Trump's Higher Impunity Revisited

Introduction - the New York Times Notes Trump's History of Impunity

In today's New York Times, and article entitled "New Trump Charges Highlight Long-Running Questions About Obstruction" touched on former President Donald Trump's long history

of gamesmanship on his part with prosecutors, regulators and others who have the ability to impose penalties on his conduct.

in the context of the recent charges of obstruction of justice after the Department of Justice found he had absconded to Mar-a-Lago with multiple confidential government documents, then tried to cover this up.  

The article further stated that "over many decades" Trump

 engaged in gamesmanship with prosecutors, regulators and officials who had authority in aspects of the industries in which he operated. He lived in a New York City where corruption touched aspects of the political and government establishments and the real-estate construction businesses, and he came to believe that everything could be worked out through some kind of deal

However, it provided no detail about how he had maintained his impunity over his long career prior to winning the presidency in 2016.

Yet, by early in that presidency, there was substantial documentation of this impunity.  In fact, in 2018, our post "A Higher Impunity - How Can we Reduce Health Care Leadership's Impunity When the President Claims His Own Impunity? summarized the best documented cases.  So to supplement the NYT article, I have re-upped the relevant content of that post below.

Examples of Donald Trump and Family's Apparent Impunity Before He Became President

As a wealthy businessman, Donald Trump and his family were often linked to apparently illegal activities, but seemed to avoid any intensive investigation, much less negative consequences.

A 2016 Politico article cataloged Trump's ties to organized crime, and found "Some of Trump’s unsavory connections have been followed by investigators and substantiated in court; some haven’t." Also,

Trump’s career has benefited from a decades-long and largely successful effort to limit and deflect law enforcement investigations into his dealings with top mobsters, organized crime associates, labor fixers, corrupt union leaders, con artists and even a one-time drug trafficker whom Trump retained as the head of his personal helicopter service.

We have found numerous examples, which are below listed chronologically according to the time of occurrence of relevant events.

Trump Accused of Lying to Federal Investigators about his Mafia Connections in the 1980s

A WNYC piece from October, 2016, was based on an interview with a federal prosecutor who had investigated organized crime in the 1980s,

Attorney Kenneth McCallion was one of the federal prosecutors involved in that investigation. He says there appeared to be a sweetheart deal between the Teamsters Local 282 and Trump, where Trump would get a promise of cooperation from organized labor—including breaking up any strikes by minority workers—in exchange for no-show jobs, a lucrative concrete contract and a luxury apartment for the union president's girlfriend.

'After we indicted them, the Teamster leaders called a citywide strike, but there were two job sites they exempted from that. One was Trump Tower and the other was Trump Plaza,' McCallion said.

Yet despite this, Trump was never prosecuted.

'Even though Donald Trump lied to law enforcement about his relationship and lying to federal agents is a federal crime, he basically got a pass at that point,' he said.

Trump Accused in Legal Papers of Accepting Kickbacks, but the Charges were not Investigated

The 2016 Politico article also noted:

[An associate of a convicted racketeer] in court papers accused Trump of taking kickbacks from contractors, asserting this could 'be the basis of a criminal proceeding requiring an attorney general’s investigation' into Trump. Trump then quickly settled, paying the woman a half-million dollars.

No further investigation ensued.

After a Judge Found that he Conspired to Violate Fiduciary Duty and Committed Fraud, Trump was able to Settle with Details Sealed

Again in Politico,

In 1991, a federal judge, Charles E. Stewart Jr., ruled that Trump had engaged in a conspiracy to violate a fiduciary duty, or duty of loyalty, to the workers and their union and that the 'breach involved fraud and the Trump defendants knowingly participated in his breach.' The judge did not find Trump’s testimony to be sufficiently credible and set damages at $325,000. The case was later settled by negotiation, and the agreement was sealed.

It is not clear that Trump was personally responsible for paying whatever the settlement entailed.  No criminal charges apparently followed.  

