How Can We Fight the Coronavirus Pandemic Under Political Leaders Who Enable the Spread of the Virus?

The Trump administration has written the book about how not to prepare for a pandemic, and how to mismanage the response once one occurs.  We have previously posted about how President Trump and his administration have hindered pandemic management in the US and around the world.  We have noted the President's support for such counter-productive policies as allowing vulnerable elderly people to fly, keeping passengers cooped up on cruise ships in which the virus was spreading, and reducing testing for the virus (in March).

Furthermore, early on we noted  instances in which the President personally promoted events at which viral spread was enabled: the CPAC conference, a large indoor event, some of whose attendees later tested positive; and a meeting at Mar-a-Lago that included officials from Brazil, some of whom later tested positive (again, in March).  Later, in May, Trump visited a factory which makes N95 masks but insisted on not wearing a mask himself, and several of his top officials, including the Secretary of Health and Human Services, followed his (bad) example and also eschewed masks.

A few such episodes could have been written off as merely particularly horrendous bungles.  However, the pattern is now so well established that it appears Trump and his followers are systematically trying to increase the spread of the virus. We have now cataloged numerous instances in which they seemed to do so. In some, there was evidence that such actions actually enabled viral spread.  I will list them by category, and within categories, chronologically.

President Trump Acting Personally to Enable Viral Spread

Trump Avoids Masks but not Close Personal Contact at Public Events

Public health experts, and the US Centers for Disease Control and Prevention (CDC) under Trump have suggested social distancing, avoiding close contact with others, and wearing masks as key measures all people can undertake to decrease viral spread.

Trump, instead has frequently sought close personal contact with others and has conspicuously avoided wearing a mask.  For example, Trump continued to shake hands with supporters, including some elderly (in Florida, March 11).  Trump continued to show up at events without a mask, usually accompanies by other administration officials who also were maskless: in Phoenix, at a mask factory, (May 5) apparently in violation of the company's policy (per the Washington Post); at another mask factory in Pennsylvanis (May 14); in the Rose Garden, accompanied by Secretary of DHHS Azar and Secretary of Defense Esper (May 15); and in a Ford manufacturing plant, violating company policy and state law (May 21).

By decreasing the number of people wearing masks and preventing social distancing at these events, Trump made it more likely that there would be virus transmission there.


While Trump Avoids Masks and Social Distancing at the White House, His Staffers Increasingly Test Positive

Similarly, Trump has deliberately tried to reduce the use of masks and social distancing in the White House and generally in his personal vicinity.  Again, this increased the likelihood of virus transmission.  On May 4, 2020, Yahoo News reported:

As the country copes with the coronavirus pandemic, millions of Americans are following social distancing guidelines from the White House coronavirus task force to slow the spread of the infection: staying 6 feet away from other people, avoiding large gatherings and wearing masks or cloth face coverings.

But inside the White House, many of these rules are not being observed. There are regularly large events with unmasked attendees in close quarters — including inside the Oval Office, where some people have been allowed to enter without wearing masks or taking tests for the virus.

Although some people have their temperatures checked,

Not everyone who goes inside the Oval Office, the president’s inner sanctum and one of the most secure spaces in the West Wing, is being tested. For both governors’ visits, a pack of pool reporters and cameramen were brought in. Though their temperatures were rechecked before they entered Trump’s office, the press pool, which stood feet away from the president, the governors and staff, were not given tests. And in the crowded confines of Oval Office press scrums, while Trump sits apart from most of the crowds, the 6-foot distancing rule is not observed, with reporters and top officials packed close together.

Another report by the Washington Post on May 8, 2020, emphasized that the lax approach at the White House was at the behest of Trump:

Several security officials with executive branch experience said in interviews Friday that the White House has taken a lax and risky approach that, in their view, reflected Trump’s consistent efforts to minimize the threat from the virus.

So,

Like Trump, most of his aides, including Pence and White House Chief of Staff Mark Meadows, have not worn face masks, and the president has huddled with guests at the White House for photo-ops that undermine the efforts at social distancing that do take place, such as seats placed more than six feet apart.

'This is a show of bravado. This is a show of ‘I got this. I’m in control,’ ' said one former security official familiar with White House security planning during past administrations.

'He’s tried to minimize this threat from day one. It’s the only way he can laugh in the face of this disease,' said this person, who like others spoke on the condition of anonymity to frankly address sensitive security matters.

Multiple anecdotes suggest that the White House is a permissive environment for transmission.  Various staffers have tested positive for coronavirus, suggesting that lax policies driven by Trump's aversion to masks were enabling spread.  First, on May 7, CNN reported:

A member of the US Navy who serves as one of President Donald Trump's personal valets has tested positive for coronavirus, CNN learned Thursday, raising concerns about the President's possible exposure to the virus.

The valets are members of an elite military unit dedicated to the White House and often work very close to the President and first family. Trump was upset when he was informed Wednesday that the valet had tested positive, a source told CNN, and the President was subsequently tested again by the White House physician.

The next day, Politico reported:

Katie Miller, a spokesperson for Vice President Mike Pence, has tested positive for coronavirus, according to two people with knowledge of Miller's diagnosis.

Miller's positive diagnosis for Covid-19 puts the potential threat of the infection squarely into the president’s inner circle. Miller serves as the vice president’s top spokesperson, traveling with him frequently and attending meetings by his side. She is also married to another top White House aide and senior adviser, Stephen Miller, who writes the majority of Trump’s speeches and spends copious amounts of time around the president, Jared Kushner and Ivanka Trump.

And on July 3, 2020, the New York Times reported:

Kimberly Guilfoyle, the girlfriend of President Trump’s eldest son and a top fund-raising official for the Trump re-election campaign, tested positive for the coronavirus on Friday before a Fourth of July event at Mount Rushmore, a person familiar with her condition said.

Ms. Guilfoyle traveled to South Dakota with Mr. Trump’s son Donald Trump Jr., in anticipation of attending a huge fireworks display where the president was set to speak.

So it is likely that despite some extraordinary measures to prevent infection in the White House, such as multiple temperature checks and copious use of rapid (but perhaps not very sensitive) tests for coronavirus, the President's insistence on avoiding masks and social distancing is allowing spread of the virus, even to staffers very close to the President.

Trump Scoffs at New Jersey Quarantine Regulations

As reported by NBC on June 24, 2020:

The White House said Wednesday that President Donald Trump will not change his plan to travel to New Jersey this weekend despite a new order by the governor requiring visitors who have been in states with high numbers of coronavirus cases to quarantine for 14 days.

'The president of the United States is not a civilian,' White House spokesman Judd Deere said when asked about Trump’s compliance with the quarantine order given his travel Tuesday to Arizona, which has seen a rise in the rate of its COVID-19 cases.

Again, Trump demonstrated his intentional disregard of standard, lawful public health measures meant to reduce the spread of coronavirus.


Trump's Tulsa Campaign Rally: No Masks or Social Distancing, Multiple Infections Documented

So far, the most vivid and elaborate demonstration of Trump's push to make the US safer for the coronavirus was provided by his campaign rally in  Tulsa, Oklahoma on June 20.  That location was one in which coronavirus cases were already climbing.  The rally went on despite Trump's and its organizers' apparent awareness of the dangers of it leading to worsening spread of the virus.

First, note that the campaign required that attendees sign a waiver to protect Trump and the organizers from liability.  As reported by CNN on June 12, 2020:

Attendees of President Donald Trump's upcoming rally in Tulsa, Oklahoma, must agree not to sue the campaign if they contract coronavirus.

Rallygoers are asked to RSVP to gain admission to the event and by registering, they must agree to a disclaimer that states they acknowledge the 'inherent risk of exposure to COVID-19 exists in any public place where people are present.'

