Dander Still Up, And Also Down, All Over the Place. What Gives?

A. The Present Moment.

I've started this piece a whole bunch of times. So in fairness to you, reader, you have a few paths through it. If you don't feel like starting by sharing some navel-staring about today's bizarre predicament, please skip to 'D.' Or 'B,' or 'C.' Wouldn't blame you in the least.

I've still got my dander up about what's happening in the many troubled reaches of health care in the United States. OK, truth to tell, also about what's up world-wide. Scary stuff. Readers have no doubt waited patiently for me to recover from confusion about this sudden mess, much of said predicament stemming from various delayed reactions to the 2008 disasters. (For the wildly popular, broader and verbally less restrained version of this consternation, from a compelling voice, see this newsletter.)

Or, at least, I've waited to get over this confusion. Now I'm over it: see 'C,' below.

Overall, anyone paying attention to the press—or even for that one lone DC Legislative Assistant just reading this blog for all her health policy info—you know things just ain't right. Not in academia, not in government, not in the private sector despite a record-shattering bull market run. (Leave aside for just a moment all those other issues in US foreign and economic policy, equally in the soup.) We thought matters couldn't get worse before the arrival of the latest residents of board rooms and corner (or oval) offices in each of those sectors. But, oh, wait: then, after January 2017, they did.

But what gives beneath the surface? The news waves have become a deluge. But, to get to the "so what?", where are the rip-currents beneath today's tsunami of chaotic news? Why are things seemingly better in some areas than others? (For some specific examples see my Grade Point Average—GPA—scores below, introduced in this edition of the CDR (Cetona Dander Report),  I've been off the air while scrambling for some way of understanding the why behind the what. Now I think I've gotten what're at least some part-answers to my writer's block. And mirabile dictu, my dander's gone back down a little, especially over there in the Department of Health and Human Services.

For one thing, as Margot Sanger-Katz recently pointed out in the Times, and we're seeing this in many places, the troubled crazy-quilt of American health care, especially among the federal branches, and the antics of the DIC (disloyalist-in-chief, or my preference, doofus-in-chief), all have paradoxically made the organization of health care somewhat less anechoic. ("You see how I did that double negative in there?") This anechoic effect I began talking about over a decade ago, during the perhaps slightly calmer Shrub and Obama years—corrupt and autocratic behavior operating under everyone's radar, and I don't miss those days—this effect has repeatedly been decried by those blogging here, especially your intrepid editor.

But today, like immigration, health care is back in the political ads and it's no longer quite so anechoic, now the DIC has lanced the boil with his shrill. Hell, DIC's our poster child for health care reverb. He even claims as he campaigned on the notion of lower drug prices and better care. Just not for those people.

No matter. You can't unring this bell. Everyone left with anything resembling an open mind—come November we'll get more on the 'N' of said group—they all know what far too many in his party are trying to do. Those with brains already fully devoured (burp) by QAnon are, of course, excepted.

Biggest place the GOP and DIC overlap in goals: dance with all the lobbyists and Fat Cats who want to kill the baby in the bathtub. Kill the VA. Kill the ACA. Kill kill kill.

If this all starts to sound a little schizzy, that's precisely the point. This is a big clue to what's become the inner dynamic of federal health policy (and economic and foreign policy) in the second half of 2018. There's campaigning to the base, and there's governing. I mean, I know, I must be the last person in Montana to recognize this dynamic, especially after everybody saw the latest blind-siding on the Russian affair. No offense to Montana. I'm not from there. I know great folks there.

The executive branch of our government has cleaved in two. The White House today—quite unlike any of its predecessor administrations arguably including that of Bush II—is a perpetual political campaign. I know, others have compared it more to television reality show or one variant of the same thing: WWE. Anyway, it's a perpetual political campaign, and solely that. Its purpose is not to govern but to retain power in order to reward friends.

This goes for everything it touches in health care. Campaigns depend interminably on donors and, fitfully, even voters. The problem is, there are cabinet departments, for our purposes notably the VA and HHS, where something else, something else besides perpetually rabble- and fund-raising, has to happen. Something we used to call "government." More and more a rare bird. In the White House, the bird is as extinct as the dodo. (Charlottesville was clear-cut proof of this point, when the DIC ducked his constitutional responsibility to console and unify, in order to play exclusively to his base.)

"Government" clearly can't be effective by defaulting to sheer adversarialism and destruction. But interestingly, it's still there outside the White House. If not thriving, as least surviving and fitfully accomplishing some important tasks. In matters of health, like the tiny furry mammals scurrying among the dinosaurs after the asteroid, government is actually beginning to make some hopeful moves. It's time we called those out as well, and scored the agencies on how they're doing as we get close to mid-term elections. It's a balancing act between the campaigning DIC and his few fitfully effective folks. (If they tick him off and get fired, they'll be retroactively labelled "deep state.")

It looks to me like health care policy management, whether around how care gets paid for, or around reuniting kids suffering from child-abuse-as-foreign-policy, has become an absurdist pas de deux between these two factions. Never have they been more distinct. In this corner, the White House, with its hacks, its DIC, its billionaire donors just a phone call away, and its campaign-job explant moles planted in key departments. And in this other corner, until maybe they get fired, cabinet appointees and sub-appointees, including some pretty good old time GOP types, who want to get the job done. The first either lets these second types do their jobs, or somebody--often one of the hacks--gets to them first.

(In all of this, of course, Rule Number One is always, don't piss off the DIC. Get the job done without losing your own job.)

Among the hacks closest to the ear of the DIC, and man is that an image, chief are Larry Kudlow, Mick Mulvaney, both on money matters; and John Bolton on matters involving anyone who looks, y'know, a little foreign. (Norwegians, good. The rest: maybe, y'know, drug dealers and rapists.) In 'D' below we talk about some of the other

B. Getting a Bit Less Jumpy.

Here's how to get out of the distracting, enervating, confusing obsession so many of us complain about when considering health care and pretty much else coming out of today's Washington. (Not just the White House and the 15 executive departments. But especially.) Extricate yourself, that is, without sticking head in sand. Don't just take a break from all the crazy. Take a cue from the DIC Head himself. Note how fond he is calling everybody a dog. But in fact his prey, take for instance, are not dogs at all. It's the secret joy of more right wing GOP Trump-heads: we're all acting like cats.

Laser cats.

Just let him move that pointer around and we all go batshit batting at it. Dudes love it when we do that. We don't have to do that. Just be quiet and keep paying attention. We're on to them. Don't pounce until there's more there there than just a flickering red light. Recognize what he's doing across the board. Read Health Care Renewal. Remember, every time the red light blinks and you leap into the air, somewhere a puppy dies and a spook's security clearance goes kerplooey.

Here's an example. The daily din of Russiagate. Mueller et al. We don't jump every time there's a new lie or a new "flipper." But the DIC's organization's CFO just flipped. Now that's worth a jump. Right over the moon.

C. Sidebar: Montana and Oklahoma.

Why mention Montana? Well, actually turns out a big source of impact on our health comes right from our natural environment and the failure of Big DIC to insure its stewardship. He appointed an Associate DIC (ADIC) to the Interior department. Ryan Zinke, best known for a career as football player (Whitefish HS, University of Oregon) and Navy Seal. (Navy.) Zinke believes the California wildfires are best explained by "environmental terrorists" rather than climate change. Not cool.

