Monday, May 06, 2019

The New (Ab)normal in Health Care Dysfunction

Introduction: The Issues Ignored by Discusisons of Health Care Reform

After the failed attempt to "repeal and replace" the Affordable Care Act (ACA, Obamacare) in 2017, we summarized what we thought were the main issues that traditional discussions of health care reform in the US (and sometimes in other countries) did not address.Despite some protestations to the contrary (e.g., here), the US health care system has been plagued by dysfunction.  According to a recent Commonwealth Fund study, the US was ranked 11 out of 11 in health care quality, but 1 out of 11 in costs.  Traditionally, health care reform has targeted ongoing problems in the cost, accessibility and quality of health care.  The ACA notably seems to have improved access, but hardly addressed cost or quality.

Now, in 2019, these issues also seem to only be getting more so.  So a little more than two years into the Trump regime, I thought we should assess the new (ab)normal in health care dysfunction, trying as best as possible to use the framework from our 2017 summary, with examples from our blog posts.

Distortion of Health Care Regulation and Policy Making: the Rise of the Incoming Revolving Door

We had previously noted that companies selling health care products and services further enhanced their positions through regulatory capture, that is, through their excessive influence on government regulators and law enforcement.  Their efforts to skew policy were additionally enabled by the revolving door, a species of conflict of interest in which people freely transitioned between health care corporate and government leadership positions.  Up to the Trump era, nearly all those cases involved people who left government who were offered corporate positions in firms that might have been affected by regulations or policies influenced by the government agencies for which they formally worked, the outgoing revolving door.

However, in the Trump era, we saw a remarkable increase in the incoming revolving door, people with significant leadership positions in health care corporations or related groups attaining leadership positions in government agencies whose regulations or policies could affect their former employers.

- We noted a stealth marketer for health care corporations becoming a key Trump economic adviser (look here)

- We found numerous more examples in October, 2017, including two people from the same lobbying firm, Greenberg Traurig Alston & Bird, which that year had  "earned more than $4.4 million lobbying so far this year for health care companies and trade groups including Novartis AG, Verax Biomedical, the American Hospital Association, St. Jude Children’s Research Hospital, and Aetna....," given top Department of Health and Human Services (DHHS) positions.

- A little later that month, we noted that one of those two former lobbyists, Mr Eric D Hargan, had become acting Secretary of DHHS (look here).

- Slightly later that month, there was an even more striking example, the new (permanent) Secretary of DHHS, Mr Alex Azar, who replaced Mr Hargan, was a former top executive of pharmaceutical company Eli Lilly.

- In November, 2017, an advocate for the discredited former CEO of UnitedHealth become an Assistant Secretary of DHHS. 

-  Later in November, we found two more examples of the incoming revolving door, including a lobbyist for pharma/ biotech company Gilear becoming director of health programs for the Office of Management and the Budget (OMB) here.

- In March, 2018, we posted a long list of industry figures, including a slew of lobbyists appointed to DHHS leadership positions.

- in April, 2018, we posted the next list, of top industry executives going to major executive branch positions.  The most striking example was a vice president at CVS, formerly at Pfizer, becoming a senior advisor to the Secretary of DHHS (who is a former Eli Lilly executive) for drug price reform. Pfizer and Eli Lilly alumni in charge of drug price reform, what could possibly go wrong?

- In July, 2018, the next list included a senior advisor at again Eli Lilly appointed to head an FDA division.

- In February, 2019, the list included a person with multiple leadership positions in for-profit health insurance companies, including WellPoint, and most recently a Medicaid managed care insurance provider, appointed to lead "health care reform" for DHHS.  Again, from the insurance industry to lead health care reform, what could possibly go wrong.

- In March, 2019, we noted that the newly appointed acting director of the FDA had founded and/ or was on boards of directors of multiple biotech companies.

This was a staggering record of managers from and lobbyists for big health care corporations being put in charge of regulation of and policy affecting - wait for it - big health care corporations, a staggering intensification of the problem of the revolving door, which some have already asserted should be regarded as not merely severe conflicts of interest, but of corruption.  

Distortion of Health Care Regulation and Policy Making: Stealth Policy and Advocacy Morphing into Propaganda and Disinformation, Now may be Orchestrated by a Hostile Foreign Power

We had previously noted that promotion of health policies that allowed overheated selling of overpriced and over-hyped health care products and services included various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or to the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.  Now this information may be connected to, or even organized by a hostile foreign power  

In March, 2018, based on revelations of what appeared to be an organized disinformation effort engineered by Cambridge Analytica and associates, using large amounts of personal data liberated from Facebook, to promote the Trump campaign, we started to ask how we could address deceptive public relations, propaganda, and disinformation in health care under a regime that had so benefited from foreign based disinformation efforts?