'By attending the Rally, you and any guests voluntarily assume all risks related to exposure to COVID-19 and agree not to hold Donald J. Trump for President, Inc.; BOK Center; ASM Global; or any of their affiliates, directors, officers, employees, agents, contractors, or volunteers liable for any illness or injury,' the disclaimer reads.

The disclaimer proclaims that Trump and rally organizers were very aware that their event would likely lead to particular risk of spreading coronavirus.

Furthermore, local health authorities warned them about the risk, per Tulsa World on June 13, 2020:

Expressing concerns about COVID-19’s increasing spread, the Tulsa City-County Health Department’s director said he wishes the campaign rally for President Donald Trump at the BOK Center on June 20 would be pushed back to a later date.

In an interview with the Tulsa World on Saturday, Dr. Bruce Dart said Tulsa is seeing a 'significant increase in our case trends' that makes a large gathering like the rally dangerous for not only attendees, but the president himself.

Local health care professionals also added their warnings, as reported by Public Radio Tulsa on June 16, 2020:

Calling it a matter of public health, not politics, hundreds of health care providers have signed their names on a letter to Tulsa Mayor G.T. Bynum, calling on him to prevent President Trump's campaign rally planned for the BOK Center on Saturday.

'As our city and state COVID-19 numbers climb at a rate previously unseen, it is unthinkable that this is seen as a logical choice," reads the letter, dated June 14th and authored by Dr. Jabraan Pasha of the University of Oklahoma Medical Center in Tulsa. 'It has the potential to shake our cities [sic] infrastructure and stress our healthcare systems. It will undoubtedly cost lives.'

In case that was not enough, top public health experts on the President's own coronavirus task force also warned against the rally. As reported by NBC News on June 19, 2020:

Leading members of the coronavirus task force warned White House officials about the health risks of holding large-scale indoor campaign rallies and advised against such mass gatherings, according to two people familiar with the discussions.

Dr. Anthony Fauci, the nation's top infectious disease expert, and task force response coordinator Dr. Deborah Birx both vocalized concerns internally in the last week about the safety of holding a rally on Saturday with as many as 19,000 people in an enclosed arena in Tulsa, Oklahoma.

Their dismissal was blase:

But President Donald Trump and his campaign advisers are proceeding with the event, which is expected to draw tens of thousands inside and outside the venue who will neither be socially distant nor required to wear face coverings. They claim attendees 'assume a personal risk' and 'that is part of life.'

Again, this response indicates that the President and associates were well aware that what they were doing would likely spread the virus.

Yet there was one final warning before the event.  As CNN reported on the day of the rally, June 20, 2020:

Six staffers working on President Donald Trump's rally in Tulsa, Oklahoma, have tested positive for coronavirus, the Trump campaign said Saturday.

Nevertheless, the show would go on, but not before one extra effort by the Trump campaign to make sure there would be no social distancing at the event. As we found out in retrospect on June 27, 2020 via the Washington Post

In the hours before President Trump’s rally in Tulsa, his campaign directed the removal of thousands of 'Do Not Sit Here, Please!' stickers from seats in the arena that were intended to establish social distance between rallygoers, according to video and photos obtained by The Washington Post and a person familiar with the event.

The removal contradicted instructions from the management of the BOK Center, the 19,000-seat arena in downtown Tulsa where Trump held his rally on June 20.

The effects of the rally were discovered very quickly.  First two members of Trump's campaign team tested positive for coronavirus after the rally (CNBC, June 22, 2020).  Then it was the Secret Service's turn, per the Washington Post on June 24, 2020:

Dozens of Secret Service officers and agents who were on site for President Trump’s rally in Tulsa last week were ordered to self-quarantine after two of their colleagues tested positive for the novel coronavirus

The agents originally testing positive were part of the six staffers who tested positive listed above. How many other Secret Service agents may have been infected is not clear.

A Secret Service spokeswoman declined to comment on how many of its employees have tested positive or were quarantined, but said the Tulsa event has not affected the agency’s ability to do its job.

A few days later, a prominent Trump supporter who attended the rally fell ill, as reported by Politico on July 2, 2020:

Former presidential candidate Herman Cain announced on Thursday that he has been hospitalized with Covid-19, almost two weeks after attending President Donald Trump’s rally in Tulsa, Okla.

Cain was diagnosed with coronavirus on June 29, nine days after the president's rally, and his symptoms worsened and required hospitalization on July 1, according to a statement from his Twitter account.

'He spent the past night in a hospital and as of today, Thursday July 2, he is resting comfortably in an Atlanta-area hospital,' the statement read, adding that Cain did not need a respirator. 'There is no way of knowing for sure how or where Mr. Cain contracted the coronavirus.'

Cain, briefly a frontrunner in the 2012 GOP presidential primary, tweeted a picture on June 20 of himself and others at Trump’s indoor rally.

“Here’s just a few of the #BlackVoicesForTrump at tonight’s rally! Having a fantastic time!” the caption read. No one in the picture was wearing a mask.

Finally, the director of the Tulsa Public Health Department concluded that the rally likely made an important contribution to the surge of cases overall in Tulsa.  As reported by AP on July 8, 2020:

President Donald Trump’s campaign rally in Tulsa in late June that drew thousands of participants and large protests 'likely contributed' to a dramatic surge in new coronavirus cases, Tulsa City-County Health Department Director Dr. Bruce Dart said Wednesday.

Tulsa County reported 261 confirmed new cases on Monday, a one-day record high, and another 206 cases on Tuesday. By comparison, during the week before the June 20 Trump rally, there were 76 cases on Monday and 96 on Tuesday.

Although the health department’s policy is to not publicly identify individual settings where people may have contracted the virus, Dart said those large gatherings 'more than likely' contributed to the spike.

'In the past few days, we’ve seen almost 500 new cases, and we had several large events just over two weeks ago, so I guess we just connect the dots,' Dart said.

So despite multiple warnings from public health experts and health care professionals, Trump and his campaign held a intentionally maskless and socially compacted rally quickly followed by the spread of infection to staffers, at least one of his prominent supporters, and apparently a large but unknown number of the population of the city in which the rally was held.  Since then, Trump et al have held two large maskless and socially compacted events, one in an urban area with already a large surge in COVID-19, although it is too early to tally their effects.


The Trump Administration and Family

Ivanka Trump's Travels

Per the NY Times, April 16:

Ms. Trump herself has not followed the federal guidelines advising against discretionary travel, leaving Washington for another one of her family’s homes, even as she has publicly thanked people for self-quarantining.

In particular,

Ms. Trump and her husband, Jared Kushner, who is also a senior White House adviser, traveled with their three children to the Trump National Golf Club Bedminster in New Jersey

On Their Own, Top Administration Officials Avoid Masks and Have Others Take Them Off

Even when the President Trump is not present, his top officials have taken it upon themselves to prevent the use of masks and social distancing.  On May 8, 2020, the Washington Post reported that Defense Secretary Esper and Veterans Affairs Secretary Wilkie stood with several very elderly, and hence vulnerable to coronavirus, World War II veterans sans masks. On May 11, the Intercept reported that Vice President Pence attended an event without a mask, and that business executives in attendance were required to remove their own masks.  This occurred right after Pence was exposed to Katie Miller (see above), so soon after Pence entered quarantine.

How ICE Spread the Virus

Days ago, on July 10, 2020, the New York Times reported:

Even as lockdowns and other measures have been taken around the world to prevent the spread of the coronavirus, ICE has continued to detain people, move them from state to state and deport them.

An investigation by The New York Times in collaboration with The Marshall Project reveals how unsafe conditions and scattershot testing helped turn ICE into a domestic and global spreader of the virus — and how pressure from the Trump administration led countries to take in sick deportees.

The scope of the problem appears large:

So far, ICE has confirmed at least 3,000 coronavirus-positive detainees in its detention centers, though testing has been limited.