The Secretary has now appointed a Whitefish team-mate essentially to vet any program that might affect our health. Steve Howke has an undergraduate business degree and a life in credit unions. So clearly he's a great pick to vet any proposed money involving more than budget-dust (i.e., > 50k) on programs. This is to make sure such expenditures "align with the administration’s priorities." Pretty much kills any chance Interior will pay attention to our health. Guy's the designated goalie to assuage the boss's desire to focus on really hopeful matters such as Clean Coal.

On a slightly brighter note, when it comes to the looming underwater loss of, oh, maybe the East Coast and all of Florida, the Big DIC seems to be appointing a real expert, Kelvin Droegemeier, as his White House Science Adviser. Job's been vacant for a long time. Maybe we'll keep Florida a little longer. Guy's impressive. See for example this actual piece of science for weather prediction. Let's fly to Oklahoma and talk to this guy.

Ah, the outsized influence of Whitefish, Montana. Is there a Trump Hotel in Whitefish? I know people there. I'll find out. If there's a solid gold toilet in Whitefish, we're finished.

D. Comparing Two Departments: a Trillion Between Them. Then Let's Grade Them.

So finally, after such all this preamble, how's life been playing out in health care? With the exception of the comparatively tiny program to reunite refugee kids with their parents, which is hapless, until now such life's not been so very vivid for most citizens glancing at their screens. Average Joe probably can't comment on either of the biggest items. But the noisy numbers, for 2019 are as follows.

• A nearly 200 billion dollar request for the VA, well over a third of which is for health care and an over 15% request over 2918.
• Almost 800 billion dollars for Medicare, most of which is for Medicare reimbursements, and just a 3% increase from the previous year.
• Compare this with a bit over two billion for all HHS-supervised vulnerable-populations programs, even with a whopping 29% increase over 2018.
• Only a tenth or so of this two billion is devoted to refugee programs. Two hundred million divided by a trillion. Hmmm, too many zeros here, so you do the math. Rounding error. But with close to a 30% increase for forcibly orphaned kids and others, maybe the Secretary tried.
• So final tally: the three above total a trillion, 80% Medicare and 20% VA.
• Keep it all in perspective, bearint these things in mind.
• These are budget requests. Medicare they want to gut, even beyond ACA, so in the end maybe the aforesaid 3% will drop down into negative numbers.
• Even here, with the 800B request, the HHS Secretary's clearly trying to be realistic on Medicare, knowing the temper of his bosses at both ends of Pennsylvania Avenue.
• Ain't it odd! VA gets a barely passing grade despite the huge increase year-over-year. But this is the reality, as we'll see below.

Back to our echo chamber and the din of the 2018 election. It's all changing now, not so anechoic any more, as Dr. Poses recently pointed out. The fact is, and you'll hear much more of this in state-by-state campaigns just now getting off the ground for the fall run-up to November 6th, it's all now as vivid as hell. We should all remember how much more vividly people feel the loss of a dollar than they feel the bestowal of a dollar. Politicians know this. The anechoic chamber fills with a joyful noise. If only because, as occurred with other earlier water-boarding-style excesses, this same political party just gave us this most recent instance of politically weaponizing cruelty.

Really, not so joyful. But likely to command attention this fall. What else will command attention? Access to health care. And something for the vets who provided proud service to their nation.

I wrote earlier about the VA versus political donors' influence, in that case a Koch brother and a hack somehow attached to said brother. For a while seemingly, until he alienated them too, Trump and his people acted as though "things go better with Koch." In my previous dander-post, I pointed out the "Concerned Veterans," who've always seemed most concerned with privately outsourcing veterans' services while sundering the agency that protected them. (I provided medical care to these brave warriors from both inside and outside the VA. They rarely had anything bad to say about the organization. Certainly a lot less bad than I did when dealing with that hoary bureaucracy. Certainly they don't want it to go away. David Shulkin felt the same way, and lost a battle with the DIC's hacks.)

But now it's much worse. So I want to go out on this here limb and give Trump's two key departments for health care, their respective mid-term GPAs. For the VA: charitably, a D-minus. But interestingly, GPA for HHS: maybe as good as a B-, albeit constantly threatening to slide into a Gentleman's C to placate the boss DIC.

Why the qualitative disparity? Well, first let's back it up a little and rack up some of the recent events upon which this GPA result is based.

First let's take the VA. The place has had major problems for years and years, many of them self-inflicted with a self-referential bureaucracy second only to the Catholic Church. (David Shulkin knew he needed to fix this and was actively trying to do so when he was fired.) But the place just can't seem to catch a break. So harsh as it is for what's hopefully a work in progress that can still be salvaged either now or after 2020, the grade for this place is D- on a good day. Here are some of the hour-exams that go into the dismal assessment.

• The VA's own internal watchdog just recently ripped it for failing in a recent program to help veterans' caregivers. This started before and continues during the Trump administration.
• The effort to privatize VA care continues to ramify. Chasing down all the leads on this issue feels like trying to lop off the head of Medusa.
• A proposed law to pay for privatization is bizarrely popular with bipartisan lip service. But it may shut down the government when you get down to finding the money.
• There's a pathetic White House VA hotline about this, which reaches some hapless third party call-center folks who're powerless and clueless.
• Most recently, Trump has essentially abdicated VA oversight to cronies, much like our high school footballer vetting spending at Interior. Specifically the "Shadow Rulers," a threesome of alte kakers—Palm Beach concierge doctor Bruce Moskowitz, sometime Marvel Entertainment chair Ike Perlmutter, and attorney Mark Sherman—who have in common one great thing: Mar-A-Lago! You can't make this stuff up. We owe it to ProPublica.com (see here, here, and here) for providing superb coverage of the narrative of their undue influence. Whether official or unofficial, it's abdication of authority, with weak official leadership.
• After Shulkin left, the place was forced to thrash around leaderless. It now has a guy Richard Stone, an unimpressive managerialist, but at least an Army Veteran. Not nearly enough!
• Stone replaced a far better suited expert, Carolyn Clancy, who was sidelined into a looking-out-the-window job under questionable circumstances. See here.
• Worth an entire blog of its own but start here: the VA's saga of health IT is a surpassingly strange, long and sordid one. The VA was among the first to have a workable EMR. It  ultimately got scrapped for lack of support and interoperability with the far more egregious and expensive failure of DOD's EMR program. (Which Shulkin sought to fix via COTS outsourcing.) Many billions down the drain on both sides. The VA system's lack of interoperability was in no way the VA's fault. They can't catch a break.
• One of Trump's earliest attempts to "deal" with the VA was to put Omarosa in charge! This early episode again underlines the White House's difficulty in dealing with government organizations that give off the scent of unprivatized "deep state" players. Veterans hated her—now why would that be?
• Another Cohen, not Michael, enters the picture. Also courtesy of New York's blogger-journalists at ProPublica, we learn that hedge fund billionaire (and of course DIC crony) Steve Cohen is cashing in with the VA. Altruistically, of caws. Just wants to help out all those PTSD patients. Privately, employing something modestly called "The Cohen Network." Read this whole sordid story at ProPublica. I'm seeing double Cohens in here.

