Sunday, May 03, 2020

"No Skin in the Game" - Does Trump's Personal Insulation from the Coronavirus Pandemic Enable His Failure to Protect the Country From It?

Introduction: Very Important Patients

Most codes of ethics for health care professionals stress that taking the best possible care of each individual patient should come before all other concerns.  Yet access to health care has been a problem for many patients in the dysfunctional US health care system.

A particularly egregious aspect of this problem has been the preferential treatment of "very important patients." In 2007 we first posted about a prestigious academic medical center that maintained an "A-list" of VIP patients, apparently contradicting it stated mission to improve care for the entire community, state, and nation.  Other examples of preferential care given by hospitals to VIPs are here, and here.  Similarly, in 2012 we posted how big corporate executives have access to "executive health insurance" which provides benefits beyond what any normal person can obtain, even from seemingly the best employer paid policy.

In 2011 we wrote

If the rich and powerful can insulate themselves from the dysfunction of the current health care system, do not expect their sympathy or support in reforming this system

During the coronavirus pandemic, access problems became more salient.  A particular problem has been access to coronavirus diagnostic testing, both for individual patient care, and to suppress the pandemic.  Identifying all infected people allows quarantining them and isolating their contacts thus suppressing future disease transmission.  Back on March 6, 2020, President Trump infamously promised “Anybody that wants a test [for the coronavirus] can get a test.” That claim was rated a "pants on fire" lie by Kaiser Health Network and Politifact.  Coronavirus testing rates continue to lag what many public health experts consider the rate necessary for good patient care and successful pandemic suppression (look here).

So maybe it should be no surprise that access to coronavirus tests and preventive measures is different for VIPs, especially for the biggest VIP of all in the US, the country's President.  This may be one reason why the US response to the pandemic has been so poor.

The White House is More Equal than Others

Coronavirus Testing Access, Frequency, and Availability of Results

The first hint of the issue appeared in articles about the visit of Vice President Pence to the Mayo Clinic.  For example, Politico reported on April 28, 2020:

Vice President Mike Pence refused to wear a mask on Tuesday as he toured the Mayo Clinic and met with hospital staff and a patient, rejecting the famed hospital’s policy that all visitors cover their faces to reduce Covid-19 risks.

His explanation was:

Pence told reporters after the visit that he believed that he was following guidance from the Centers for Disease Control and Prevention, and he asserted that he was not infected by Covid-19.

'As vice president of the United States, I'm tested for the coronavirus on a regular basis, and everyone who is around me is tested for the coronavirus,' Pence said, according to a pool report.

While many Americans cannot get a coronavirus test even when they are symptomatic, Pence suggested that he gets tested "on a regular basis," and "everyone" around him is tested, all presumably in the absence of symptoms.

It turns out that coronavirus testing at the White House is far more prevalent even than that at another co-equal branch of the US government.  As the New York Times reported on May 1, 2020:

Dr. Brian P. Monahan, the tight-lipped doctor who attends to Congress, sent up on Thursday what some have construed as a warning: His office, he told senior Republican officials on a private conference call, cannot screen all 100 senators for the coronavirus when they return to work on Monday.

The article made explicit the comparison with what happens at the White House

Two miles down Pennsylvania Avenue at the White House, the story is very different. President Trump and Vice President Mike Pence are tested frequently, aides who come into close contact with them are tested weekly and the list of people who need to be tested daily keeps expanding, according to officials familiar with the process.

The stark contrast between the testing haves at the White House and the have-nots on Capitol Hill, first reported in Politico, makes clear that Mr. Trump’s pronouncement that 'anybody that wants a test can get a test,' as he said on March 6 at the Centers for Disease Control and Prevention in Atlanta, is far from true. Although the rich and powerful are clearly favored, not even all the powerful have equal access.

Furthermore, there is a marked inequality not just in the access to and frequency of testing, but the timing of the information available from the testing.

At the White House, the medical unit is using a rapid-testing kit developed by Abbott, which yields results in about five minutes. But Dr. Monahan told the Republican aides on Thursday that he lacked such equipment, and that it would take at least two days to get test results.
So President Trump and his White House staff get far more tests with more rapidly available results than anyone else, even US Sentators.

Face Masks

Actually, this was not the first example the the very special access to health care given to the White House.  As described by the Washington Post, April 15, 2020, the Trump administration strongly discouraged the general public from wearing face masks: 

From January until April 3, the White House task force, the CDC and the U.S. surgeon general were all telling the American public that healthy people should not use masks or face coverings to protect themselves from the coronavirus.

