be seriously politically supported by a critical mass of Republican politicians and activists. The result would be that it would either a) die in the arse as soon as it met serious opposition publicly or b) would just make matters worse.
Contrast this with a counter-factual: John Hewson winning the 1993 Australian election. Medicare had only been in place for 9 years, and John Hewson (for all his flaws) is a serious thinker. He would, I contend, have been able to rustle up a group of serious politicians and policy-makers, with the support of the Department of Health for practical advice, to come up with a free-market alternative to Medicare. It would have had serious policy-makers contributing to it, grounded in reality, and with serious political backing to be forced through parliament, and the opposition parties would have likely followed their traditional role of opposing but not obstructing [<-or should that be the other way round?]. This alternative might not have worked, but in that context and with that leadership, it would at least have been a serious attempt. But it speaks volumes to the difference between early-1990s Australian political culture and America's current plutocratic mess.
I don't think given the history of US healthcare and its cost explosions that there is a private option that can solve the problems. And if there is, it must involve a mandate. There is no private market plan that can offer universal health coverage and cost containment that does not force the young and healthy to buy insurance. And in the current US context, any mandate appears to be “anti-freedom” and therefore anathema to Republicans. So I just can’t see a free-market alternative to Obamacare being successful there. So from a health policy perspective, it seems to me that the best hope for the USA is 8 more years of Democrat presidency (and ideally control of both houses) to ensure that Obamacare gets a decent run and time to fiddle with it responsibly.
August 8, 2014 at 1:59 pm
“There is no private market plan that can offer universal health coverage …that does not force the young and healthy to buy insurance”
Well that’s axiomatic, isn’t it? If the young and healthy didn’t have health cover then it wouldn’t be universal?
But I see what your getting at which is the risk pool point. But that’s not 100% true. You could work on a basis of not being insured while young and healthy and then having the population at large stung when they get older and decide to take it up. But such an approach assumes that people will be smart enough to save money while young to afford the later high insurance rates. Failing to have your populace save in that way means you’ve got a choice between moral dilemmas: 1) Letting people die for lack of insurance or 2) letting people get free health care cause they didn’t buy/can’t afford health insurance.
Ultimately any “freedom” argument needs to be willing and able to defend “free to die in a gutter”, otherwise it’s always going to have some sort of flaw in it (i.e. lack of funding or inability to explain the prevalence of dead kids in gutters).
A “freedom” argument does better when it sets some limits for what it’s willing to define as freedom. So that the freedom to eat yourself to death (e.g. obesity) is defended and the “freedom” to die from pure poverty isn’t. The Republicans don’t seem to be willing to state a firm position on freedom [1] so instead its policy by soundbite.
”So from a health policy perspective, it seems to me that the best hope for the USA is 8 more years of Democrat presidency (and ideally control of both houses)”
Hmm. I’d say (even from a health policy perspective) that the US would be better served by abolishing presidential veto and the philibuster. Both just seem to be ways for 1/3rd of the government to be able to block policy and the odds of holding all 3 branches to a sufficient extent is pretty low.
[1] The Democrats have this problem too [2]. It’s essentially a slippery slope argument that runs the gamut between people dying in gutters and government minders controlling your bowel movements.
[2] Other countries have it to a lower extent because of broad consensuses on how society works that appears to be lacking in the US. In Australia if any political party (i.e. the Liberals) tried to abolish universal healthcare they’d be signing their own death (panel) warrant. The debates on freedom therefore tend to focus on relatively easy discussions like “Should we track metadata” or “Is it ok to go fight for a terrorist organisation? What about just visit an area where you could do that?”
August 8, 2014 at 5:23 pm
I’m thinking of writing a post in the next few days about free market alternatives to Obamacare, so let’s hold that cost containment debate till then. I’ve just put up a post about presidents, in which I mention that I think modern Republicans fetishize freedom as a concept. I don’t agree, however, that the Democrats fetishize government control (in general, though at some times and in some places maybe). Obamacare is crafted to retain as much free market involvement in healthcare as possible, and there are a million ways that the Democrats could have done it differently (e.g. nationalization) if they really wanted the government to be controlling your bowel movements. Which isn’t to say that the Democrats aren’t vulnerable to sliding down the greasy slope, I guess, they just need a bunch of loons to get them started with a decent push – but the people who would push the Democrats down that slope would be some kind of communist hard left bloc, and they just don’t exist as a force in any way shape or form in modern America.
August 10, 2014 at 9:26 pm
“I don’t agree, however, that the Democrats fetishize government control”
I wasn’t suggesting Republicans fetishize freedom either. The problem really is that setting policy settings on something like health involves a trade off between freedom and optimal health outcomes. Mandatory testing for AIDS followed by tattooing sufferers and criminalising either sex with them or non-sexual discrimination against them may impact HIV transmission rates. But it’s still stomping on the face of everyone in order to achieve it’s outcome [1].
So even on something like dental care the argument starts with “Let’s steal from (almost) everyone to provide dental to everyone”, then “Let’s penalise parents if they don’t take their kids to the dentist” then “Not taking kids to dentists is a valid reason for them to be taken away”. There’s basically an infinite number of positions to take along that spectrum. Even if we agreed on a point on this spectrum as being optimal neither of us would have any justification to support why we chose that point other than the voices in our heads.