Why does the VA story seem so haplessly fragmented, with lovers and haters constantly duking it out? A recent piece in Washington Monthly, by noted authors Suzanne Gordon and Jasper Craven, offers a simple and I think largely correct answer. Its supporters, especially those in Congress, know VA medicine is popular but they keep ragging on it as though it hurts its patients more than the private sector does. Not true! These guys just don't like government-run programs when the private sector friends want in. The private sector is also beset with inefficiencies, IT disconnects, and corruption. Shulkin was on the right track but got derailed. In every case, the common denominator is how VA medicine is a single frog in a single barrel. Shoot it or slowly boil it. Either way, a far easier target for meddling than HHS. This is the answer, folks. It's not that the VA needs more help than HHS, or that publicly supported health care's inherently bad. VA and HHS certainly both need a lot of help, but the VA did many fine things over recent decades. But boy is it an easy target.

Now to HHS, a very different story. A much more elusive target, for any journalist but more importantly for any DIC-hack or -backer. And now it has a Secretary about whom we may at least point to dramatic improvement over his spendthrift predecessor. The latter was a physician at that, should have had his head on straight, but who proved to be so far right, and frankly so peculiar, that at any given time he clearly could take a bite out of his own prostate.

Salient points about HHS's performance under Trump:

• Key people are Alex Azar, the Secretary and Seema Verma over at CMS.
• They're both clearly being forced to walk a tight-rope between White House and DIC-backers' ideology, and getting a whole host of jobs done. And those jobs require a great deal of organic interaction with the private sector.
• PBM companies
• Big Pharma
• The AMA
• The payers
• Patient advocates.
• Last and probably least, advocates for vulnerable populations—for reasons stated above.
• They both seem to be learning on the job. B.
• Not all's well. Trimming back access to ACA benefits, hotly opposed by many, is still a campaign in the Congress and White House, but seemingly opposed at least in part by many within HHS. Jury's out on this one, as ACA is super-popular nation-wide. D-.
• Evidence for this: tackling the ticklish issue of stabilizing the Obamacare marketplaces. Much ink-shed over this, e.g. here and here and here.  Devilishly complex but suffice it to say that some states and perhaps the Congress will go ahead (one of the above links even refers to Scott Walker and Wisconsin) and make sure reinsurance is assured. Can this be anything other than the insurance industry pushing back on the nihilists? B+.
• Medicaid and its expansion are also fighting back from the preferred GOP method of compression and extinction. The abusive work requirements, playing to the DIC's base and its resentment of "free-loaders," are not likely to last. The WaPo in fact now reports the emergence of multiple objective health-services-research studies showing the salutary effects of expanded Medicaid, especially for chronic illness like diabetes. So risk payments may be restored. B+.
• Drug-price negotiations are see-sawing like crazy. Trump says he believes strongly in this. Do we believe him or the PHRMA lobbyists? He touts token prize freezes. Azar seems on the fence, though he talks a good game. Congress tries to be encouraging. Jury's out. C-.
• The corner of Medicare known as Advantage programs, emphasizing Accountable Care Organizations or ACOs, is another complicated matter. Verma seems to be looking to restrict ACOs to those with real accountability. Some view this as more draconian behavior, but I see her point. B+.
• PBM companies—those lucrative outfits that "manage" pharmaceutical benefits—are also on the DIC's hit list. I see little progress. What I see is rural pharmacies dying out because they get caught in the PBM companies' baroque pricing schemes. D- to F.
• A almost wholly unnoticed federal regulation from last month deserves much more attention. This voluminous document dramatically revises fee schedules for Medicare patients, emphasizing many of the services traditionally provided with little or no reimbursement by primary care physicians. New billing codes are proposed. For the first time the playing field may soon be leveled for many PCPs. This is a potential big win for those working for Verma. A solid A+.
• The above's an excellent example of emerging claims, for example those in a worthy new Brookings piece, that real cause for optimism exists in health care reform. At least some of that stems from activities within HHS. The conservative author, Stuart Butler, deserves a careful read. He signals several "under the radar" patterns from both the states and HHS itself, flowing from increased flexibility that HHS now has. (For all its strengths, ACA was hamstrung by some fairly inflexible regulations on matters such as metrics for improving Health IT.) A+.

Average grade for HHS: B-. Why this good in an abysmal administration? As I've intimated, for every meddling White House apparatchik there's an outside interest pushing back on Azar and Verma. Lots of IT vendors. Lots of payers. Lots of innovators. (And, of course, lots of outraged citizens in the one conspicuous but miniature case of the separated children.) The very protean and risibly shuffling-buffalo scale nature of HHS may have been its greatest virtue. In an effort to satisfy the spirit of "anything but Obama," they're trying some new stuff, and some of it isn't half bad.

Thus VA and HHS are fascinating bookends juxtaposing the risks and benefits of homogeneous versus heterogeneous health planning. Right now HHS is winning, if only because of a political atmosphere in which the latter is better adapted to thrive. It could, of course, go the other way. Personally I hope the VA is restored to its former strength, perhaps in a spruced-up and more streamlined form: less bureaucratically stodgy to get away from the current predicament in which everyone from a bad manager to a bad nurse can tie the place in knots. I also hope HHS, even if Medicare For All becomes a reality, preserves opportunities for experimentation and innovation.

Making Abusive Contracts Great Again - Non-Disclosure Agreements, Which Have Bedeviled Employed Physicians, Go From Anechoic to Viral Courtesy Omarosa

Introduction: Confidentiality Clauses, Non-Disclosure Agreements, Non-Disparagement Clauses

In 2016, Dr Wally Smith and I published an article on how contracts employed physicians sign may threaten their patients and professionalism.(1)  At the time, we wrote,

clauses in the contracts that physicians sign with their employers or that their employers sign with third parties may be part of a growing class of subtle but protean and pernicious restrictions on employed physicians' professionalism and autonomy.  These provisions may financially benefit employers and their management. No clear arguments that they benefit patients or support physicians' professionalism have been made.

The first such provision we listed was the worst one, in our opinion.

The most pernicious threats created by employed physicians' contracts may arise from blanket confidentiality clauses. For example, a hospital system subjected physicians to an 'ironclad confidentiality clause' under which 'the doctors could not publicly discuss their situations or, for that matter, anything else of significance about the corporation' that employed them....

These were particularly troubling because

Such clauses do not obviously benefit physicians or patients; instead, they may bury evidence of poor quality or safety problems, choke whistleblowers, or conceal mismanagement and malfeasance.

The clauses had a self-referential aspect

Because these clauses [themselves] are confidential, they have rarely been discussed in public, and corporate managers have never been called to justify their existence.

Finally,

Blanket confidentiality clauses could also hide other obnoxious contract provisions.

Up to 2016, obnoxious clauses in physicians contracts were, as noted above, quite anechoic, if not mostly totally secret.  I am afraid our article did not have many echoes.  But in our brave new political era, things have changed.

Donald Trump's and Associates' Use of Confidentiality Clauses, aka Non-Disclosure Agreements

By July, 2016, it became clear that the Trump campaign was requiring staffers to sign non-disclosure agreements similar to the blanket confidentiality clauses described above.  An Associated Press article stated that the campaign meant to enforce such agreements,

Republican presidential candidate Donald Trump is seeking $10 million in damages from former senior campaign consultant Sam Nunberg, alleging that Nunberg leaked confidential information to reporters in violation of a nondisclosure agreement.