And,

So far, the governments of 11 countries have confirmed that deportees returned home with Covid-19.

So members of Trump's administration and family have also undermined public health measures meant to prevent the spread of the coronavirus, likely enabling infection in some affected people.

Trump Supporters in the US Congress

Trump's political supporters in the US Congress, and in state houses and legislatures have also enthusiastically followed his lead, promoting a maskless and not socially distanced life, despite increasing evidence that their efforts are leading to more people infected with coronavirus.

Republican Members of Congress Refuse Masks and Social Distancing

Republican members of the US House of Representatives have repeatedly refused to wear masks during their official duties while indoors and when close to other people.  On April 23, 2020, the NY Post reported:

Republican members of Congress were noticeably reluctant to wear masks on the House floor Thursday, sparking a sharp debate with Democrats, who readily accepted the federal guidance.

As lawmakers gathered for a morning debate on creating a coronavirus stimulus oversight committee, the GOP side of the chamber largely left their mouths and noses uncovered

The leadership provided the bad example, provoking mockery of masks as a pandemic prevention measure:

Minority Leader Kevin McCarthy (R-Calif.) and Minority Whip Steve Scalise (R-La.) arrived on the House floor without masks, as did many GOP peers.

'Nice mask!' a colleague told Scalise.

'Thanks! I wear it for Halloween, too!' the second-ranking Republican said, laughing uproariously.

Those who did not wear masks included Reps. Jack Bergman (R-Mich.), Andy Biggs (R-Ariz.), James Comer (R-Ky.), Louie Gohmert (R-Texas), Brett Guthrie (R-Ky.), Jody Hice (R-Ga.), David Kustoff (R-Tenn.), Michael McCaul (R-Texas), Tom McClintock (R-Calif.), Cathy McMorris Rodgers (R-Wash.) and Chip Roy (R-Texas).

Despite continuing exhortations from public health experts about wearing masks, House Republicans remained defiant.  As reported on May 28, 2020 by CNN:

A contingent of House Republicans continues to defy the recommendations of public health experts and Congress' top physician to wear face coverings to limit the spread of Covid-19, refusing to wear them on the floor of the chamber, in the hallways of the Capitol or when chatting with aides and colleagues -- even when they're unable to maintain a social distance.

Some of those anti-mask Republicans seem to have acquired coronavirus infections, suggesting that their deliberate avoidance of masks and social distancing has enabled the spread of the virus, even to those who advocated such defiance of public health orthodoxy.  As reported by USAToday on June 15, 2020:

South Carolina Republican Rep. Tom Rice announced Monday that he and his family contracted COVID-19, becoming the latest member of Congress to contract the deadly disease that has infected about 2.15 million Americans.

Rice, in a Facebook post to his constituents, said he and his family contracted the disease last week and were recovering. He joins seven other members of Congress who tested positive for the disease or who were diagnosed with a presumed case. But his case comes months after his colleagues' and comes as states push to reopen businesses and their economies.

And the defiance continues.  CNN reported on June 26, following up on a Congressman listed above whose state now experiencing a major surge in infections:

Texas Republican Rep. Louie Gohmert spends ample time on the House floor not wearing a mask, often talking with aides and lawmakers at length while not maintaining a social distance.

Asked why not, the 66-year-old Gohmert had an explanation that defied the science and the recommendations of leading public health experts.

'I don't have the coronavirus, turns out as of yesterday I've never had it. But if I get it, you'll never see me without a mask,' the conservative Texan told CNN Friday.

Told that health experts say that people who don't have symptoms may be carrying the virus and can unknowingly spread it to others, Gohmert responded: 'But I keep being tested and I don't have it. So I'm not afraid of you, but if I get it I'll wear a mask.'

Leading Republican Member of Congress to Hold Fundraising Event in Florida During Huge Virus Surge

I found one other example of a well known Congressman who seemed intent on holding an event that could risk further virus spread in a state already experiencing a major surge.  On July 7, 2020,Axios reported

House Minority Whip Steve Scalise’s PAC is inviting lobbyists to attend a four-day 'Summer Meeting' at Disney World's Polynesian Village in Florida, all but daring donors to swallow their concern about coronavirus and contribute $10,000 to his leadership PAC.

Why it matters: Scalise appears to be the first House lawmakers to host an in-person destination fundraiser since the severity of pandemic became clear. The invite for the 'Summer Meeting' for the Scalise Leadership Fund, obtained by Axios, makes no mention of COVID-19.

Trump Supporters in State Governments

Maskless Governors Went To Restaurants

Early on in the pandemic, despite evidence that crowded restaurants provided an ideal environment for virus propagation, one governor who supports Trump made a point of showing up in restaurants.

March 16, 2020, via the Independent:

[Republican] Oklahoma governor Kevin Stitt, has declared a state of emergency in response to the coronavirus outbreak just a day after he was slammed for tweeting a picture of his family at a crowded restaurant.

Two months later, two others made the restaurant scene, sometimes encouraged by Vice President Pence.

May 14, 2020, via the Arizona Republic

[Republican Governor Doug] Ducey’s office posted photos on social media of the governor stopping for lunch at Pita Jungle in Phoenix with a bipartisan group of legislators.

The get together was a show of support for the restaurant industry as eateries reopened dine-in service this week as the governor pulled back state restrictions in place because of the COVID-19 pandemic.

None of the politicians were wearing masks in the pictures. Restaurant staff appeared to be wearing masks.

The state’s own guidance for restaurants says eateries should develop standards for employees to wear masks around customers and coworkers.

May 20, 2020, via ABC News:

Vice President Mike Pence did something Wednesday that most Americans haven’t done in many weeks amid the coronavirus pandemic: He sat down for lunch at a burger joint.

The vice president held a photo op at Beth’s Burger Bar in Florida along with GOP Gov. Ron DeSantis to highlight efforts to allow restaurants in the state to begin reopening for limited, in-person service.

But,

Neither the vice president, nor Steele, nor DeSantis, or many others nearby, wore masks.

May 22, 2020 via the Atlanta Eater:

Photos posted to social media by WSB reporter Richard Elliott, AJC photojournalist John Spink, and AJC reporter Tamar Hallerman show Gov. Kemp and Vice President Pence speaking to the owners, staff, and diners at Star Cafe, and lunching on pulled pork and meatloaf paired with sweet tea.

But,

Despite the governor urging the public to face wear masks and to social distance during the ongoing COVID-19 health crisis, neither Gov. Kemp or the vice president — or most of their entourage — entered the restaurant wearing a mask or when conversing with people before dining, and social distancing seemed to be on the back-burner.

Note that since then Oklahoma, Florida, and Georgia have all experienced big coronavirus surges.


Pennsylvania Legislators Concealed COVID-19 Infection Acquired by One of Their Own

On May 28, 2020, the Washington Post reported:

Democratic state legislators in Pennsylvania accused their Republican counterparts Wednesday of keeping a GOP lawmaker’s positive coronavirus diagnosis under wraps for days, arguing the lack of transparency may have increased their risk of contracting the potentially deadly infection.

Republican state Rep. Andrew Lewis released a statement Wednesday revealing he received his positive test result on May 20 — a jarring announcement that rattled House Democrats who said they had no idea he had been sick or other GOP members had been told to self-quarantine due to possible exposure.

Lewis, whose last appearance at the state Capitol was on May 14, said he immediately went into isolation after testing positive and informed House officials about his condition.

In particular,

state Democrats were appalled that their Republican colleagues did not promptly inform them of Lewis’s positive test result or the subsequent self-quarantines of other GOP members, instead allowing them to potentially risk exposure by continuing to participate in person in voting sessions and House committee meetings. Several Democrats said Wednesday they only became aware of Lewis’s diagnosis from the media.

The connection between intentional behavior by the state legislators and their colleagues initially unknowing assumption of increased risk is clear.