“Obamacare is crafted to retain as much free market involvement in healthcare as possible”
The key part in this phrase is “as possible”. As possible according to whom? By what criteria? What where you unwilling to trade off? Clearly it’s not as much free market involvement while endorsing the organ trade, so can you justify why you didn’t feel the need to specify that? Having justified that, can you justify all the other assumptions you made?
Of course not. You made a call based on a set of trade offs you judge acceptable. You can probably specify and justify a non-trivial number these. But don’t kid yourself that your so amazingly self aware that you can explain them all. At some level you’re making a call based on gut feel, and the result is I guarantee I can find an edge case that makes you uncomfortable [2].
The Democrats aren’t currently quickly sliding towards an extreme the way the Tea Party urges their puppets to. But that just means we’re debating relative rates of movement on a slope rather than attempting to determine the true optimal point on that slope, right? If I argued that it was OK to become a racist shithole in 1000 years instead of a socialist utopia in 500 I doubt you’d accept that the lengthier time frame was a valid reason to support the people in white hoods, right?
The solution I’d nominate is always being willing (as a society and individual) to debate where the optimal point should be, assess the evidence and be willing to change your position. It’s also valid to accept that the optimal position 1) changes over time and 2) is sometimes missed or just incorrect – meaning that correction is required.
If I were conservative I’d also suggest that movement towards the assessed optimal position should be gradual, but I try never to claim to be conservative [4].
[1] Such heavy handed approaches also tend to be unsuccessful as there’s a heavy incentive to tell the people driving the policy to go fuck themselves one way or another.
[2] I recall that in the UK, NICE justified not spending money on expensive drugs to save the sight in one eye of people suffering a type of eye degeneration. That was based on the QALY [3] gained costing more than £X per year gained. OK. Now explain why it’s £X and not £Y where Y>X. At the end of the day, someone made a call.
[3] Quality Adjusted Life Years for those just joining us
[4] Barring some fields such as art, where no visual work in the last 500 years can compare to what has come before. However I may reverse this position when a sufficiently cool computer game comes out and shits on Michelangelo’s David.
August 11, 2014 at 1:02 pm
I found an interesting (and short) article on the evolution of employer provided healthcare in the US:
http://www.npr.org/templates/story/story.php?storyId=114045132
August 11, 2014 at 9:53 pm
The Blue Cross Blue Shield websites give a slightly different (but broadly similar) take on this evolution. The Michigan website, for example, has a picture of an old poster that implies the “nobody bothered to get serious healthcare” idea wasn’t the main reason they were selling insurance, and the site overall suggests they were selling insurance to ensure that local people could actually afford care (“When an administrator at Baylor University in Texas noticed teachers couldn’t afford their hospital bills, he came up with a plan.”) The NPR report also doesn’t mention (probably because it’s short) the long history of attempts by different politicians to build universal insurance systems based on employer mandates (see e.g. the wikipedia article on the history of health insurance reform in the USA, especially the 1970s, which seem to be thick with attempts from both sides of the political aisle to come up with a plan).
Just to give some perspective, a bronze plan for a 40 year old male Michigunner[1] who doesn’t smoke is $200 a month. This gives a 40% coinsurance payment, $5,900 excess, and $6,300 cap. By way of comparison, the Japanese universal health coverage system offers a 70% coinsurance payment and $1200 cap [don’t quote me], and costs about 5% of your income (I think; it’s a little vague), so you’d need to be earning $48,000 to pay $200 a month. A gold plan, which has an 80% coinsurance payment, $150 excess[2] and $5000 cap, costs $350 a month, so you’d be on $140,000 a year in Japan before you paid that. Obamacare offers some subsidies to reduce the cost of these plans, and of course they’re cheaper if you get them through your employer. But this gives some perspective on what a “caring” organization with a reputation for efficiency and cost containment is able to give you as an individual purchaser. It ain’t pretty!
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fn1: This is the correct term, right?
fn2: If I’m interpreting this right, any doctor’s fee less than $150 is all yours, and you just keep on paying till you get to $5000. That seems … incredibly profitable. Unless doctors are … incredibly expensive.
August 11, 2014 at 10:28 pm
I think you’re getting lost in details here. I’m happy to look at the over-arching political principles. Democrats are generally to the right of most of the rest of the world, classic free-market big-statists, and Obamacare fits well within that framework. They aren’t going to slide down the freedom slope because there are lots of people in their movement who would be considered freedom-fetishizing loons in the rest of the world. Meanwhile the Republicans have decided that Batshit Crazy is a policy option. And the whole system is a degraded plutocracy where delivery of actual policy is secondary to supporting the interests of whoever paid for your gerrymandered seat, or whoever is going to pay for you when you leave office. All overlaid with a nice, wholesome balm of American Education System and Born Again Religion. Plus USA!USA!USA! They’re going nowhere fast, which is why every role-playing game set in the future that isn’t Star Trek has no place for the USA in space, and/or models the USA as a collection of chaotic, warring states.