Applying for a Casino License, Trump Failed to Disclose he was Under Grand Jury Investigation, but Later Kept his License

As also reported by Politico, when Trump was trying to obtain a license for a New Jersey gambling casino,

Trump was required to disclose any investigations in which he might have been involved in the past, even if they never resulted in charges. Trump didn’t disclose a federal grand jury inquiry into how he obtained an option to buy the Penn Central railroad yards on the West Side of Manhattan. The failure to disclose either that inquiry or the Cody inquiry probably should have disqualified Trump from receiving a license under the standards set by the gaming authorities.

But it didn't. And despite the fact that

Once Trump was licensed in 1982, critical facts that should have resulted in license denial began emerging in Trump’s own books and in reports by Barrett—an embarrassment for the licensing commission and state investigators, who were supposed to have turned these stones over. Forced after the fact to look into Trump’s connections, the two federal investigations he failed to reveal and other matters, the New Jersey Division of Gaming Enforcement investigators circled the wagons to defend their work. First they dismissed as unreliable what mobsters, corrupt union bosses and Trump’s biggest customer, among others, had said to Barrett, to me and other journalists and filmmakers about their dealings with Trump. The investigators’ reports showed that they then put Trump under oath. Trump denied any misconduct or testified that he could not remember. They took him at his word. That meant his casino license was secure even though others in the gambling industry, including low-level licensees like card dealers, had been thrown out for far less.

Trump's Casino Company Paid Multiple Fines for Violating Regulations, but Trump was not Personally Sanctioned 

An Atlantic article from January, 2017, stated,

Trump has been repeatedly fined for breaking rules related to his operation of casinos. In 1990, with Trump Taj Mahal in trouble, Trump’s father Fred strolled in and bought 700 chips worth a total of $3.5 million. The purchase helped the casino pay debt that was due, but because Fred Trump had no plans to gamble, the New Jersey gaming commission ruled that it was a loan that violated operating rules. Trump paid a $30,000 fine; in the end, the loan didn’t prevent a bankruptcy the following year. As noted above, New Jersey also fined Trump $200,000 for arranging to keep black employees away from mafioso Robert LiButti’s gambling table. In 1991, the Casino Control Commission fined Trump’s company another $450,000 for buying LiButti nine luxury cars. And in 2000, Trump was fined $250,000 for breaking New York state law in lobbying to prevent an Indian casino from opening in the Catskills, for fear it would compete against his Atlantic City casinos.

Also, while Trump was attempting a hostile take-over of a rival casino,

the Federal Trade Commission fined him $750,000 for failing to disclose his purchases of stock in the two companies, which exceeded minimum disclosure levels.

Trump and Family were Accused of Self-Dealing and Accepting Illegal Donations while Operating the Trump Foundation, but were not Individually Penalized

Also reported by the Atlantic,

The [Trump] foundation appears to have broken IRS rules on 'self-dealing” by paying to resolve the legal disputes as well as buying a portrait of Trump and a Tim Tebow helmet that went back to the Trump family. In November, in tax filings posted online, the Trump Foundation said it had violated self-dealing rules in 2015 and in previous, indeterminate, years. On the donation, Trump and Bondi both say there was no quid-pro-quo, but the donation was an illegal one for a charitable nonprofit, and the foundation had to pay a $2,500 fine. Liberal watchdog group Citizens for Responsibility and Ethics in Washington charges other laws may have been broken as well. New York Attorney General Eric Schneiderman has reportedly launched an investigation into the foundation. Schneiderman has also informed the foundation that it is in violation of rules on fundraising and ordered it to quit. Trump has announced plans to shutter his foundation, but reportedly cannot do so while it is under investigation.

Yet so far no person has been charged with any related violations. Note that it appears that Trump may have had leverage on Mr Schneiderman, who has now resigned (see below).  Although there were reports in 2017 that the Foundation was going to shut down, as of March, 2018, according to an article in The Hill, the ranking Democratic member of the House Oversight and Government Reform Committee was still trying to get records related to the self-dealing described above from the leadership of the apparently still existing foundation (look here). 

Trump's Taj Mahal Casino Was Fined for Breaking Rules about Money Laundering, but Trump Paid no Penalties

A May, 2017, CNN story stated,

The Trump Taj Mahal casino broke anti-money laundering rules 106 times in its first year and a half of operation in the early 1990s, according to the IRS in a 1998 settlement agreement.