In April, 2019, we discussed evidence that Russia had orchestrated a systemic disinformation campaign meant to discredit childhood vaccinations, particularly for the measles, which was likely partly responsible for the 2019 measles outbreak, and possibly for some of the unsupported assertions made about measles and measles vaccinationa by government leaders (see below).  The Soviet Union, which of course then included Russia, had orchestrated a disinformation campaign about HIV in the 1980s.  Erroneous beliefs generated by this campaign persist to this day.  The USSR had a principle role in the development of disinformation and other active measures meant to destablize western democracies.

 As recently documented in the redacted version of the Mueller report, Russia launched a disinformation campaign to swing the election to its preferred candidate, Donald Trump.  The role of a hostile foreign power which had used active measures during the election also using active measures to spread disinformation about medicine and public health should not be dismissed. 

Bad Leadership and Governance: Ill-Informed Leadership Now Approaching Flagrant Ignorance While Eschewing Expertise

We have long decried leaders of big health care organizations who seemed to have little background in or knowledge of biology, medicine, health care, or public health.  Typically, these were leaders of big health care corporations, such as pharma/device/ biotech companies, health insurance companies, hospitals and hospital systems, etc who were trained in management, and thus could be called managerialists.  

However, during the Trump regime we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics.  We had not previously expected leaders of government to be personally knoweldgeable about health related topics, but traditionally they consulted with experts before making pronouncements.

Since the Trump regime began, perhaps inspired by examples from Trump himself, various political/ government leaders began to publicly say ignorant or downright stupid things about such topics.

-  For example, in September, 2017, we noted a series of examples showing some basic ignorance of health policy, including fundamental confusion about the nature of health insurance.

- In August, 2018, we noted that Trump had long been an apologist for asbestos, which is known to cause asbestosis, lung cancer, and mesothelioma, claiming that those opposing use of asbestos were associated with organized crime, while more recently Trump's EPA seemed willing to relax regulation of asbestos, at a time when Russia seemed ready to become the major US supplier of it.

Bad Leadership and Governance: From Incompetence (in the Colloquial Sense) to Cognitively Impaired or Demented Leadership

Again, previously we had discussed  ill-informed and incompetent leadership in terms of leaders who had no training or experience in actually caring for patients, or in biomedical, clinical or public health research.

However, we began to note concerning examples suggesting that the top leader of the US executive branch, President Trump himself, could be cognitively impaired perhaps from a dementing, neurological or psychiatric disorder.

- In October, 2017, we first started cataloging pronouncements by President Trump on health care and related topics that started with a grossly cavlier attitude toward health policy (e.g., it is only about fixing somebody's back or their knee or something," and ended with word salad:

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.

As we were taught in medical school, word salads may be produced by patients with severe neurological or psychiatric disorders.

- In January, 2018, we discussed more examples of Trump's confused, incoherent comments on health care.

- In May, 2018, we noted attempts by Trump Organization functionaries to intimidate Trump's former personal physician, presumably to prevent him from revealing details of the president's medical history.

- In December, 2018, we cataloged Trump's counter-factual, and often severely incoherent pronouncements - basically more examples of word salad - about public health, health care and other topics, at times interspersed with claims of his high intelligence.

Health care led by people with business or legal training who are willing to get advice from health care, public health and medical specialists may be as good as it gets.  Health care led by such people who do not consult experts if worrying.  Health care led by people who report to a cognitively impaired, demented or psychotic leader is extremely worrying (as is government with such leadership.)

Bad Leadership and Governance: Mission-Hostile Management Now Driven Less by Pecuniary Considerations, More by Ideology, Partisanship, and Religious Sectarianism

We had previously noted that health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values.  The example we cited then was a hospital CEO who allegedly over-ruled medical leadership to hire a surgeon despite reports that his patients died more frequently than expected, gamed reports of clinic utilization, and associated with organized crime (look here).  Most such examples seemed to be generated by leaders who put their organization's revenue, often in parallel with their own compensation ahead of patients' and the public's health.

We also began seeing examples of how politically appointed officials of health related government agencies who had no experience or expertise in health care or related fields began to assert control over health care professionals in the agencies to facilitate the Trump regime's political agenda apparently regardless of the effects on health. Sometimes the problem seemed to carry over from the leaders' previous management, rather than medical, health care or public health experience.  For example, in February, 2018, we noted that the physician who was Secretary of the Veterans Administration was challenged by a political a political appointee who used to run a brewery.

However, we then began noting leaders who also lacked medical, health care or public health background or expertise whose agenda seemed to be overtly religious or ideological, without even a nod to patients' or the public' health.

