Sunday, October 29, 2017

The Ultimate Version of Ill-Informed Health Care Leadership: Dumb, Incoherent, Confused, Perhaps Psychotic Things President Trump Says and Does About Health Care Policy


The controversy over the Affordable Care Act, aka "Obamacare," still goes on in the US.  The ACA, which is still the law of the land after congressional Republicans made attempts to repeal and replace it, was meant to increase access to health care by increasing access to health care insurance without disturbing the current US reliance on private, mostly for-profit health insurance companies It used a variety of complex, if not Rube Goldberg like mechanisms to tweak the US health care market.

During the past month, President Trump has produced some dumbfounding verbiage concerning the basic issues of health care and health policy that provide the context for this controversy

The Scope of the Problem: "Fixing Somebody's Back or Their Knee"

Per the Hill, Oct 7, 2017, when asked about health care block grants, President Trump said,

I want to focus on North Korea, I want to focus on Iran, I want to focus on other things. I don't want to focus on fixing somebody's back or their knee or something. Let the states do that.

The ACA, of course, affects not just a limited range of elective orthopedic procedures, but the entire scope of US health and health care, from acute care for severe problems, to management of common diseases, to public health.  Trump appeared to totally underestimate the scope of the health care issues about which he so cavalierly opined

The Approach: "Vaccilate Daily"

An analysis in the Washington Post on October 18, 2017 showed Trump's wildly inconsistent approach to the specifics of managing the ACA.

Early Tuesday, Trump decided upon a justification for his controversial decision to cancel Obamacare payments to insurers that subsidized policies for low-income Americans: The insurance companies are getting rich off this stuff, he claimed.

His argument was dubious at best; insurance companies are making lots of money, but not on Obamacare plans. And not only that, but Trump then suggested at a news conference that he actually supported a newly struck deal that would restore the payments that he had said were lining insurance-company pockets.

And then he did a 180. He told the Heritage Foundation later Tuesday that 'Congress must find a solution to the Obamacare mess instead of providing bailouts to insurance companies.' Then he tweeted the same Wednesday morning.

I am supportive of Lamar as a person & also of the process, but I can never support bailing out ins co's who have made a fortune w/ O'Care.

— Donald J. Trump (@realDonaldTrump) October 18, 2017

Sen. Lamar Alexander (R-Tenn.) who spearheaded the deal with Democratic Sen. Patty Murray (D-Wash.), is now suggesting Trump pulled the rug out from underneath him.

Lamar Alexander to press, per @GarrettHaake: 'The president called me 10 days ago and asked me to work with Senator Murray to do this'

— Benjy Sarlin (@BenjySarlin) October 18, 2017

If I counted that correctly, that was four reversals starting on Oct 17.  The article's conclusion that the president "seemed to vacillate daily" appears too kind. Over a short period of time he repeatedly contradicted himself, demonstrating wild inconsistency. 

The Responsibilities of the President: From "Gonna Blow That Thing Up" to "Its Dead.  It's Gone"

The ACA is still the law of the land.  As a Vox opinion piece by Professor Abe Gluck of Yale Law School on Oct 17, 2017, reminds us that

The president has a legal obligation, under Article II of the US Constitution, to 'take Care that the laws be faithfully executed.' That means he must make sure that our laws are implemented in good faith and that he uses his executive discretion reasonably toward that end.

However, it appears that President Trump's believes he is entitled to wreck, not implement the law.  For example, per the Guardian, Oct 15, 2017, Steve Bannon, President Trump's last campaign manager and former White House strategic adviser said about the president's approach to the Affordable Care Act,

Not gonna make the CSR [cost-sharing reduction] payments, gonna blow that thing up, gonna blow those [insurance] exchanges up, right?
How could a president "faithfully execute" a law by "blowing up" fundamental sections it?

Also, per the Guardian, Oct 16, 2017, when asked about "the Republicans' failure to repeal and replace the Affordable Care Act (ACA),"

'Obamacare is finished,' Trump told reporters before a cabinet meeting. 'It’s dead. It’s gone. You shouldn’t even mention it. It’s gone. There is no such thing as Obamacare any more.'

However, since the law has not been repealed, per the constitution, it is very much still in existence.

Furthermore, Prof Gluck documented specific actions Trump has taken to "blow up" the law.  He first noted that

The ACA requires the federal government to support the open enrollment period — in which individuals must sign up for insurance or lose their chance to do so. The ACA requires the federal government to, among other things, maintain a website and work with local “navigators” and other groups to educate consumers and encourage them to sign up for insurance.

However, Gluck alleged that Trump has sabotaged the law by cutting the open enrollment period in half, scheduled  extensive shutdowns of the enrollment website, canceled previously "scheduled events in which federal officials had planned to visit states and help with enrollment, cut by 90% the federal advertising for open enrollment, and cut funding for the navigator program by 40%.