Furthermore,

Trump requires nearly everyone in his campaign and businesses to sign legally binding nondisclosure agreements prohibiting them from releasing any confidential or disparaging information about the real estate mogul, his family or his companies. Trump has also said he would consider requiring such agreements in the White House.

That prediction proved to be correct.  In March, 2018, Washington Post editor Ruth Marcus started by quoting an interview Trump had given to Post reporter Robert Costa in 2016,

Costa: 'One thing I always wondered, are you going to make employees of the federal government sign nondisclosure agreements?'

Trump: 'I think they should. . . . And I don’t know, there could be some kind of a law that you can’t do this. But when people are chosen by a man to go into government at high levels and then they leave government and they write a book about a man and say a lot of things that were really guarded and personal, I don’t like that. I mean, I’ll be honest. And people would say, oh, that’s terrible, you’re taking away his right to free speech. Well, he’s going in.'

Reader, it happened. In the early months of the administration, at the behest of now-President Trump, who was furious over leaks from within the White House, senior White House staff members were asked to, and did, sign nondisclosure agreements vowing not to reveal confidential information and exposing them to damages for any violation. Some balked at first but, pressed by then-Chief of Staff Reince Priebus and the White House Counsel’s Office, ultimately complied, concluding that the agreements would likely not be enforceable in any event.

The nondisclosure agreements, said a person who signed the document, 'were meant to be very similar to the ones that some of us signed during the campaign and during the transition. I remember the president saying, ‘Has everybody signed a confidentiality agreement like they did during the campaign or we had at Trump Tower?’ '

Again, this implied that Trump and his business associates had long had a policy of requiring non-disclosure agreements (confidentiality clauses) of most if not all employees..

In addition, the agreements apparently were supposed to be valid in perpetuity.

Moreover, said the source, this confidentiality pledge would extend not only after an aide’s White House service but also beyond the Trump presidency. 'It’s not meant to be constrained by the four years or eight years he’s president — or the four months or eight months somebody works there. It is meant to survive that.'

The provisions were extremely broad, blanket if you willl .

It would expose violators to penalties of $10 million, payable to the federal government, for each and any unauthorized revelation of 'confidential' information, defined as 'all nonpublic information I learn of or gain access to in the course of my official duties in the service of the United States Government on White House staff,' including 'communications . . . with members of the press' and 'with employees of federal, state, and local governments.' The $10 million figure, I suspect, was watered down in the final version, because the people to whom I have spoken do not remember that jaw-dropping sum.

It would prohibit revelation of this confidential information in any form — including, get this, 'the publication of works of fiction that contain any mention of the operations of the White House, federal agencies, foreign governments, or other entities interacting with the United States Government that is based on confidential information.'

These agreements were apparently required even though they appeared to be blatantly unconstitutional.

Unlike employees of private enterprises such as the Trump Organization or Trump campaign, White House aides have First Amendment rights when it comes to their employer, the federal government. If you have a leaker on your staff, the cure is firing, not suing.

'This is crazy,' said attorney Debra Katz, who has represented numerous government whistleblowers and negotiated nondisclosure agreements. 'The idea of having some kind of economic penalty is an outrageous effort to limit and chill speech. Once again, this president believes employees owe him a personal duty of loyalty, when their duty of loyalty is to the institution.'

A New York Times article again from March suggested that these agreements were required not just from White House staff, but from journalists who embarked on official administration trips.

Mr. Trump’s White House has also broken with convention in trying to impose written nondisclosure agreements in other instances. A small group of journalists scheduled to travel on a trip to Afghanistan with Vice President Mike Pence were instructed in December to sign a confidentiality agreement before they would be given the details of the trip, for security reasons.

The issue of blanket confidentiality agreements now being used in government despite Constitutional free speech guarantees caused a brief ripple in the force, but that soon faded away, until Omarosa, that is.

Omarosa's Case Puts Non-Disclosure Agreements in the Headlines

This month it seemed impossible to avoid the saga of Omarosa Manigault Newman whose tell-all book about the president and his administration was just published to great tumult.  Ms Manigault Newman was the former reality television villain of Trump's Apprentice program.  She became a campaign aide (and somewhat infamously warned us that all Trump's critics would be forced to bow down to him, look here), then a White House aide with unclear duties, only to leave abruptly.  The story was everywhere in the media, and soon involved her allegations that she was pushed to accept "hush money" not to reveal goings on in the White House.  In fact, it became apparent that a blanket confidentiality agreement was one means Trump meant to use to keep her quiet.

On August 12, 2018, per Politico, KellyAnne Conway, erswhile WH drug czar (look here) said in an interview

'It is typical, and you know it, to sign an NDA … in any place of work,' Conway, counselor to the president, said to host Jonathan Karl on ABC’s 'This Week.' 'I’d be shocked if you didn’t have one at ABC.'

'I’m told she signed them when she was on 'the Apprentice,’ certainly at the campaign. We’ve all signed them in the West Wing,' she added. 'And why wouldn’t we?'

Again, Ms Conway did not seem to recognize that there should be any differences in what goes on in the government and in a private business.  Furthermore, the implication was that non-disclosure agreements, or blanket confidentiality agreements, are now standard practice in private business, and are worthwhile and objectionable.  Of course, she did not give any reasoned justification for their use in business, much less any explanation how their use in the executive branch was not a blatant violation of the First Amendment.  But onward,...

Just to underline the similarity with practices were originally discussed in 2016, the White House agreements were required of everyone, and were self-referential in that they made their own existence secret.  On August 14, 2018, the Weekly Standard reported

President Trump’s escalating digs at ex-aide Omarosa Manigault Newman over her gossipy new tell-all have brought new scrutiny to this White House’s unconventional—and, arguably, unconstitutional—policy of requiring staffers to sign non-disclosure agreements to prevent them disparaging the president.

The rule extended not just to those public-facing West Wing regulars, like Apprentice star Manigault Newman or former press secretary Sean Spicer—but also to lower-level recruits less likely to shop a White House memoir.

'We had to sign them when we went into the building,' said one former White House and former Trump campaign staffer, who described the practice as just a part of this president’s modus operandi going back many years.

Furthermore, one staffer stated,

'When we all got onboarded one of the things we had to do for our official ethics briefing was sign an NDA,' the staffer said—but they could not keep a signed copy for themselves. 'Everything got taken away as soon as we signed it.'

Just as in the case of the contracts handed to physicians, Trump's White House confidentiality agreements made their own existence a secret.

Summary and Discussion

In 2016 we published an article decrying the requirement that employed physicians sign contracts containing confidentiality clauses as well as other obnoxious provisions in order to practice.  We asserted the confidentiality clauses, also known as non-disclosure agreements, did no good for physicians or their patients, but did allow the managers of the physicians' corporate employers to hide embarassing information, poor quality care, and malfeasance.  At the time we urged physicians to carefully review their contracts and get legal advice before signing.  But we worried that little could be done to stop the use of exploitive contracts without wholesale changes in health care, which would probably require the organization of employed physicians.  Our concerns were inspired not a little by the lack of recognition of exploitive contracts as a problem.