- In April, 2018, we noted a host of appointments of people who flagrantly lacked any health care or public health related experience or expertise to leadership positions in government agencies whose agenda seemed to be overtly religious or ideological, without even a nod to patients' or the public' health. For example, a 23-year old whose only experience after college was in Trump's campaign was given a significant position in the Office of National Drug Control.

- In April, 2018, we posted another such list, including a blogger who promoted racism and conspiracy theories given the Deputy Directorship of Communications for DHHS.

- In July, 2018, we noted the appointment of a physician to a leadership position in family planning within the DHHS who cited "facts" completely unsupported by evidence to justify religiously based health care policies, e.g., using her argument that adopting a child is like a "second death" to argue that mothers should not give their children up for adoption.

- In August, 2018, we discussed  three political appointees to DHHS, none of whom had any health care or public health related experience or expertise, all of whom made pointedly political public comments after their appointments, from deriding their political opponents as "clueless" and "crazy"to alleging Hillary Clinton arranged a murder.

 - In November, 2018, we noted pronouncements about health care or public health by federal agencies under the Trump regime, right-wing politicias who back Trump, and propagandists who back Trump which were unsupported by evidence, but seemed designed to support right-wing ideology or sectarian religious belief.  These included assertions that immigrants and asylums seekers carried infectious disease, that intersex patients do not exist, that contraception causes cancer and violent death, that pornography is a major public health hazard, etc.

- In March, 2019, our list included examples of multiple leaders at the state level, all Republicans, including the Kentucky Governor asserting that zombie television shows cause mass shootings, but exposure to extreme cold does not harm schoolchildren; and numerous unsupported pronouncements by state legislators about measles, including the Texas state representative who stated antibiotics can treat measles.

- In April, 2019, we discussed another batch of bizarre statements about the measles and vaccination policy made by President Trump, again the Republican Governor of Kentucky, and various Republican state legislators.  

Again, basing health care and public health decisions primarily on money seems likely to be bad for patients' and the public's health, but basing them purely on political ideology or religious belief seems worse. In some cases, the resulting mission-hostility seems to translate into violations of the US constitution.  For example, making health care decisions based on a particular religion's beliefs could be harmful for patients or citizens who do not share these beliefs, plus violate the Constitution's guarantee of freedom of a government establishment of religion.

Bad Leadership and Governance: Mission-Hostile Management by Now Partisan Corporate Leadership  

Again, previously the mission-hostile management we noted at the corporate level seemed mainly driven by pecuniary concerns, putting corporate revenues and resulting management compensation ahead of patients' and the public's health.  However,we began to see evidence that leaders of health care corporations were using their power for partisan purposes, perhaps favoring their personal political beliefs over their stated corporate missions, patients' and the public's health, and even  corporate revenues.

- In June, 2018, we first noted how a large health care corporation, the huge pharmacy chain CVS, had been secretly making contributions to an ostensibly non-profit organization which actually served solely to promote Trump regime policies, including some that seemed to subvert claims the corporation had made about social responsibilty.  The contributions themselves seemed to conflict with the corporation's charitable giving policies.

- In September, 2018, we noted that big health care corporations often make high-minded public pledges about supporting patients' and the public's health, and sometimes social responsibility, but have been found to be covertly supporting policy initiatives that seemed to subvert these goals, using "dark money."  The dark money groups they used to channel this money often had explicitly partisan leadership and direction, usually right-wing and Republican.

 - In October, 2018, we discussed important but incomplete revelations about corporate contributions to such dark money groups that mainly favored again right-wing ideology, the Republican party, and Trump and associates.

- In November, 2018, we noted that health care corporations funneled funds through dark money organizations to specifically attack designated left-wing, Democratic politicians.

- In March, 2019, we noted a Transparency International study of policies on political engagement of multinational pharmaceutical companies, all of which operate in the US.  Only one disavowed the revolving door, and only two eschewed direct corporate political contributions.

- Also, in March, 2019, we discussed a study of the personal political contributions of CEOs of large corporations.  In the 21st century, the CEOs' contributions were increasingly partisan, that is individual CEOs gave predominantly or exclusively to one party, and for the vast majority, to the Republican party.

This suggests yet another route towards government putting ideology and partisanship ahead of patients' and the public's health.

Bad Leadership and Governance: Conflicted, Corrupt Corporate Leaders Now in the Context of Flagrant Conflicts of Interest and Corruption at the Highest Levels of the US Government

We had previously discussed numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions, albeit usually of corporate entities, not individuals.  One would hardly expect corrupt leadership to put patients' and the public's health ahead of the leaders' ongoing enrichment.

Prior to July, 2017, we had discussed some particular cases in which Donald Trump and his family had been involved in ethically questionable activities prior to his becoming president.  However, by  August, 2017, we started to discuss the corruption at the top of the regime. 