After Refusing Masks and Social Distancing, Mississippi Legislators Acquiring Coronavirus Infections

On July 10, 2020, AP reported:

Packed elevators and crowded committee rooms. Legislators sitting shoulder-to-shoulder on the House and Senate floor. People standing close to each other and talking, sometimes leaning in to whisper, without a mask in sight.

Those were common scenes at the Mississippi Capitol in June — a month that saw a historic vote to remove the Confederate emblem from the state flag — and now at least 26 lawmakers have been diagnosed with the coronavirus in the biggest known outbreak in any state legislature in the nation.

That works out to about 1 in 7 Mississippi legislators.

Among those testing positive in the heavily Republican body are the GOP presiding officers, House Speaker Philip Gunn and Lt. Gov. Delbert Hosemann.

Again, there is a plausible connection between lack of masks and social distancing, and then rise in infections.  Note again that Mississippi has been also undergoing a major coronavirus surge.

Summary


We have thus seen an extensive array of examples in which President Trump, his administration, and his political supporters in the US Congress, state houses and state legislatures have deliberately undermined standard public health measures meant to reduce the spread of the coronavirus and better control the pandemic.  There are examples in which their defiance at least was temporally related to specific or general increases in infection.  These examples occurred before and during the latest and now most severe surge of the pandemic.  The examples occurred despite many, many warnings and cautions by public health and health care professionals, and protests by political opponents.

How can we explain this apparently perverse behavior?  Given its duration despite warnings and pushbacks, it is hard to attribute it to lack of knowledge, miscommunication, or error.  One can never dismiss the possibility of grotesque stupidity.

However, at this point, I cannot dismiss the likelihood of malevolence.  As Jurecic and Wittes postulated in the Atlantic back in March,

As the former Justice Department official Carrie Cordero declared on Twitter: 'To invert a @benjaminwittes formulation, the Trump administration #COVID19 response might be characterized as incompetence exacerbated by malevolence.'

It is an inversion in more ways than one. In the original formulation of the phrase—malevolence tempered by incompetence—the incompetence not only comes second, but it mitigates the malevolence. In Cordero’s rather apt reformulation, by contrast, the incompetence comes first, and the malevolence doesn’t mitigate it. It makes things worse.

So,

[Addressing] the malevolence. President Trump’s statements since the virus first appeared in the United States have been wholly untouched by concern for anything except blame avoidance.

Furthermore,

He barely bothers to express concern about public health, choosing instead to wax indignant about how the virus is affecting his public image. This has led to some scenes that might have been bleakly funny if not for the many lives at stake.

And as Greg Sargent wrote in the Washington Post on July 8,2020:

Not clueless and hapless.  Malevolent.

Once we dispense with the idea that Trump remains 'in denial,' we’re left with a few interpretations. The most charitable is that Trump continues to have principled disagreements with experts over these matters, but there are zero indications he has any substantively grounded views on them of any kind.

A far less charitable interpretation is that he’s merely indifferent to the catastrophic consequences that are resulting from these failures — and will continue to do so — and that he’s prioritizing nakedly self-interested political calculations over any such concerns.

Finally,

Central to getting this right is dispensing with the idea that Trump is a hapless, clueless actor rather than a deliberate and malevolent one.

If he is right, only then will be come up with a real solution for a malevolent and now life-threatening regime.

Parlous Times—so Why Is My Dander Down?

Yes, these are parlous times, my friends, with all sorts of threat levels bouncing up and down and up again to all sorts of new heights. I've personally felt almost paralytic, in this present "Dander" series, about repeating the latest outrages from Trump-land and Corona-land.  (Lather. Rinse. Repeat.) What is there new to say? The outrages are all there, still, but with a single, over-arching theme.

To quote the great philosopher, Frankie Valli, "It's a sign!!!" The sign: a new system of governance run by a cabal of family and cronies, no inspectors-general in sight, and a whole lot of unconfirmed "acting" secretaries, under-secretaries, under-under-secretaries and under-under-under secretaries.

I've written about this syndrome in HCRenewal before, mainly in connection with the Veterans Administration. Look it up right here in HCRenewal (e.g. see here). It's a systemic neurological disorder we could call MS: Mar-a-Lago Syndrome. In this disorder the federal government is paralyzed not by the Deep State, but a pernicious Deep Nonstate of golf buddies, far-right pundits and other self-dealing defilers of democracy.

Oh, where are the mere managerialists we used to go after in HCRenewal? We do miss them so! Lather. Rinse. Repeat.

Anyway, we're in the summer of 2020 and lives have been lost. The system stays awash in waste and cronyism. But I just couldn't muster writing more about it: what was new? It's all MS and the thousand flushes of oppositional, know-nothing populist careerism that go along with it. All courtesy of a motley crew of hackers, sadly gullible flat-earthers and one particular political party busy pushing itself and the rest of us off the deep end. All exploiting the hell out of each other. Only one, the US Senate's leadership, has an internally-valid long-term goal—the judiciary—that purports to make the exercise worthwhile. Everybody else can just bump along in their miserable gerrymandered "corporations are people" lives, liking it and lumping it.

And yet: along the way, something strange seems to be happening. It's true that, yoked together and spurring on their steeds, our four horsemen of the apocalypse—America's flawed democracy, its corrupt GOP, the pandemic and its exposed systemic racism—just stay on the rampage. But look underneath all this, in health care and just maybe in the larger society, there are young hopeful shoots, sprouting somehow in the mud below. And that is something new and worth writing about.

So just now, oddly enough the dander's down. (Provisionally. Check in again in, oh, four to five months.)

Some years ago Dr. Poses, this blog's venerable editor, already pointed out how HCRenewal's message has begun to "go mainstream." Now and again, he points out further new examples.

Maybe this mainstreaming of the message—health care independence and integrity—somehow relates to a couple of major shifts in the medium, or mediums, that carry the message. The first, social networks, have worked in part to the detriment of good government. But they also enable ground-up protest in a new communications ecosystem.

Another part of this ecosystem, less evident to lay people and leaders but potentially a potent force, is the advent of a new and more independent-minded generation of science and medicine journal editors, with their accompanying editorial boards. Here we find some more of the tender young shoots, exemplifying the change that genuinely seems afoot. Let me cite three recent examples.

• The Annals of Internal Medicine has gone from strength to strength in recent years. Under its current editor, Christine Laine, the first woman to hold that post, Annals now boasts its highest-ever impact factor [C. Laine MD, personal communication]. That's an impact in general medicine, the nation's largest specialty, boasting over a million page views per month.
  
  The current number of Annals, for mid-June 2020, offers an article entitled "a cautionary tale," describing last year's "orphaning" of the entire house staff of Hahnemann University Hospital. Both the content and the very fact of the publication of this article are noteworthy. The article that follows, in its title, asks "is it time to more fully address teaching religion and spirituality in medicine?" (answer: "truly caring").
  
  
  
  But stick for the moment with the Hahnemann debacle. The article, written by three former Drexel University College of Medicine (DUCOM) faculty members who're now spread to the four winds, probes the "diametrically opposed goals of hospital owners and educational leaders" that led to an enormously disruptive hospital closure on the verge of a pandemic, a tsunami that orphaned nearly 600 trainees and that faculty quite simply "found hard to believe."
  
  Those of who were around in the 1990s didn't find it so hard to believe. The authors allude to the prehistory of the Hahnemann bankruptcy in the earlier one endured by Allegheny, or "AHERF" in the late 1990s. They don't insist on the earlier one prefiguring the later one, "the largest orphaning event" in medical history, in any causal or direct fashion. But I'd argue precisely that: at the least, it made it much more likely.
  