Now the phrase "non-disclosure agreement" is frequently in the headlines.  The confidentiality clauses in contracts that Donald Trump has forced his private employees, then his campaign workers, and now White House staffers to sign are apparently very similar to those physicians had to sign.  They are extremely broad in what they make confidential.  They make their own existence, and other obnoxious contract provisions secret.

What is to be done?  Maybe the new publicity surrounding this problem will embolden physicians to address the issue in their own bailiwick.  Maybe it will suggest that blanket confidentiality clauses, and other obnoxious contracts provisions we had discussed should be rigorously regulated, if not outlawed by state and the US governments.  However, as long as we have the confidentiality clause imposer-in chief in charge of the US government little is likely to be done.


Reference

1. Poses RM, Smith WR. How Employed Physicians' Contracts May Threaten Their Patients and
Professionalism.  Ann Int Med 2016; 165: 55-57.  Link here.

Reminder: Frontline trailer that includes Omarosa's "bow down" warning

#WHISTLEBLOWER tonight on CBS at 9 pm: Brendan Delaney and Electronic Medical Records

I received this today. I have been writing on healthcare information technology problems for 20 years, on this site since 2004 and others since the late 1990s.

This eClinicalWorks EHR story is the worst-case scenario: bad health IT, and vendor cheating in the (already weak) "certification" process to get the EHR to market without consideration of the severe harms that could result, Ford Pinto-style. 

This type of scenario is not what the pioneers intended, and is an example of how some in the healthcare information technology industry may have less of the altruism and responsibility that clinicians feel towards the medical mission.

Settlement information is here: https://www.healthcareitnews.com/news/eclinicalworks-pay-155-million-settle-suit-alleging-it-faked-meaningful-use-certification
--------------------------------------------------- hashtag#WHISTLEBLOWER tonight on CBS at 9 pm: Brendan Delaney and Electronic Medical Records Tune in tonight to hear Brendan Delaney’s Medical Records Whistleblower story – with Stowe Vermont Gables Inn’s Randy Stern, Phillips and Cohen LLP’s Colette Matzzie, and Ass’t US Attorney, VT Owen Foster’s help telling the story. Please share widely on your social media! https://lnkd.in/deaCH2k for a clip. Thanks to all of you who have made our telling of this important story possible. And to Alex Ferrer our host and Alex, Susan Zirinsky and Ted Eccles our EP’s Ron Hill our DP! And Editors: Maria Barrow, David Spungen and Greg Kaplan. Best regards, Team Medical Records: Chiara Norbitz, Peter Bull and Marty Spanninger Martha Spanninger Producer

--------------------------------------------------- -- SS

Addendum 8/20/2018: The entire program is now available via streaming at:
 
https://www.cbs.com/shows/whistleblower/video/fnhybgQYhfSLYT9aM32V7MyYFeHHcFd7/whistleblower-the-case-against-eclinicalworks-the-case-against-chartwells/

-- SS

Make Asbestos Great Again? - Trump Once Claimed "Movement Against by Asbestos was Led by the Mob," Now EPA Wants to Relax Asbestos Regulation

Introduction:  An Old Public Health Menace

This is somewhat personal.  In the early 1980s, as a general internal medicine fellow, I gave a series of talks about important medical problems that generalist physicians often missed.  One was asbestos related disease.  Although asbestos had been heavily regulated since 1973, there were stilll large numbers of people exposed to it alive in the 1980s.  One of my primitive slides, seemingly a picture of type writing, stated that around then, 2 to 4 million people who had histories of significant asbestos exposure were likely alive.  Asbestos is known to cause several cancers.  It is likely the nearly exclusive cause of mesothelioma.  It also causes lung cancer, and may act synergistically with smoking, and likely gastrointestinal and head and neck cancer.  It causes asbestosis, which can lead to respiratory failure.

In 2018, the evidence that asbestos is a major health hazard is quite clear. (See summaries by The National Cancer Institute, the Agency for Toxic Substances and Disease Registry, the Occupational Safety and Health Adminstration.)  Note that the rates of death from mesothelioma per capita are declining, but still substantial (look here).  The application of asbestos can be very hazardous, but once applied it can still endanger not only those who remove it, but firefighters, other first responders, etc.  People can be exposed indirectly, e.g., from asbestos on the clothes of people who work directly with it. 

Unlike other countries, the US never banned asbestos outright.  However, per the NCI report, 

In the late 1970s, the U.S. Consumer Product Safety Commission (CPSC) banned the use of asbestos in wallboard patching compounds and gas fireplaces because the asbestos fibers in these products could be released into the environment during use. In addition, manufacturers of electric hairdryers voluntarily stopped using asbestos in their products in 1979. In 1989, the U.S. Environmental Protection Agency (EPA) banned all new uses of asbestos; however, uses developed before 1989 are still allowed.

Trump Called the Movement Against Asbestos a Plot by Organized Crime

As we discussed in 2016, Donald Trump has pooh poohed all that.  Per Mother Jones,

In his 1997 book, The Art of the Comeback, Trump warned America not to buy the crusade against 'the greatest fire-proofing material ever used.' He claimed the movement to remove asbestos—a known carcinogen—was actually the handiwork of the mafia:

'I believe that the movement against asbestos was led by the mob, because it was often mob-related companies that would do the asbestos removal. Great pressure was put on politicians, and as usual, the politicians relented. Millions of truckloads of this incredible fire-proofing material were taken to special 'dump sites' and asbestos was replaced by materials that were supposedly safe but couldn’t hold a candle to asbestos in limiting the ravages of fire.'

Trump claimed asbestos is '100 percent safe, once applied,' and that it just 'got a bad rap.'

This year, Rolling Stone revealed,

Trump has also on multiple occasions blamed the collapse of the two World Trade Center towers on the absence of asbestos. In June, All in With Chris Hayes aired a clip of Trump defending the material before Congress in 2005. 'A lot of people say that if the World Trade Center had asbestos is wouldn’t have burned down, it’s wouldn’t have melted. OK?,' he said. 'A lot of people in my industry think asbestos is the greatest fireproofing material ever made.' Trump went on to compare asbestos to a 'heavyweight champion' compared to other building material, which he likened to a 'light-weight from high school.'

The article also stated that

As Hayes notes, Trump’s penchant for asbestos is almost certainly due to the cost of having it removed, which was undoubtedly a nuisance to a man known for stiffing contractors and cutting every regulatory corner imaginable.

Trump's beliefs, not to put too fine a point on it, to be nonsense, albeit somewhat consistent nonsense. In 2016, I wrote,

It is disturbing when one candidate for the most powerful political office in the US repeatedly disregards the best clinical and public health evidence, and offers ill considered opinions about public health that could potentially harm patients.

Now Trump is President, and in a position to act on nonsense.

Trump's EPA Appears Ready to Relax Asbestos Regulation

This week, the distinguished occupational health journal Rolling Stone reported,

On June 1st, the EPA enacted the Significant New Use Rule, which allows the government to evaluate asbestos use on a case-by-case basis. Around the same time, the EPA released a new framework for how it evaluates chemical risk. Not included in the evaluation process are the potential effects of exposure to chemicals in the air, ground or water. It’s as absurd as it sounds. It is ridiculous,' Wendy Cleland-Hamnett, who recently retired after four decades at the EPA, told the New York Times. 'You can’t determine if there is an unreasonable risk without doing a comprehensive risk evaluation.'