It's a bit of forgotten history that's buried in federal records held by an investigative unit of the Treasury Department, records that congressional committees investigating Trump's ties to Russia have obtained access to, CNN has learned.

The casino repeatedly failed to properly report gamblers who cashed out $10,000 or more in a single day, the government said.

Trump's casino ended up paying the Treasury Department a $477,000 fine in 1998 without admitting any liability under the Bank Secrecy Act.

There is no record suggesting anyone looked into Trump's involvement with these violations. Note that

The 1998 settlement was publicly reported at the time, and the Associated Press noted it was the largest fine the federal government ever slapped on a casino for violating the Bank Secrecy Act.

However,

But key details of the casino's cash reporting violations are missing from the publicly released documents, including the identities of the gamblers and casino employees involved in the transactions.

Then, in 2015, FINCEN publicly announced:

The Financial Crimes Enforcement Network (FinCEN) today imposed a $10 million civil money penalty against Trump Taj Mahal Casino Resort (Trump Taj Mahal), for willful and repeated violations of the Bank Secrecy Act (BSA). In addition to the civil money penalty, the casino is required to conduct periodic external audits to examine its anti-money laundering (AML) BSA compliance program and provide those audit reports to FinCEN and the casino’s Board of Directors.

Trump Taj Mahal, a casino in Atlantic City, New Jersey, admitted to several willful BSA violations, including violations of AML program requirements, reporting obligations, and recordkeeping requirements. Trump Taj Mahal has a long history of prior, repeated BSA violations cited by examiners dating back to 2003. Additionally, in 1998, FinCEN assessed a $477,700 civil money penalty against Trump Taj Mahal for currency transaction reporting violations.

'Trump Taj Mahal received many warnings about its deficiencies,' said FinCEN Director Jennifer Shasky Calvery. 'Like all casinos in this country, Trump Taj Mahal has a duty to help protect our financial system from being exploited by criminals, terrorists, and other bad actors. Far from meeting these expectations, poor compliance practices, over many years, left the casino and our financial system unacceptably exposed.'

Trump Taj Mahal admitted that it failed to implement and maintain an effective AML program; failed to report suspicious transactions; failed to properly file required currency transaction reports; and failed to keep appropriate records as required by the BSA. Notably, Trump Taj Mahal had ample notice of these deficiencies as many of the violations from 2012 and 2010 were discovered in previous examinations.

Again, there is no record of any negative consequences for Mr Trump

Trump Made False Statements Under Oath, but was not Charged with Perjury

A Mother Jones article published February, 2016, recounted that in connection with a libel suit Mr Trump filed against journalist Timothy O'Brien alleging O'Brien under-reported Mr Trump's wealth,

In 2007—two years before a New Jersey judge tossed out the case—Trump was questioned during a deposition. Over the course of the two-day-long interrogation, Trump was forced repeatedly to acknowledge having made false statements. And at one point, a lawyer for O’Brien and his publisher asked Trump a straightforward question: Have you ever before associated with individuals you knew were associated with organized crime?'

Trump, who was testifying under oath, answered, 'Not that I know of.'

That was a clear and unequivocal response. But it was not true. Two years earlier, O’Brien had interviewed Trump and specifically asked him about Sullivan and Shapiro. O’Brien, now an editor and writer at Bloomberg, has provided Mother Jones with a transcript of the interview, and it conclusively shows that Trump believed that these two men were associated with organized crime....

Trump: They were tough guys. In fact, they say that Dan Sullivan was the guy that killed Jimmy Hoffa. I don’t know if you ever heard that.

O’Brien: I have heard that. And that he was, you know…

Also,

Trump: I just was able to handle them. And I, really, I was able to handle them. I found Sullivan to be the tougher of the two. I started hearing reports about Sullivan, that he killed Jimmy Hoffa….

Also,

O’Brien: What was Shapiro like?