Surgeon General Jerome Adams stressed that most Americans faced low risk of infection, but warned that mask wearers could heighten their risk because they were more likely to touch their faces as they adjusted their masks. He urged the public to save the supply for medical workers on the front lines.

'Seriously people- STOP BUYING MASKS!' Adams tweeted on Feb. 29, as stores across the country sold out. 'They are NOT effective in preventing general public from catching #Coronavirus.'

Yet by mid-March,

The National Security Council, in a 'race behind the scenes,' secured a supply of masks from Taiwan for White House staff.

The resulting arrangement he struck with Taipei made thousands of masks available for White House staff use two weeks before the administration reversed policy and advised that citizens should broadly begin wearing cloth face coverings in public.

This also happened at a time when President Trump was contradicting

top White House officials [who] were pushing for a wider embrace of masks early on to help slow the infection’s spread.

President Trump resisted endorsing such guidance, the subject of sharp debate between his advisers and government health experts, and even after doing so, declared that he would not wear one himself.

Since Trump would not wear a mask, the person most likely to benefit from his staff wearing them would be Trump himself.

Furthermore, importing the masks from Taiwan also apparently violated that country's stated public policy:

The deal was sensitive in Taiwan, which had banned commercial exports of masks to protect supply for its citizens.

So also in this example, not only did Trump, and perhaps his White House staff receive extraordinarily preferential access to health care, e.g., face masks at a time of huge national shortage, but this access was secretly afforded at a time when Trump and his cronies were denying that face masks conferred any benefits, and were discouraging their use.

Given the importance of the office of the President, I cannot deny the need for the President to get good, if not exemplary health care.  However, in these two examples, the President got extraordinary health care, beyond even what was available to the top stratum of one of the other co-equal branches of government.  At the same time he got such access, he denied the very obvious limitations in public access to one aspect of care (testing), and the benefits of another (masks).


There have been multiple summaries of the manifest failures of the US response to the coronavirus pandemic.  See just some of the many examples: in the Washington Post, Vox, and Raw Story.   Americans are daily paying the price: in lives lost, suffering from disease, and economic disaster.  If we survive, the reasons behind this historic failure will be analyzed for years.

Let me propose, however, one additional reason: the lack of "skin in the game" from the top of the US executive branch.

Back in 2011 we postulated

that the US has a secretive parallel health care system for the very rich.  The most important implication is that such a system could protect the very rich from the access problems and bureaucratic annoyances that plague ordinary patients in larger dysfunctional health care system.  By thus having "no skin in the game," those among the very rich who are not themselves directly involved with health care would have little reason to care or want to do anything about the problems besetting the larger health care system.  Since the very rich have become increasingly politically powerful, the absence of such interest or motivation for change among them would make true health care reform much more difficult.

Now when one very rich person is also the leader to whom all US health agencies report, the dangers to health and health care for all Americans of his lack of any "skin in the game" are obvious.

In this case, the dangers of Trump's lack of skin in the game go beyond that.  On May 1, 2020, the Washington Post reported that Trump may be using his special access to health care to prop up his propaganda extolling his response to the coronavirus pandemic, and promoting the notion that the country can soon end the lock-down that has punished its economy.

At the White House this week, President Trump sat less than six feet from New Jersey Gov. Phil Murphy (D) in the Oval Office. He invited small-business owners to crowd behind the Resolute Desk for a photo shoot. His vice president toured a medical research center without a face mask in defiance of its policy.

The daily images projected a sense of confidence that life, at least for the nation’s most prominent resident, is returning to a semblance of normalcy during the coronavirus pandemic — a visual cue to the public that conditions are improving as Trump pushes to restart sectors of the economy.

Yet even as Trump aides have signaled that he could soon begin regular travel, the reality is that the White House has created a picture of security that is propped up by special access to the kind of wide-scale testing for covid-19, the disease caused by the novel coronavirus, that most of the nation remains without.

The article also suggested that the special access to testing for White House staff was being used to promote Trump's magical powers, his ability to nullify the realities of epidemiology amidst a pandemic:

J. Stephen Morrison, a global health policy expert at the Center for Strategic and International Studies [said] 'In that sense, what Pence did at the Mayo Clinic was very deliberate as a sign of defiance against the authoritiesthumbing his nose at the medical authorities who run that institution and signaling to others watching you don’t have to buy into this.'

Prematurely "opening" the economy while the virus is still actively infecting new patients, without adequate testing and contact tracing to suppress it, could lead to many more infections, more illness, and more deaths.  So such propaganda could be actively dangerous to those living in the US.

These dangers will only get worse unless Trump quickly acquires skin in the game, and thus is made to realize that there will be severe negative consequences to him for his continuing failure to protect public health in the US.

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