The new evaluation framework is a nifty way for the EPA to circumvent an Obama-era law requiring the EPA to evaluate hundreds of potentially dangerous chemicals. Asbestos is among the first batch of 10 chemicals the EPA will examine, and also one of the most blatantly dangerous to public health.

Quartz explained further,

On July 1, the US Environmental Protection Agency issued a 'significant new use rule,' which invites manufacturers to petition the EPA to seek approval of any new asbestos product on a case-by-case basis.

The rule says that the EPA will evaluate new asbestos products as 'new use' if they’ve determined they aren’t currently being manufactured. The categories the EPA says it will consider as new uses include 'adhesives, sealants, and roof and non-roof coatings; arc chutes; beater-add gaskets; extruded sealant tape and other tape; filler for acetylene cylinders; high-grade electrical paper; millboard; missile liner; pipeline wrap; reinforced plastics; roofing felt; separators in fuel cells and batteries; vinyl-asbestos floor tile; and any other building material (other than cement).'

Today, the New York Times reported that the EPA's new approach was launched by Trump political appointees over the objections of career, professional staff.

Top officials at the Environmental Protection Agency pushed through a measure to review applications for using asbestos in consumer products, and did so over the objections of E.P.A.’s in-house scientists and attorneys, internal agency emails show.

So it looks like these top officials are trying to operationalize Trump's enthusiasm for asbestos despite the absence of any new evidence that asbestos is less dangerous than previously thought, and despite the suggestion that Trump's enthusiasm may be self-interested.

On No, Russians Too

Two years ago, it seemed that one could attribute all of Trump's bias against asbestos regulation had to do with his real estate development background.  However, Rolling Stone found another possible influence on him.

As with many of his more insidious actions as president, there’s a Russia connection. As the Washington Post points out, until recently, 95 percent of asbestos used in the United States came from Brazil, while the rest came from Russia. But the South American nation recently banned the mining and sale of the toxic substance, opening the door for Russia to fill the gap, which will be even larger if the U.S. resumes using the carcinogen in building materials. Russian asbestos manufacturers are thrilled. In July, the Russian company Uralasbest posted an image of its asbestos packaging, which features a smirking President Trump.

The NY Times verified that 

the Russian firm Uralasbest posted on Facebook an image of its asbestos packaging that featured President Donald J. Trump’s face along with the words: 'Approved by Donald Trump, 45th president of the United States.' 

So it appears that the push by EPA political appointees to make asbestos regulation lax again would benefit Russia, a country for which Trump seems to feel great affection. 

Summary

Donald Trump long has had strong opinions on all sorts of topics.  His opinions about the public health hazards of asbestos seemed more informed by his self-interest as a real estate developer than anything resembling clinical or epidemiological evidence.  When he was just a rich real estate developer these seemingly misinformed opinions were of little consequence.

Now he is US President and his misinformed decisions could have major consequences, including eventually lethal ones.  Unfortunately, he seems to make such decisions so rapidly that no one can keep up.  And few of the people he has appointed to top leadership positions, particularly in health care and public health, seem inclined to stand up for more logical, evidence-based, and unconflicted and uncorrupted decision making. 

Obscure parts of asbestos regulation may not get a lot of attention, and may not be as dangerous as decisions about, say, nuclear weapons, but they still could be quite dangerous.  I hope those who care about medicine, health care, and public health will speak out against any new laxity in asbestos regulation.  In 2016 we had an opportunity to prevent a regime of the conflicted and uninformed.  Now we must challenge its bad decisions more directly. 

Musical Interlude

The immortal Warren Zevon, Lawyers Guns and Money: "how was I to know she was with the Russians too?" - Live Version

Ill-informed, Mission-Hostile Health Care Leadership... in the White House and the US Department of Health and Human Services

Introduction - What Has Gone Wrong with the Leadership of Health Care Organizations

A major focus of Health Care Renewal has been problems in leadership and governance of health care organizations, which we believe became major causes of health care dysfunction.  For example, we have discussed how leadership is often ill-informed.  More and more people leading non-profit, for-profit and government health care organizations have had no training or experience in actually caring for patients, or in biomedical, clinical or public health research as professional managers largely supplanted health care professionals as leaders of health care organizations.  This is part of a societal wave of "managerialism."  Most organizations are now run by such generic managers, rather than people familiar with the particulars of the organizations' work.  Obviously health care and health policy decisions made by ill-informed people are likely to have detrimental effects on patients' and the public's health.

Through 2016, our examples of ill-informed leadership in health care tended to be executives of hospital systems (e..g.,in 2014, here, on the mishandling of a patient with Ebola in a hospital system led by generic managers; and in 2013, here, on a luxurious hospital led by a former hotel executive).  Others were top executives of pharmaceutical corporations (e.g., in 2011, here, on previous Pfizer CEOs).

We have also discussed mission-hostile management, which in many cases has been demonstrated by ill-informed leadership.

Physicians professional values require them to put the interests of their individual patients ahead of all else, including the physicians' self interest.  The AMA Principles of Medical Ethics, for example, includes

A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

Similarly, in health policy and public health, the goal ought to be putting the health of patients as a group, and the public at large, ahead of other considerations.

However, we have often discussed how leaders of large health organizations seemed to put other considerations ahead of individual patients', patients' collectively, or the public's health.  Most of those examples of mission-hostile management involved putting organizational finances, or the leaders' own self-interest ahead of patients' and the public's health.  For example, in 2017 we discussed a New York hospital CEO who seemed to put revenue generation in support of his own very generous paycheck ahead of quality of care and patient safety (look here).  Also, the revered Mayo Clinic seemed to let patients with more remunerative commercial insurance coverage get attention before poor patients who have only government insurance, despite its stated mission "providing the best care to every patient" (look here).  Before November, 2016, our examples of mission-hostile management were mainly from hospitals and health systems, insurance companies, and pharmaceutical, biotechnology and device companies.

But since November, 2016, the most vivid cases we have found of ill-informed and/or mission-hostile management have come from the US federal government, run by the Trump regime. Note that Mr Trump himself has a bachelors degree in business administration, but no experience as a government leader prior to his election.

New cases continue to arise, while old cases continue to fester. In chronological order based on date of reporting,...

Taylor Weyeneth, Former Deputy Chief of Staff, Office of National Drug Control Policy 

We first discussed the hapless Mr Weyeneth in April, 2018.  At the time he was appointed to a position in the White House Office of National Drug Control Policy (ONDCP), Mr Weyeneth was 23, had recently finished his bachelor's degree, and had previously worked as a legal assistant.  He rose to be Deputy Chief of Staff, before he was moved to another job.

In June, 2018, the Washington Post published a long article on Mr Weyeneth's brief government career.  It noted how rapidly at first he rose through the ranks:

Weyeneth received six promotions in the campaign and administration. They culminated with his appointment as deputy chief of staff at the Office of National Drug Control Policy, where he oversaw veteran employees and helped steer an operation that was supposed to lead the fight against the opioid epidemic.

