Friday, January 05, 2018

Ill-Informed, Incompetent* Health Care Leadership: the Case of President Trump's Interview in the New York Times

[* - see discussion of definitions below]

On December 28, 2017, the New York Times published an impromptu interview by reporter Michael S Schmidt with President Donald J Trump at one of Mr Trump's private golf clubs.  Excerpts from the transcript appeared here.  An analysis of 24 points made by the president appeared in the Washington Post.  A number of commenators later weighed in on the interview.

The interview touched on some major issues in health policy relevant to Health Care Renewal.  I will first present in full the transcript of relevant part of the interview by health care topic.  Then I will present comments from the Washington Post article, and then by some of the commenators.

That all sounds rather mundane, but even this stolid method of presentation cannot conceal how things quickly ran off the rails.

Relevant Interview Excerpts

President Trump's Health Care Policy Expertise

I know more about the big bills. … [Inaudible.] … Than any president that’s ever been in office. Whether it’s health care and taxes.

I know the details of health care better than most, better than most. And if I didn’t, I couldn’t have talked all these people into doing ultimately only to be rejected.

Association Health Plans, and Sales of Health Plans Across State Lines

Also, beyond the individual mandate, but also [inaudible] associations. You understand what the associations are. …

[Cross talk.]

TRUMP: So now I have associations, I have private insurance companies coming and will sell private health care plans to people through associations. That’s gonna be millions and millions of people. People have no idea how big that is. And by the way, and for that, we’ve ended across state lines. So we have competition. You know for that I’m allowed to [inaudible] state lines. So that’s all done.

Now here’s the good news. We’ve created associations, millions of people are joining associations. Millions. That were formerly in Obamacare or didn’t have insurance. Or didn’t have health care. Millions of people. That’s gonna be a big bill, you watch. It could be as high as 50 percent of the people. You watch. So that’s a big thing. And the individual mandate. So now you have associations, and people don’t even talk about the associations. That could be half the people are going to be joining up. … With private [inaudible]. So now you have associations and the individual mandate.

The Affordable Care Act (ACA, "Obamacare") and Its Mandate

But now that the individual mandate is officially killed, people have no idea how big a deal that was. It’s the most unpopular part of Obamacare. But now, Obamacare is essentially. … You know, you saw this. … It’s basically dead over a period of time.

The Washington Post Article on Trump's Claims

 The article began:

We combed through the transcript and here’s a quick roundup of the false, misleading or dubious claims that he made, at a rate of one every 75 seconds.

President Trump's Health Care Policy Expertise

Lawmakers who dealt with Trump on taxes and especially health care privately told reporters they were shocked how little he knew about these issues.

Association Health Plans, and Sales of Health Plans Across State Lines

Trump is referring to an executive order, mentioned above, but it has no force in law on its own and no one has yet joined these associations. The rules spelling out how the executive order would work have not been issued yet, so Trump is simply making up his 'millions' number.

Trump signed an executive order encouraging the formation of health plans across state lines. But there is still a law in place that exempts insurance companies from aspects of federal antitrust law and ensures that individual states remained the primary regulators of insurance.

The Affordable Care Act (ACA, "Obamacare") and Its Mandate

While the individual mandate was an important incentive for Americans to seek health insurance, it was only one part of a far-reaching law that remains intact. The repeal does not take effect until 2019, and enrollment in Obamacare has remained strong. The Congressional Budget Office says the marketplaces are expected to remain stable for years.

Commenators' Take on Trump's Statements

Ezra Kelin wrote a commentary for Vox published December 29.  Yuval Levin wrote a commentary for the National Review published the same day

President Trump's Health Care Policy Expertise

Klein wrote:

In psychology, there’s an idea known as the Dunning-Kruger effect. It refers to research by David Dunning and Justin Kruger that found the least competent people often believe they are the most competent because they 'lack the very expertise needed to recognize how badly they’re doing.' This dynamic helps explain comments like the one Trump makes here.

Association Health Plans, and Sales of Health Plans Across State Lines

Klein wrote:

I can, with some effort, untangle what Trump might have been trying to say here, but it’s so incoherent, so suffused with half-related ideas and personal obsessions (why did Trump feel the need to bring up McCain’s vote?), that it’s hard to say for sure.


At best, Trump is saying something that is comprehensible but incorrect. He signed an executive order making it easier to form association health plans, which are health plans formed by groups of small businesses, and making it easier for those plans to skirt Obamacare’s insurance regulations and to contain small businesses from multiple states.

As of now, and Trump doesn’t seem to realize this, it’s just an executive order — the rules defining and implementing it have not been written, so it is not yet happening, and we don’t know how it will work in practice, much less how many people may eventually sign up. Nor does the order get rid of the prohibition on selling insurance across state lines for most people — it’s only for this one kind of plan which can include members in multiple states, and which will only serve a tiny minority of the health insurance market.