  The reason, simply, a circumstance to which to their credit the authors point, was the original sin of the deal that bailed out a medical school (pre-bankruptcy MCP-Hahnemann, post-bankruptcy Drexel) and a group of hospitals (originally Tenet Healthcare). That original sin was a quarter-century earlier when the Philadelphians did a deal-that-was-never-gonna-work with Tenet Healthcare, a for-profit based west of the Mississippi. The original sin fast-fowards a quarter-century to the present authors noting that at the critical moment in 2019, "Drexel and Hahnemann released separate talking points for P[rogram] D[irector]s, but these documents contained discordant information." But the discord started in 1995 and never stopped. Graduate Medical Education run by frenemies.
  
  The American system of GME, like the US Constitution, contains any number of these ill fated compromises. When this happens, only a few norms serve as guardrails against disaster: in this case, the manner in which hospitals—recall that Tenet was a for profit system, and one for which both education and research are distinctively secondary—control the medical education dollars coming to them from Medicare reimbursements. "Discordant information": how can you lose?
  
  The departure of hundreds of residents, with all its displacement of both faculty and trainees, and with all its emotional turmoil, hardly seems like something that would cheer one up. And on its face, it's not. One can hardly overestimate the pain these authors and their colleagues went through. But what strikes me is the fact that this whole crummy system is no longer anechoic: that those within it are out there on the hustings, stating the lessons learned, trying to create the antibodies that might protect against future such occurrences. And Annals gladly published this excellent exposition-cum-cautionary tale.
  
• In the same week that I received this number of Annals, I received the 25 June 2020 number of The New England Journal of Medicine. NEJM, also a super-high-impact journal, changed editorship—just a few months before the onset of the pandemic— much more recently than Annals. One waited to see whether it, too would be, shall we say, feminized. (Be clear: in this case "feminization" is for me an uncomfortable shorthand for what I dearly hope my commentators below will suggest a better word, and more or less an unmitigated good.)
  
  I grew up in a tradition of ritualistic CPCs—clinicopathologic conferences—in my own medical school and in key journals such as NEJM. A case would be presented of a patient who had to die. They had to die because the autopsy findings would be tortuously predicted by the academic physician as the solution to a diagnostic dilemma. This would be followed by a learned exposition of the histology and gross pathology of the disease that furnished the answer to the puzzle. Sometimes the clinician even got it wrong. The pathologist of course was always right, He—it was virtually always a he—always got the last word.
  
  But what the CPC model did was to reify the classic post-Laennec medical model of equating medical decision making to its laboratory-based problem-solving narrative. This began to change a bit beginning in the Journal's post-Ingelfinger and post-Relman eras, where editors began to stress correlations of clinical findings with those of the new molecular biology and immunochemistry. Now the patient didn't even have to always die! But the classic medical model, even then, was preserved. Riddle me a riddle: bench science, properly coupled with bedside wisdom, will provide the answer.
  
  Imagine my surprise then to find the CPC of a few weeks ago, entitled "a girl with severe psychological distress after family separation," focused on "trauma-informed care" in which the clinical outcome was not "a post-mortem examination was performed" or "a diagnostic procedure and laboratory study were performed." Here "a diagnosis and management decisions were made" and both clinical and patholgocial diagnoses were "post-traumatic stress disorder."
  
  The graphic is that of a cartoon pediatrician with an immigrant child, blowing bubbles together.
  
  Make no mistake: this is both a scientific and literary breakthrough, and a political statement. It is enormously heartening to view such a sea change in one of our most august journals. It tell us that a new, younger leadership in academic medicine is stepping up to address the socioeconomic problems that are now—far more than whether or not SARS-CoV-2 does or does not interact with ACE inhibitor agents—threatening health care in the more dire existential fashion.
  
  Can we extrapolate from these straws-in-the-wind? Is medicine becoming less anechoic and able to counter the threats against it? I know of no other recent precedent, but there's one from classical antiquity: the very bedrock of our medicine today, the Hippocratic tradition. In his magisterial 1995 work Hippocrates in an Age of Pagans and Christians, Owsei Temkin of Johns Hopkins showed how the classical traditions of independent medicine were able to persevere even in a later era in which they were threatened by religious authority. It was a close call then and it's a close call now: viz., the decision by a mere five to four, just a few days ago, preserving the physician's right without hindrance to provide services to a pregnant woman.
  
  Sometimes it comes down to one vote. And, granted, it ain't over until it's over: in November, voters in the United States will, in momentous fashion, decide the future direction not just of their own people but of the healthcare they're going to get going forward.
  
• What's going on here? In truly extraordinary circumstances, leaders in medicine seem to be not abandoning the scientific model, but expanding it to incorporate insights and perspectives drawn from ethics and the social sciences, including economics. (The Allegheny-Hahnemann case is a classic example of business-economics-gone-wrong through failures of basic socioeconomic analysis.) Even in the non-clinical literature, if you take even a cursory look, you can find these tender young sprouts of freedom.
  
  The journal Cell, in a number published last month, began with an editorial entitled "Science has a racism problem," stating that "We are the editors of a science journal, committed to publishing and disseminating exciting work across the biological sciences. We are 13 scientists. Not one of us is Black." Cell also boats an editor of recent vintage (2018).
  
  But what followed was even more astounding. Amidst articles discussing matters such as how "Epitope pools detect CD4+ and CD8+ T cells," in the very next number of the journal, Duke neuroscientist and MD-PhD Kafui Dzirasa provides his account of how "[f]or Black scientists, the sorrow is also personal." This article has been widely reprinted and sent out to many thousands of physicians who practice in domains as far away from cell biology as orthopedics. It is worth quoting in extenso, and speaks for itself.

I am a medical doctor and a scientist; the first African American awarded a PhD in neuroscience at Duke University. I have led a National Institutes of Health-funded research lab for almost a decade, and I was awarded the Society for Neuroscience Young Investigator Prize in 2019. I am an American Association for the Advancement of Science Alan I. Leshner Public Engagement Fellow, and I have hosted TEDMED three times. I am a scholar, teacher, mentor, speaker, and mental health advocate. I have served on national commissions, I have advanced federal policy, and I have even held court with a president of the United States. I have published in Cell scientific journals, and as a peer reviewer, I have worked to advance the scientific rigor of my colleagues. Yet, most days, I am unseen and unknown. As I watched a knee slowly, mercilessly, and inhumanly extinguish yet another black life, I was overwhelmed by anger and sorrow, and at this very moment, I am terrified to run on the trail near my home. I am a black academic in America.

That these three examples of medical communication all point to inherent problems in American medicine, no doubt in world medicine as well, is daunting in one sense. But in another it is undaunting. It shows us how far we have left to go. By looking in the mirror and recognizing that they share the challenges of the larger society, medicine and science have at least a fighting chance of transcending them—and in doing so, regain their independence. The manner in which these authors have taken the knee, and in doing so stood very, very tall, shows us a path of speaking truth to power. In doing so, and in our anticipation of their being heard, they give us hope.

That Old Time Revolving Door Keeps Spinning

Traditionally, the American examples we have seen of the revolving door involved people leaving leadership positions in governmental bodies which regulate health care or make health care policy then soon obtaining jobs in the health care industry, particularly organizations which they previously regulated or were affected by the policies they made, the outgoing revolving door.  These examples occurred during Democratic and Republican administrations.  However, during the Trump regime, we began to see many examples of the incoming revolving door, people coming form leadership positions in the health care industry to take government health care regulatory or policy positions that could affect their former organizations' interests (look here).

However, the old-time bipartisan outgoing revolving door keeps spinning.  Here is a collection of examples in chronologic order by the date they were made public.  Also, I found an example of the incoming revolving door at the US state level, involving Democrats, not Republicans.


From Secretary of Veterans Affairs to the Board of Armada Health

On March 12, 2019, a brief item in Modern Healthcare stated:

Former Veterans Affairs Secretary Dr. David Shulkin has joined the board of ArmadaHealth, a Maryland health data company that offers a database for patients to find physicians.