The main reason for his rise seemed to be politics, not any particular qualifications. The White House office of personnel:

wanted someone loyal to Trump and his policies in a position of authority, at a time when the office had lost most of its political appointees and had no leader, Weyeneth said.

Weyeneth had worked on the Trump campaign, starting as an intern, rapidly rising to coordinator of interns, then coordinator for national voter services.  He joined the Trump transition team in an administrative role which included '"helping staff with travel arrangements."  In these roles, he was tasked with determining political loyalty.  For the campaign he created "a list of Republican lawmakers and political figures who openly supported Trump."  For the transition team, he "helped compile a list of trusted politicians who could serve on the 'beachhead teams' that would flood federal agencies in the days and weeks after Trump's inaguration."  We had noted  here various ill-informed, and/or conflicted appointments to the beachhead teams that operated in the health care sphere.  Mr Weyeneth subsequently joined the beachhead team for the Treasury Department.  From there he jumed to the Office of National Drug Control Policy.  Then he became Deputy Chief of Staff, third in command of that agency.

There is nothing in his background to suggest he had any knowledge of medicine, health care, biomedical science, public health, or biomedical science, related or not to drug use.  He did seem to realize how unqualified he was for this job:

'This is more than I ever dreamed of,' Weyeneth recalled thinking, even as he worried about a possible backlash over his lack of qualifications: 'Have I reached too far? Is public opinion going to take over? Is this going to become an article?'

Thus he seemed to realize that he was a profoundly ill-informed leader.


Meanwhile, though, he seemed to have a role in spying on, and ensuring the political loyalty, if not the competence of Office of National Drug Control Policy career staff

The White House tasked him with reporting back on the ­ONDCP operations and the activities of its acting director, a career bureaucrat, Weyeneth said.

That would seem to be an example of mission-hostile management, since government employees are supposed to uphold the US Constitution and work for all the people, and those in health care have an obligation to put patients' and the public's health first.

 In any case, after the media discovered his lack of qualifications, he soon was gone.

Today, Weyeneth is doing temp work, including outdoor labor for a contractor at an intelligence agency.

Ximena Barreto, Former Deputy Director Of Communications, Office Of The Assistant Secretary For Public Affairs,, Department of Health and Human Services (DHHS)

We first discussed Ms Barreto in late April, 2018, here.  She was appointed to a responsible position of leadership in communications for DHHS.  Note that the mission of DHHS currently is:

to enhance the health and well-being of all Americans, by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services.

Nonetheless, her previous experience was as an extreme right-wing political commentator who regularly impugned African-Americans and Muslims.  She had talked about hanging former Presidents Clinton and Obama, and accused the latter of being a "Muslim terrorist."

Thus she seemed likely to be a remarkably mission-hostile leader.  Furthermore, there is no evidence she had any background or experience in medicine, health care, biomedical science, public health, or health policy.  Instead, it appears that she was appointed for no reason other than her extreme political beliefs.

In fact, a CNN article from June 22 indicated that Ms Barreto listed her previous on-line career, which would have included some of the postings listed above, on her resume, and hence posited them as qualifications for her leadership position at DHHS.

A copy of Barreto's resume, obtained by CNN on Thursday through a Freedom of Information Act request, shows she listed her previous conspiratorial work on her resume as a qualification for the communication position.

The resume noted her work from June 2017 through the present on 'The Right View' and on the Halsey News Network -- YouTube shows she co-hosted where she said Islam was 'a cult and said the Republican Party shouldn't allow a Muslim to run for Congress.

Another portion of her resume noted her work as a writer for the conspiracy-driven website 'Borderland Alternative Media' from April 2017 to the present. Barreto notes in description the website was funded by 'Joe Biggs, ex-InfoWars journalist' who himself repeatedly pushed the false Pizzagate conspiracy.

So she too was a profoundly ill-informed leader.

By June, she had been suspended, and then demoted, but still seemingly held a responsible position at DHHS.  After her extreme reviews became public, on June 21, 2018, the Mediate website reported 

Health and Human Services official Ximena Barreto publicly apologized recently for her 'heated and hyper-passionate' tweets on race and far-right conspiracies, after they were reported on by CNN.

And,

After her apology, Barreto, who worked as a far-right media personality before joining HHS in December 2017, was allowed to keep her Trump administration job — albeit, with a demotion from her old deputy director of communications post.

In that capacity

She made her Twitter account private ..... But on that now-private account, she’s been unapologetic — recently calling the reports exposing her fringe views a 'smear campaign.'

Mediaite conducted an extensive review of her social media posts and found that the HHS appointee pushed the baseless Pizzagate conspiracy theory even more than previously reported. Her tweets include smearing former Clinton campaign chairman John Podesta as 'a pedophile,' accusing Democrats of hosting 'Pedophile dinners,' and claiming liberals abuse children during satanic rituals.

Remember, this is the former Deputy Director of Communications for DHHS who was still in a leadership position, albeit one whose nature was unclear.

The Department of Health and Human Services and Barreto were contacted repeatedly via email and phone for comment, but did not respond. After this reporter asked for comment, Barreto shut down her private Twitter account and deleted her tweet calling the CNN articles on her views a 'smear campaign.'

Further gory details of her previous online posting are describe in the Mediate article.

Despite all this, Ms Barreto hung onto her DHHS position for more than a month. On July 27, 2018, Politco finally reported:

Ximena Barreto — a Donald Trump political appointee who used social media to spread conspiracy theories about a supposed pizza shop sex ring and made other inflammatory remarks — was escorted from Health and Human Services Department headquarters Friday, according to an individual with knowledge of the situation.

Barreto resigned, the individual said. HHS did not immediately respond to a request for comment.

Gavin Smith, Former Deputy Director of Communications, DHHS; David Pasch, Digital Director, DHHS; Tim Clark, Former White House Liaison and Interim Director of  Communications, DHHS


The issue with Ximena Barreto was her activities prior to taking a leadership position at DHHS.  However, on June 29, 2018, Politico reported on several DHHS officials who had been publishing pointed political opinions on the internet while in office.  It opened with

One staffer publicly mocked senators who criticized Donald Trump as 'clueless' and 'crazy.' Another accused Hillary Clinton of having a campaign aide killed and employing pedophiles. A third wrote the 'shameful' press was trying to deny Trump his victories.

These are not faceless trolls but midlevel political appointees at the Health and Human Services Department who have helped shape the agency’s communications strategy — even while taking a page out of President Donald Trump’s playbook.

Politico summarized how this might be mission-hostile management.

The behavior evokes Trump’s taunts and gibes, suggesting that some officials feel empowered to mimic the president even while representing the government to millions of taxpayers and working alongside career federal employees.

Again, as noted above, DHHS is supposed to work for all the people, not just the political allies of the current administration.  Furthermore, because these activities were by people within the government, there was an immediate legal question.

It also raises questions about whether any officials are violating the Hatch Act, which is intended to ban most federal personnel from bringing politics into the workplace.

Further details about each individual case follow.

Gavin Smith

One official involved was "Gavin Smith, an HHS staffer who identifies himself as deputy communications director."  His interests focused on pursuing Republicans who had opposed Trump in some sense.  His offerings on Twitter included the following directed to Republican Senator Bob Corker, who has frequently disagreed with Trump:

Just saw where Crazy @BobCorker called the #TrumpTrain a 'cult! Let's be clear sir, we're not a cult — we're a movement that defeated Crooked @HillaryClinton and that's committed to ridding Washington of politicians like you. Good riddance — DC will be better off with you!