- In January, 2018, we first discussed the accumulating evidence of pervasive corruption at the top of the US executive branch, based on articles in the media, and the launch of a website devoted to tracking such corruption.

- In July, 2018, we summarized new sources of evidence about top level government corruption.

- In October, 2018, we posted yet another update, including summarizing a new and very lengthy report about the scope of Trump and associates' conflicts of interest and corruption, which at the time required 26 pages to print. It documented multiple ongoing instances of the Trump Organization, whose biggest owner is Trump, receiving large ongoing payments from foreign governments, the US government, and state governments.  The former payments seemed to explicitly violate the "foreign emoluments clause" of the US  Constitution, which bans presidential conflicts of interst involving foreign governments, and the "domestic emoluments clause," which bans those involving the federal and state governments.

- In October, 2018, we discussed the latest advances in understanding of global corruption, via Tranparency International's global meeting, which included description of trans-national kleptocratic networks, which now seems to describe Trump and the Trump Organization.

- In April, 2019, we posted our latest discussion of pervasive high-level corruption, which referenced updates from sources mentioned earlier, plus three new sources.

Prior to the Trump regime we had criticized law enforcement for a lack of interest in vigorously prosecuting health care corruption.  We documented numerous examples of the impunity of top health care corporate executives who almost always escaped any negative personal consequences even when their organizations paid large fines for bribery, kickbacks, fraud and the like.  We often attributed this laxity to excessive sensitivity respect of the value of these corporations and their products.  However, the potential for encouraging health care (and other kinds of) corruption under a regime that is itself frankly corrupt is mind boggling.

[picture of Trump International Hotel in Washington, which is frequently patronized by foreign government officials, whose payments to Trump via the Trump Organization appear to amount to the "foreign emoluments" prohibited by the US Constitution.]

Overarching Issue: Taboos Previously Enabled by Private Organizational Behavior, Now by Government Agencies and Officials, Despite the First Amendment

When we started Health Care Renewal, such issues as suppression and manipulation of research, and health care professionals' conflicts of interests rarely appeared in the media or in medical and health care scholarly literature.  While these issues are now more often publicly discussed, most of the other topics listed above still rarely appear in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant.  For example, a survey by Transparency International showed that 43% of US resondents thought that American health care is corrupt.  It was covered by this blog, but not by any major US media outlet or medical or health care journal.  We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who personally profit from the status quo in health care.  As we noted above, the people who profit the most, those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.  But, if we cannot even discuss what is really wrong with health care, how are we going to fix it?

Since the beginning of the Trump administration,  we began to note more examples of government officials under Trump attempting to squelch discussion of scientific topics that did not fit in with its ideology, despite constitutional guarantees of speech and press free from government control.

- In September, 2017, we noted an attempt for Trump political appointees to blockade information released from the Department of Health and Human Services (DHHS) that the regime found offensive.

- In February, 2018, we noted attempts by a consultant for the Center for Medicare and Medicaid Services (CMS), a major component of DHHS, to intimidate a health care journalist.

- In April, 2018, it became apparent that the head of CMS has directed millions in contracts to a Republican public relations firm, partly to burnish her image, and that firm had hired the consultant noted above.

- We also found attempts to squelch attempts by current or former government workers to criticize Trump and his policies.  In August, 2018, we noted Trump had White House staffers sign non-disclosure agreements, which seems to expressly violate first amendment protections of free speech and federal law.

Given how hard it was to reverse the anechoic effect in the past, how much harder will it be to open discussion of what is really wrong with health care when the power of the US government is used to censor ideas which the regime dislikes?


For years, I thought that health care dysfunction was primarily about individuals and private organizations, including but not limited to pharmaceutical, biotechnology and device companies; hospitals and hospital systems; insurance companies, academic medical institutions; physicians and their practices; etc, etc, etc.  Consequently, I thought these individuals and organizations needed better awareness of health care dysfunction to provoke them to improve matters.  I thought of the government as being involved, but mainly because of well-intentioned, sometimes bumbling government actions and policies that often had unintended effects, and sometimes excess coziness with the health care industry.  While I knew that the government was subject to regulatory capture and various leadership problems, its role, at least in the US, seemed almost secondary.

But in the Trump era, there is a new (ab)normal.  All the trends we have seen since our last discussion of health care reform are towards tremendous government dysfunction, some of it overtly malignant, especially in terms of corruption of government leadership of unprecedented scope and at the highest levels, and overt influence of government-favored political ideology and religious beliefs on health care policy and other policies and actions.

I hope that the above attempt to summarize these new trends will urgently point health care and public health professionals, patients, and all citizens towards a much more vigorous response.  US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways.  We do not have much time to act.

If not now, when?

If not us, who? 


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