President Donald Trump fired Shulkin last year from the top post at the VA, where the former secretary also served under President Barack Obama.

I could find little further information.  Note that Dr Shulkin served in both Democratic and Republican administrations.  Note further that with the increasing push to privatize the VA, its operations may have more to do with companies like ArmadaHealth.

From US Senate to Lobbying Firm Akin Gump Strauss Hauer & Feld

On March 14, 2019, Maplight.com noted:

Months after advising the Democratic Party to abandon the idea of 'Medicare for All,' a former U.S. senator has been hired by a lobbying firm whose clients are leading the fight against changes to the nation’s health care system.

Akin Gump Strauss Hauer & Feld LLP, a Washington, D.C.-based law and lobbying firm, announced on Wednesday that former Sen. Joe Donnelly is joining the firm as a partner and will be counseling clients in the health care and financial industries.

In particular, the article stated that:

Akin Gump has lobbied for the Healthcare Leadership Council since 2016. The trade organization’s members include health insurance, pharmaceutical, and hospital interests -- industries whose profits could be threatened by a single-payer system. The firm has also lobbied for Pharmaceutical Research and Manufacturers of America (PhRMA) and the Biotechnology Innovation Organization, two powerful drug industry trade groups.

PhRMA, BIO and the Healthcare Leadership Council are members of the Partnership for America’s Healthcare Future, a coalition created last year to oppose Medicare for All, as well as any of the weaker measures offered by Democrats to provide health care coverage or insurance to more Americans.

Donnelly seemed like a pretty good candidate to lobby for thiese firms because:

He campaigned against Medicare for All, even though polling by Data for Progress and the Kaiser Family Foundation last year estimated that 55 percent of Indiana residents support a universal health insurance plan. In one Donnelly campaign ad, a narrator warned that 'socialists want to turn health care over to the government.' Donnelly replied: 'Over my dead body.'

Since his loss, Donnelly has continued to warn Democrats against pushing for a single payer health care system. 'When you talk Medicare For All … you start losing the people in my state,' he said in December. 'When we start talking about, 'Hey, we're going to work together with the insurance companies to lower premiums,' that's what connects. The talk on the coasts just doesn't get it done in the middle.'

So Donnelly's new position lobbying for industry groups that oppose single payer health insurance, which they presumably see as a threat to their revenues, could be viewed as a reward for his previous advocacy of their positions.

In that vein, the article quoted health care insurance whistleblower Wendell Potter:

a former health insurance executive who has spent a decade investigating the industry’s predatory practices, panned Donnelly’s career move.

'Sen. Donnelly kept health care reform efforts at bay his whole tenure in Congress, and on his way out he went on national news to tell Democrats that Medicare for All was dangerous,' said Potter. 'Now we see his reward: A cush lobbying gig working for the health-care industry.'

'Color me shocked,' he said.

Were Senator Donnelly to have advocated the industry position because he thought it would enhance the chances of eventually getting a lucrative industry position, that could have appeared to be an abuse of entrusted power (as a Senator, to set public policy) for private gain, that is, as corruption in the ethical, if not the legal sense.

An article in the Indianapolois Star found this response from the Republican Party:

Indiana's GOP criticized Donnelly's decision.

'While Donnelly may have moved back to Granger, he clearly can’t get enough of the swamp,' said Pete Seat, executive director of strategic communications for Indiana Republicans. 'From this day forward, consider ‘Democrat Donnelly’ retired, and ‘D.C. Lobbyist Donnelly’ deployed.'

That is a reasonable criticism, but I wonder if they would make the same criticism of similar behavior by a Republican politician?   

Meanwhile, in April, Politico briefly noted

Former Rep. Lamar Smith (R-Texas), meanwhile, who also joined Akin Gump after leaving Congress in January, reported lobbying for four clients. They include HerdX, a ranching logistics company; Otis Eastern Service, an oil-and-gas pipeline company; Pebble Limited Partnership, which is trying to develop an open-pit mine in Alaska; and Pfizer, the giant pharmaceutical company.

So this particular pathway from the Senate to this lobbying firm and then to health care industry clients is a well trodden one.

From the US  Drug Enforcement Administration to Consultant for Purdue Pharma

On March 20, 2019, NBC News reported:

A former senior U.S. Drug Enforcement Administration official who testified before Congress on the government's efforts to stop the opioid epidemic is now paid to advise one of the largest opioid manufacturers in the country, Purdue Pharma, according to people familiar with the matter.

Demetra Ashley, the former acting assistant administrator of the DEA who told a Senate committee in 2017 about the need for a 'robust regulatory program' to stop the diversion of opioids and other controlled prescription drugs, left the DEA last spring and started a consulting firm called Dashley Consulting, LLC

The arrangement inspired some critcism, for example,

'This should not be allowed,' said Dr. Andrew Kolodny, the co-director of opioid policy research at Brandeis University. 'Former DEA and FDA officials should not be allowed to take money from companies they regulated.'

The issues here seem obvious.

From Top White House Adviser to Adviser to Juul

On May 21, 2019, the Washington Post reported that Johnny "DeStefano, a counselor to the president who served as a bridge between the Republican Party and the administration, is leaving on Friday." As to his destination,

He is expected to advise a number of companies, including Juul, the e-cigarette company, while helping on the campaign, according to people familiar with his plans. Juul has significant business in front of the Food and Drug Administration

I could not find much more about this. However, as a top White  House adviser without a specific portfolio, DeStafano could have affected health care and specifically FDA policy.

From Venture Capital Firm New Enterprise Associates to Director of the US Food and Drug Administration (FDA) and Back to New Enterprise Associates

On May 22, 2019, Axios reported that

Scott Gottlieb, who recently stepped down as the head of the Food and Drug Administration, has rejoined venture capital firm New Enterprise Associates as a full-time investing partner, Axios has learned.

Context: Gottlieb had been a venture partner with NEA before President Trump tapped him to lead the FDA, where he became known for cracking down on e-cigarettes and working to battle the opioid epidemic.

Gottlieb previously spent a decade with NEA, but the new role is more substantive. He's expected to lead investments in life sciences startups and take board seats.

Again, there was little other information and no substantive commentary publicly available about Dr Gottlieb's return to his old firm.

We briefly noted the considerable public discussion about Dr Gottlieb's conflicts of interest at the time of his ascension to the FDA post here. He had multiple relationships with multiple for-profit health care corporations in the years leading up to his 2017 appointment.    I should note that we have discussed previous examples, in 2007 and 2008 (look here, here, here and here), of Dr Gottlieb's strident promotion of the interests of pharmaceutical and biotechnology companies.  After 2008, I  naively thought further discussion of this topic would be redundant. 

From Director of the National Institute of Mental Health (NIMH) to Google's Verily, to Mental Health App Developer Mindstrong, to California "Czar" for Mental Health

Last, but not least, also on May 22, 2019, StatNews reported:

Noted psychiatrist and former Verily leader Dr. Tom Insel is going to be the 'mental health czar' for the state of California, Democratic Gov. Gavin Newsom announced Tuesday.

Insel, the former National Institute of Mental Health director, will also continue his work with Mindstrong, a startup that is working on a mental health app, a company spokesperson confirmed. Insel joined the company in 2017 after leaving Verily, Google’s life sciences arm.

Insel’s new job will be to 'inform the state’s work as California builds the mental health system of tomorrow, serving people whether they are living in the community, on the streets or if they are in jails, schools or shelters,' according to a press release from the governor’s office.

In a press conference, Newsom said Insel was 'volunteering' his time as an adviser. 'I’m calling him the mental health czar in the state of California,' he said.

The article also noted that

Mindstrong, which is focused on using data on how people use their smartphone to detect trends in their mental health, already has a relationship with public officials in California. One of Mindstrong’s first large-scale rollouts was slated to happen in the state through county-level public mental health systems, STAT reported in October.