So rather than "faithfully execute" this law, he seems to be simultaneously sabotaging multiple sections of it.

Citing Trump's statement that Obamacare is already dead (see above), Prof Gluck maintained,

Motive matters, with respect to whether the president exercises his power legally. If the president exercises his discretion to further the purpose of a statute, he complies with the take care clause. If he uses his power pretextually or unreasonably, he violates the Constitution. President Trump’s motives are unambiguous.

Per the title of his article, Prof Gluck declared "that's illegal."

Underlying It All: Complete Gibberish

On Oct 23, 2017, a Vox article by Matthew Yglesias discussed Trump's interview with Maria Bartiromo on the Fox Business Channel.  The article provided this transcript of Trump's discussion the proposed legislation by Senators Alexander and Murphy (the same legislation that provoked many reversals from Trump as above.)

Well, I’ve — I have looked at it very, very strongly. And pretty much, we can do almost what they’re getting. I — I think he is a tremendous person. I don’t know Sen. Murray. I hear very, very good things.

I know that Lamar Alexander’s a fine man, and he is really in there to do good for the people. We can do pretty much what we have to do without, you know, the secretary has tremendous leeway in the — under the Obama plans. One of the things that they did, because they were so messed up, they had no choice but to give the secretary leeway because they knew he’d have to be — he or she would have to be changing all the time.

And we can pretty much do whatever we have to do just the way it is. So this was going to be temporary, prior to repeal and replace. We’re going to repeal and replace Obamacare.

Yglesias made a heroic attempt to extract some meaning from this response, by suggesting that Trump judges the bill "entirely on the basis of his personal impressions of the legislators involved," although he also allowed "Trump has no information about, interest in, or knowledge of the substance of the bill."

Again, that is too kind.  Trump did not decline to answer, or say that this issue was one in which he was not interested (as he did above by dismissing it as involving only "bad backs and knees.")

Instead, most of Trump's verbiage was entrirely incoherent.  I challenge anyone to make sense out of the phrases highlighted above.  At best he seems to care so little about this issue that he cannot be bothered to make a coherent response.  At worst, this demonstrates he becomes temporarily incapable of rational speech or thought.  Parts of the passages above suggest the word salad produced by somebody with fluent aphasia versus the nonsensical responses produced by patients suffering from acute delusional states. 

And just to ice the cake, when asked about the Federal Reserve Bank during the same interview, Trump replied that it is

important psychotically

Again, I wonder if Yglesias was being too kind in concluding that he "meant to say 'psychologically.'"

Discussion

We have discussed the doctrine of managerialism promoted in business schools that people trained in management should lead every type of human organization and endeavor.  Management by people from the disciplines most relevant to the mission and nature of particular organizations should be eschewed.  So managers, not physicians or other health care professionals, should lead health care organizations.  Following that theme, managers, or those like them, rather than health care professionals and health policy experts should lead health policy. 

However, managers who run health care organizations, or make policy, have an unfortunate tendency to be ill-informed (as well as unsympathetic if not hostile to health care professionals' value and the health care mission, and subject to perverse incentives that often put short-term revenue ahead of the health of patients and the population.)

In some sense, President Trump is the ultimate embodiment of managerialism.  He is a life long businessman, whose highest academic training resulted in an MBA from the Wharton School, with no demonstrated knowledge of or experience in public policy, the law, or the US Constitution.  Yet for years he has felt free to make pronouncements about any subject which caught his eye.

Now he is in charge of health care and health care policy at the federal level, amongst other things. In this role, Mr Trump also appears to be the ultimate embodiment of ill-informed leadership, a term that again now appears much too kind. His message and actions have been not just ill-informed, but dumb, incoherent, confused, and possibly psychotic.

As I have said before,... We need health policy leadership that is well-informed, understands the health care mission, avoids self-interest and conflicts of interest, and is accountable, ethical and honest.   (Of course, we have often said we need leadership of health care organizations with these characteristics.)

Instead, as Mr Yglesias concluded,

On some level, it’s a little bit funny. On another level, Puerto Rico is still languishing in the dark without power (and in many cases without safe drinking water) with no end in sight. Trump is less popular at this point in his administration than any previous president despite a generally benign economic climate, and shows no sign of changing course.

Perhaps it will all work out for the best, and someday we’ll look back and chuckle about the time when we had a president who didn’t know anything about anything that was happening and could never be counted on to make coherent, factual statements on any subject. But traditionally, we haven’t elected presidents like that — for what have always seemed like pretty good reasons — and the risks of compounding disaster are still very much out there.


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