Levin wrote:

My best guess is that at some point President Trump was briefed by his staff about the executive order he signed in October that, among other things, instructed his administration to expand the scope of association health plans. The word salad we find here is what remained of that briefing (or maybe of a conversation with a knowledgeable AHP supporter, like Rand Paul) after it was minced and digested by the president’s mind into a mess of little unconnected proofs of his own acumen and prowess. Trump appears to believe that millions of people are joining such plans, but in fact his order has yet even to be translated into a proposed rule, so that it has had no practical effect so far. He describes his order (I take it) as 'a big bill'—and this from the man who earlier in the same interview said  'I know more about the big bills. … [Inaudible.] … Than any president that’s ever been in office'. But maybe he just meant a big deal. He suggests that half of some presumably significant group of people will join such plans, and that in combination with the zeroing out of the individual mandate these plans will somehow drive Democrats to make a deal on health care.

The Affordable Care Act (ACA, "Obamacare") and Its Mandate

Neither commenator specifically addressed this issue

General Comments on Trump's Approach to Health Care

Both commentators were very concerned about Trump's approach beyond any questions of truthfullness of claims or arguments about whether proposed policies would be good for the country.

Klein wrote:

Whatever Trump is saying, it does not reveal much familiarity with health policy, or even with the status and limits of his own actions. And yet Trump believes himself, on policy, to be the most informed president in American history. As the Dunning-Kruger effect suggests, he doesn’t know how much he doesn’t know, and that, combined with his natural tendency toward narcissism, has left him dangerously overconfident in his own knowledge base.

Even worse:

This is the president of the United States speaking to the New York Times. His comments are, by turns, incoherent, incorrect, conspiratorial, delusional, self-aggrandizing, and underinformed. This is not a partisan judgment — indeed, the interview is rarely coherent or specific enough to classify the points Trump makes on a recognizable left-right spectrum.


I am not a medical professional, and I will not pretend to know what is truly happening here. It’s become a common conversation topic in Washington to muse on whether the president is suffering from some form of cognitive decline or psychological malady. I don’t think those hypotheses are necessary or meaningful. Whatever the cause, it is plainly obvious from Trump’s words that this is not a man fit to be president, that he is not well or capable in some fundamental way. That is an uncomfortable thing to say, and so many prefer not to say it, but Trump does not occupy a job where such deficiencies can be safely ignored.

Levin wrote:

After reading this, it is advisable to take a moment to wonder at the absurdity of life, to offer a quiet prayer of thanks for the fact that any of us is still alive, and then to pursue—yet again, and surely not for the last time—that recurring question of our era: What in the world is the president talking about?


I have no doubt these claims began as duly grounded and modest statements of fact in some policy discussion. But they have ended up as worse than nonsense—worse, I say, because the only function they are left to perform is to affirm the president’s belief in things that aren’t true.

This is a narrow example of a broader pattern, of course. It doesn’t matter all that much if the president doesn’t really know anything about Association Health Plans. He’s got bigger problems to worry about. But it’s hard to deny that he seems to approach those bigger problems in the same general way, and that the broader pattern is therefore itself a very big problem, given the nature and demands of the modern presidency.


We have frequently criticized the leadership of big health care organizations as ill-informed, incompetent, ignorant of or even hostile to the values of health care professionals, deceptive, self-interested, conflicted or even corrupt. The President of the United States is the country's most important health care leader, since all government agencies that deal with health, health care, health care policy, etc report to him.  Unfortunately, we have previously discussed examples of how the president appeared to be an ill-informed or incompetent health care leader, for example here

So it would be easy to just say that his responses in his recent interview as discussed above just corroborate this opinion. 

However, in his latest interview with a reporter from the New York Times, it was not that the President of the United States deferred on issues of health policy to health policy experts.  It was not that he was evasive, or exaggerated.  It was not that he advocated policies that were controversial.  It was not even that what he said was untrue.

As per the title of Levin's commentary, it was that the President created a word salad.  What he said often made no sense.

This goes way beyond ill-informed or incompetent leadership as we have used these terms previously.   When we have discussed incompetence, it was in the sense of ordinary English usage.  For example, per, incompetent means "lacking qualification or ability; incapable." 

We have seen many leaders of big health care organizations who did not seem to have adequate qualifications or abilities to run such organizations, even though they might be perfectly intelligent, well-educated, generally capable people.  Such leadership often seemed to be a consequence of 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 one 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. 

Yet as we first noted here, the problem goes beyond the ignorance about health care of the managerialist health care manager.  How he thinks about health care at times seems incoherent, confused, or demented.  Questions about the President's competence, in terms of his ability to sustain rational thought, have become a national concern (e.g., look here and here.)  An approach to this has got to be devised at the highest levels of US government, but independent of Mr Trump.

Meanwhile, in the hope that the country can recover from this, maybe the case of President Trump's word salad will remind us that we have to rethink who should become leaders of health care organizations.


Judy B said...

Trump just claimed that he is "a very stable genius." Oh my....

Anonymous said...

"an MBA from the Wharton School"

Mr. Trump doesn't have an MBA. He attended Wharton as an undergraduate, and emerged with a BSc in Economics. Just trying to keep the record straight....

Link to relevant AP article.

Judy B said...

For your enjoyment, google The Drunken Tenor - A very stable genius.
(I'd post the link but I wasn't sure if that was allowed here.)