A spokesperson for Mindstrong said that Insel would recuse himself from conversations about the company, and noted that he will have 'no fiscal or regulatory authority and will have no oversight of current programs in this voluntary role.'

Note that even after such specific recusal, Dr Insel would be in a position to generally influence state policy in ways that could favor Mindstrong.  Futhermore, state officials working for a "mental health czar" would be aware of his commercial ties and might thus tend to try to favor Mindstrong to please him.  

Note also that in 2010 our late blogger, Dr Bernard Carroll, wrote a series of posts about conflicts of interest and other ethical questions about Dr Insel's tenure as director of the National Institute of Mental Health (NIMH) here, here, here, here, and here.  Also, in 2015 I noted that Dr Insel transited the revolving door from the NIMH to Google Life Sciences.  This is just another example of how people and organizations that get on our radar once for ethical and leadership lapses tend to appear again and again.

[photo of Dr Carroll]


Discussion

We have repeatedly said,  most recently in March, 2019, ...

The revolving door is a species of conflict of interest. Worse, some experts have suggested that the revolving door is in fact corruption.  As we noted here, the experts from the distinguished European anti-corruption group U4 wrote,

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door once again suggests how the revolving door may enable certain of those with private vested interests to have disproportionate influence on how the government works.  The country is increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism. The latest cohort of revolving door transits suggests that regulatory capture is likely to become much worse in the near future.

Remember to ask: cui bono? Who benefits? The net results are that big health care corporations increasingly control the governmental regulatory and policy apparatus.  This will doubtless first benefit the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people, due to detriment of patients' and the public's health, the pocketbooks of tax-payers, and the values and ideals of health care professionals.  

 The continuing egregiousness of the revolving door in health care shows how health care leadership can play mutually beneficial games, regardless of the their effects on patients' and the public's health.  Once again, true health care reform would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.

More Than Just Dander

First, a sort of meta-comment in the form of a shout-out to HCRenewal's intrepid editor, Dr. Roy Poses, for his just-published analysis of what we might call "blogging: rise and fall." He sees decline reflected in publications long  devoted to health and health policy, yet now flaking off.

Methinks, however, despite the usefulness of his overview of recent decades, Dr. P need not fret excessively. Water spilling out of the barrel's lip will slow down once folks come along and punch a whole bunch of little mid-section tweet-holes in it. Information still flows. (Sort of.)  In any case, surely there's overlap between blogs' and tweets' readerships. Surely well-researched and -reasoned long form still has its place. Unfortunately, hard to know for sure: it's hard to measure. Nobody's polling these folks and to my knowledge information scientists haven't published much--a quick search inside Google Scholar bears this out--that's of a quantitative nature.

So we're left with admittedly rather unsatisfactory anecdotal reports on people who need blogs like ours and find their way to it. Congressional staffers you know who you are. Rightly or wrongly, I'm hopeful. Maybe we shade this a little by the suspicion that many younger social media users share with me a short attention span. Hence they come to rely more and more on quick hits. In any case, let's hope this is evolution and diversification, not just entropy and a race to the bottom.

Now to my theme of the day. Yet again the dander hath risen for I've lost count how many times around what ails our health delivery systems. And so is my lunch: the gorge, too, hath risen. The miscreants' very relentlessness is nauseating. More, then, on two of them that keep cropping up here like those small burrowing insectivores in this tedious yet oddly riveting game of Whack-A-Mole.

A. Chicanery at the VA: looking back and looking forward.

On balance, and despite its many flaws, VA health's operation in all its enormity is not itself a miscreant. Different story for those folks trying to destroy it from within, on the dubious premise that lest we privatize it it's irredeemable. Search this blog on "VA Cetona" for detail on such matters.

Why does this even happen? We've described the VA's Shadow Rulers (search here on that as well) in these pages. The SR's fall in the 0.1%. Why do they need or want the headache of trying, in what's fated to be a futile effort, to upend and hollow out the health lifeline extended for nearly a century to patriots returning from the military?

When the left gets power it tries to expand and improve government. (Of course the efforts can unfortunately go awry, viz. Hillarycare in the 1990s, and cast shade on future attempts.) When the right gets power, at least in the two generations since an actor became president in 1980, government is seen as "not the solution but the problem." The response may be to try to rejigger and downsize. "Drown the baby in the bath." Or, perhaps far more likely, something else now happening in the VA and throughout the Trump kakistocracy.

Namely, don't seize power to return it to the people. Seize it in order to use it in a third-dimensional play to drain resources. As for the first two dimensions, don't even try to improve--David Shulkin's mistake (see below)--or eliminate (despite Mick Mulvaney's baby drowning proclivities, hugely unpopular) care provided by the VA. Not when there's a third way: divert those resources. In fact, from the earliest instances of frontier exploitation to the newest frontier we have--our heretofore private personal information--despoliation has been the watchword, the core motive, the secret sauce: don't ameliorate. Don't eliminate. (Honestly: viz., Shrub's expansion of guvmint.) Despoliate.

It is, as Shrub used to say (maybe), one of our country's most basic pieces of strategery.

Such a strategy was discussed (and surely it's as old as the hills) by Times tech reporter Steve Lohr in a recent piece on, of all things, artificial intelligence. ("Elixir of prosperity [or] job killer"?) Lohr makes clear that what's old is new again, linking the asset of private data to all the other assets that've been strip-mined. "In the American model," notes Lohr, "coming from Silicon Valley in California, a handful of Internet companies become big winners and society is treated as a data-generating resource to be strip mined."

As Buffy the Vampire Slayer once said, "can you spell 'duh'?"

Strip mining started with the earliest settlers, and now ... data, the final frontier. Same deal, though. The American model, and economic maldistribution, and so much of our plight is bound up with this baked-in trait, which seems to've seeped into society's DNA. Or else originated there. Find a mine. Strip it. Let others pick up the pieces.

But let's go back to that last credible VA Secretary. How do we know that Shulkin pissed off the strip-miners? Why, just read what he himself wrote in a scholarly publication just a few months ago in the prestigious New England Journal. In a piece entitled "why the VA needs more competition," he and closely-associated Michigan colleague Kyle Sheetz first declared, unequivocally and repetitiously, competition: good!!! Emphasis in the original through repetition. Clever. After reassuring their audience how much they liked competition they let the cat out of the bag in the final paragraph of a long-ish article: "Privatizing the VA by offering unregulated access to private-sector providers is probably not feasible, necessary, or the best way to care for veterans."

That's exactly what the quietly-undermining, unelected Trumpsters pushing for strip-mining veterans' health care didn't want to hear. We know (see below) how that came out.

Similar in emphasis is a piece just out (January 2019) in the equally prestigious Annals of Internal Medicine, by (no pun intended) veteran federal health official Carolyn Clancy and her own VA/AHRQ colleagues. I'm perplexed at the way Clancy herself has hung in there (and yet she persisted) at the federal agencies to which she's contributed greatly over recent decades. I'm perplexed about how, within these agencies,she's been bounced around, most recently landing as the VA's "Deputy Under Secretary for Discovery, Education and Affiliate Networks." (That top's spinning so fast what I just wrote may already be superannuated news.)

In any case Clancy et al. put their shoulders to Shulkin's wheel extolling the May 2018 federal MISSION legislation streamlining VA and non-VA care, and the ostensible role their new Center for Innovation might play in such an effort. They pointed out all the right innovation-cum-research caveats about the need for adequate data: "paying for value could backfire without accurate measurement of costs and outcomes." In this case they were certainly correct: privatizers in this particular world aren't interested in evidence-based anything. They're profiteers. (See: "Department of Education." See: "Department of the Interior." See: Environmental Protection Agency.)