Other Tweets included:

'Well, we've always known he's clueless,' Smith said, retweeting a quote about Sen. Lindsey Graham, and in another tweet telling the Republican senator to 'delete your account.' Other Smith tweets mocked Mitt Romney as a “clown” and encouraged all living ex-presidents 'to finally pipe down and get on board with the will of the #American people to #MAGA!

'Getting your ass kicked once just wasn't enough for you, was it @JohnKasich? Lookin' forward to Round Two! #MAGA' Smith tweeted in response to reports that the Ohio governor was considering a 2020 presidential bid. Meanwhile, Smith has waded into politics in his home state of South Carolina, including sharing an article about him possibly challenging a sitting House representative and repeatedly weighing in on local issues.

'Perhaps the South Carolina legislature will finally listen to @TreasurerLoftis — or will they make yet another bad deal on behalf of the #SC taxpayers?' Smith wrote in December, referencing a failed energy project. 'Make no mistake legislators, we are watching you. Each and every one of you.'

Smith's pinned tweet, posted last Saturday and retweeted hundreds of times, features a photo of Smith behind a Trump-emblazoned podium and endorses South Carolina Gov. Henry McMaster for reelection.

Note that #MAGA stands for Trump's campaign slogan, not an official US government policy.

So Smith was again acting like his job was to promote Trump's politics, not patients' and the public's health.  So he was at least a mission-indifferent leader.

Smith's LinkedIn profile claimed he, unlike Ms Barreto, actually had a background in communications/ public relations.  His other positions ranged from managing in a real estate firm and a deli, and various political jobs.  A managerialist might have deemed him qualified.  However, he provides no evidence of any background or experience in medicine, health care, biomedical science, public health or health policy. Thus he was another ill-informed leader.

The Politico article quoted one expert who suggested that Smith's Tweets might have been illegal

Government transparency experts said that some of Smith’s tweets could violate the Hatch Act’s prohibitions on executive branch employees engaging in partisan messages, pointing to February 2018 guidance released by the Office of Special Counsel.

'The Hatch Act prohibits federal employees from engaging in political activity, including posting on Twitter or Facebook, while on duty or in the federal workplace,' said Daniel Stevens of the Center for Accountability. 'If James posted comments regarding McMaster while in a federal building or during his work hours, he likely violated the Hatch Act.'

David Pasch

The article included a picture to illustrate how

David Pasch, who ran HHS’ digital communications until this month, regularly parked his car — with 'FAKENWS' vanity license plates — outside of agency headquarters.

Pasch also had a

Facebook profile photo also touts an image of him with the message 'fake news.'

Pasch's LinkedIn profile only included political jobs.  One was with an organization called  Generation Opporunity. A 2015 Politico article stated

Generation Opportunity, a libertarian-leaning group with ties to the Koch brothers, released a series of ads featuring 'Creepy Uncle Sam' to discourage young people from enrolling. But this season, the group is putting its energy into other issues like higher education and unemployment, said communications director David Pasch.

We had posted about the Creepy Uncle Sam ads as examples of stealth health care policy advocacy that encouraged bad decision making.  So Mr Pasch seemed to be a classically ill-informed leader, whose previous work on "Creepy Uncle Sam" suggests he was mission hostile as well.
 
And just to gild the lilly, while Pasch's disclosures of possible financial conflicts of interest per ProPublica are not too striking, an easy Google search revealed one possibly significant conflict of interest that he did not reveal, albeit on involving his spouse.  Per their marriage announcement in the New York Times from 2017,

The bride’s father is the chairman, president and chief executive of Sanderling Healthcare in Nashville. He was also the founder of REN Corporation-USA, a provider of dialysis services.

Tim Clark

The Politico article stated

Tim Clark, the agency's White House liaison who also served as HHS' interim communications chief this year, in 2016 sent tweets sharing allegations that Hillary Clinton's campaign paid people to incite violence at Trump's rallies, based on a hidden-camera video produced by Project Veritas' James O'Keefe. Democrats disputed the charge and distanced themselves from the individuals in the edited video.

'Wikileaks & O'Keefe video shows Hillary blatantly disregards election laws,' Clark tweeted in October 2016, while he was California director for the Trump campaign.'"Election must be free & fair.'

Clark also repeatedly used a #SpiritCooking hashtag to promote his pro-Trump tweets, referencing allegations about Clinton campaign chief John Podesta engaging in Satanic practices, based on an email forwarded to Podesta's brother Tony and obtained by WikiLeaks. The term 'spirit cooking' was used by artist Marina Abramović, who was hosting a dinner and invited the Podestas, and in November 2016 said the term was "taken completely out of my context ... it was just a normal dinner."

Clark's Twitter account is now private.

Clark seems likely to have been mission-hostile because of his apparent hostility to various groups within the US population whom he was obligated to serve while at DHHS.

Because he has a very common name, searching did not reveal much specific information about Clark's background, but a subsequent article on July 13, in Politico that noted his and Smith's departure, stated, 

Clark was the California chairman of Trump's campaign and became the health department's chief liaison with the White House, a crucial gatekeeper for the agency's policies and staffing. Clark worked to hire and protect a number of Trump campaign veterans who were allowed to remain on the job after their social media posts became public, according to multiple sources inside the agency.

These included Ms Barreto. I found nothing to suggest Mr Clark had any experience or expertise in medicine, health care, biomedical science, public health, or health policy.  So he was an ill-informed leader as well

Again, per the July 13 article, Clark and Smith have left DHHS.

Summary

So our knowledge of cases of ill-informed and mission-hostile leadership of health care agencies within the US government increases.  As we stated in April,

We have noted, most recently here, how the current Trump administration has been appointing many people without any qualifications in biomedical science, health care, or public health to leadership positions in health and public health agencies.  Obviously health care and health policy decisions made by ill-informed people coule have detrimental effects on patients' and the public's health.

Worse, it now seems that some ill-informed appointments have more nefarious purposes, including the subversion of the mission of these health related agencies.  The group of leaders discussed above seem to be hostile to the notion that health care and public health should serve all people, regardless of their religious beliefs, race, ethnicity, or sex.

Furthermore, they seem to be undermining fundamental principles of US government enshrined in the Constitution, including prohibiting the government from establishing a religion or preventing the free expression of any religion, and equal application of the laws and provision of due process to all people, again regardless of their religious beliefs, race, ethnicity or sex.

We have been writing about health care dysfunction since 2003, and publishing this blog since 2004.  A major concern all along has been how threats to health care professionals' core values generate  health care dysfunction.  Up through 2016, these threats came principally from large private health care organizations.  While the US government was not always as good at defending these values as it could have been, at least it rarely presented its own set of active threats.  Under Trump, that situation has been changing for the worse.  This is obviously hugely dangerous, (and made more so by the regime's threats to other core values of US society, to US law, and the US Constitution.)

To prevent the decline and fall of US health care, and maybe the entire US experiment in representative democracy, health care professionals, academics, patients and citizens concerned about health care will have to join up with the larger populace to defend our core values while they still have any force.