Shulkin's words saw the light of day about a month after the MISSION legislation, in the final days of June, 2018. But here's why I put Shulkin having "liked competition" in the past tense. By the time his NEJM piece appeared Shulkin, also accused of what I still deem to've been truly flimsy ethics violations, was already gone from his organization. By the end of March the Orange Man had already fired him. As a personal fiasco this was unseemly, since the VA secretary was a rare bird who both consented to be a hold-over from early administrations, yet managed early on to be a current POTUS favorite. Surprising? In this White House?

In none of these events was there ever put forward any really compelling justification either for privatizing VA care or for starting with the assumptions that outside "leaders" and outside doctors could do a better job than--what with all their flaws--VA medical staff. Suzanne Gordon, a distinguished journalist and author, admittedly parti pris as a fellow of the Oakland-based 501(c)3 Veterans Healthcare Policy Institute, has just published an American Prospect piece on "Trump’s under-the-radar push to dismantle veterans' health care." Her central thesis is worth quoting in extenso.

[The Republican] strategy will not only erase what has been the most successful American experiment in government-delivered health care, but will also send veterans out into a private system that is more expensive, less accountable, and unable to meet their particular needs. The key notion underpinning the Mission Act, that the private sector can offer comparable care to the VHA, is deeply flawed. Study after study (after study) has found that the VHA generally outperforms the private sector on key quality metrics, and that private providers are woefully unprepared to treat the often unique and difficult veteran patient population. The most recent evidence came in a Dartmouth College study published in December, which compared performance between VHA and private hospitals in 121 regions across the country. The results: In 14 out of 15 measures, government care fared “significantly better” than private hospitals.

Gordon also has a new book out on this subject, as most supporters of the traditional VA system already know. Worth a look. Meanwhile the Senate and White House and those advising them clearly never really cared about quaint ideas such as "studies," "evidence," or "data." They cherry-pick a few quotes about the brusqueness of some VA care, which often is admittedly more bureaucratic than today's "consumer-facing" and endlessly-polling private-care organizations. You can find those quotes as well as I can--any search engine known to man will do the trick.

Recent events on the larger political canvas make it abundantly clear, in the meantime. It's not about quality. It never was. It's about callously starting with a dismissive attitude toward government workers, then back-solving from there. Having worked for years at the VA, I can vouch for its quality as well as its struggle to assist the really needy patients who depend upon it. In fact, this new study shows quite rigorously that the VA was already dramatically reducing wait-times within multiple VA installations, right down to private-sector levels. So this branch of government has listened and successfully striven to achieve a performance level that's not just high-science but also high-touch, as medicine's "customers" (yechhh) have come to expect.

The present furlough of federal employees proves the point. If you can dismiss someone as human collateral-damage, you don't start first by examining the good things they've done for you. You're an elephant poacher. Take the spoils and leave the carcass to rot.


B. More on the Opiate Eaters Who Eat Very Well.

Speaking of despoliators, Dr. Poses and I both wrote here recently on how, in the world of dangerous narcotics, this single family of mostly physicians, the Sacklers, garnered a much more grand market share than they like to let on. Time to add to that and earlier reporting with a few updates.

When, in a different venue than the VA I was providing front line medical care to privately-insured patients, I noticed an arresting change. I saw more and more folks arrive in my office in shop-till-you-drop mode seeing opiate renewals. Always OxyContin, Percocet or Vicodin. If I didn't provide the "fill" they'd go next door. The demand built and built. The drug makers kept assuring they were safe and effective. At free dinners they paid an army of fellow physicians to regale us with the same message.

Then those patients started to die on me. OD courtesy of "safe" Purdue (and others') product.

Then in the past very few years, and I honestly should've seen it coming but didn't, the crisis spilled over from doctors' exam rooms into the political arena. It's actually something, unlike the VA, that's garnering a certain timid degree of nonpartisan interest in finding practical solutions, call it consensus even, starting with decriminalizing measures. But I find it gorge-raising to see the usual suspects continuously fighting the notion that as a society, we blew it with opiates. We blew it. With their help.

I've spent a fair amount of time looking at similar medico-legal crises, including the far-reaching tobacco and environmental lead poisoning matters, as well as narrower ones such as evolving surgical and pharmacological approaches to certain diseases. In every case our tort system, combined with the deep pockets of those who are (allegedly) truly guilty, conspire to perpetuate Bleak House-style court battles over culpability. Strip miners seem to believe--or want us to swallow whole the absurdist notion--that they leave the world a better place. In the case of Purdue, this false consciousness is undoubtedly propped up by the Sacklers' prowess as culturati: one can hardly turn around, as I recently did at the Met in New York, without finding their name plastered on this gallery or that institution of higher learning. But the motive, be it within the strip miners' organization or that of a cultural organization, comes down to the same thing: "we need the money." Allegedly.

Recent disclosures from "sources," including internal Purdue emails, clarify all this. Fortunately for us it turns out the founder's (Raymond's) son Richard was an early adopter--relatively so--of email. Both were physicians, but Richard was of the first generation to be granted an American MD. Email was barely used at all in 1995 when Microsoft first added a TCP/IP stack to its operating system, with the introduction of Windows 95. Then email really took off, by 2001 having a fair amount of penetration in the business world. So maybe we shouldn't be so surprised that Purdue Pharma was squirreling away some of Richard's pronouncements in an archival time capsule for our delectation nearly a generation later.

According to a new court filing recently revealed in the NY Times, Richard Sackler said some, um, fairly incriminating things to say in these internal emails. Still earning his spurs as head of daddy's (and Uncle Mortimer's) company after a couple of years or so in the saddle, and undoubtedly aware of the dramatic uptick in addiction issues that I saw in my own clinic in those turn-of-the-century years, he allegedly blasted everyone else in sight--except, of course, his own ever-so-cultured family.

"[T]he launch of OxyContin tablets will be followed by a blizzard of prescriptions that will bury the competition. The prescription blizzard will be so deep, dense, and white...." said Sackler fils. Based on no evidence reps were told to claim a “less than one percent" risk of addiction. As for that small subset of patients who did find themselves hopelessly addicted, the claim was to be made that “We have to hammer on abusers in every way possible.... They are the culprits and the problem. They are reckless criminals.”

Now, hot off the press in 2019, the Guardian reports how this overall attitude has been replicated within the lobbyist-influenced government of Messrs. Trump and Azar. Since 2015 (pre-Trump! pre-Azar!) chair of the FDA's own Anesthetic and Analgesic Drug Products Advisory Committee, Kentucky anesthesiology professor Raeford Brown has bravely characterized the rift that now mires down the FDA in tackling this crisis seriously. Admittedly with cover from many in Congress, Brown said this to interviewers.

I think that the FDA has learned nothing. The modus operandi of the agency is that they talk a good game and then nothing happens. Working directly with the agency for the last five years, as I sit and listen to them in meetings, all I can think about is the clock ticking and how many people are dying every moment that they’re not doing anything. The lack of insight that continues to be exhibited by the agency is in many ways a willful blindness that borders on the criminal.

Scott Gottlieb, who's tying your hands? Is it this guy? The FDA seems to be replete with such interlocking-directorate staff, all trying to assure  the "level playing field." And what is that playing field? Who are the players? We can answer this. Talk to the drug reps (I have). Except of course those who wake up and see what they're really doing, burn out and bail out. Talk to the lobbyists and the investors (I have). The watchword is not "safe and effective." It's blame-the-victim and lucrative. Let's get our motives straight here. You can do that just fine without listening to us at Health Care Renewal. Just listen to Richard Sackler in a time capsule from 2001.

Ever wonder why the strip-miners need so much of our patients' loot? Well, take a little trip to Davos, Switzerland, where the rich and rich go to rub shoulders and tell each other how smart they are: YouTube offers a hint here.

B'bye--too much dander, got to go take a bath.

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.