Trump: He was like a third-rate, local, real estate mob guy. Nothing spectacular. And I, you know, I got lucky. I heard a rumor that Sullivan, because Sullivan was a great con man, I heard a rumor that Sullivan killed Jimmy Hoffa. And because I heard that rumor I kept my guard up. You know, I said, 'Hey, I don’t want to be friends with this guy.'

So here was Trump connecting Sullivan to the Hoffa murder and calling Shapiro a 'mob guy.'

The same article also asserted that Trump lied in a deposition about knowing and working with Felix Sater, who who "had once been involved in a Mafia-linked stock swindle," and who "had worked with the Trump Organization."

Ivanka Trump and Donald Trump Jr Escaped Indictment for Fraud

As reported by the New Yorker in October, 2017, despite considerable evidence that the two children of Donald Trump had misled potential buyers of Trump SoHo condominiums, Cyrus Vance, the Manhattan District Attorney overruled his staff by halting an investigation of them in 2010.  Later, the Trumps' attorney, Marc Kasowitz, made a large donation to Mr Vance's campaign.   

Trump University Settled Fraud Allegations, Trump Not Charged

As reported by the New York Times in 2017, "the final settlement of allegations that 'Trump University students had been cheated out of thousands of dollars in tuition through high-pressure sales techniques and false claims about what they would learn" was approved by a judge. Litigation about these allegations had gone on for years, but after his election in November, Mr. Trump reversed course and agreed to pay $25 million to resolve the litigation. He did not admit fault, and he maintained in posts on Twitter after the settlement announcement that he "did not have the time to go through a long but winning trial on Trump U."

The settlement resolved lawsuits brought by the Attorney General of New York, Eric Schneiderman, among others.  However, Mr Trump was never charged with a crime by Mr Schneiderman among others.  There is some reason to think Mr Trump took actions to ensure his impunity.

According to Bloomberg on May 11, 2018,

Back in 2013, Donald Trump was exploring a presidential run. His Trump University was in the crosshairs of New York’s crusading attorney general. Around the same time, Trump and his personal lawyer got an interesting piece of information: Eric Schneiderman, the AG, was accused of sexually abusing two women.

The details of the accusations were not made public at that time, but later,

Trump took aim at Schneiderman in a tweet on Sept. 11, 2013, that also referred to New York politicians who’d resigned over allegations of sexual misconduct, Anthony Weiner and Eliot Spitzer.

'Weiner is gone, Spitzer is gone -- next will be lightweight A.G. Eric Schneiderman. Is he a crook? Wait and see, worse than Spitzer or Weiner,' Trump tweeted.

Mr Schneiderman never brought criminal charges against Mr Trump.  Could it be that he was made aware that Trump had information about Schneiderman's sexual behavior that he could use against him? This month, the allegations of his sexual misconduct were finally made public and he then resigned.  The settlement, again absent any charges against Mr Trump, was approved in March, 2017.

Summary of Trump's Pre-Presidency Impunity

While Trump's firms have had to pay multiple fines for breaking rules and laws, and Trump and the immediate family members who work with him in the Trump Organization were credibly accused of multiple types of wrong-doing, including various apparent crimes, neither Trump nor his family members were ever indicted, or apparently investigated for crimes.

Summary

We concluded our 2018 post by summarizing how Trump's record of impunity made it much more difficult to push to address health care corruption and related issues.  But since 2018, we have become more aware of the multitudinous effects that Trump's corruption has degraded our society and representative democracy.  Lately, some have suggested that Trump would drag us into authoritarianism if not fascism simply to keep his sorry self out of jail.  See, for example,  Netanyahu and Trump: two desperate men exploiting power to save themselves.

 There were examples going back decades showing how Trump eluded accountability and justice by manipulating the system.  They were reported at the times they occurred, recalled by journalists before and soon after Trump's 2016 election victory, and largely ignored.

Maybe if we as a society had been paying better attention, we would all be in a better place today. 

Threats to Democracy Round Up - Selected Topics, Late May, 2023

Influence of Hostile Foreign Powers

We have previously posted lots of words about the anechoic effect: the lack of echoes produced by seemingly important stories about health care dysfunction.  It seemed as if such stories were taboo, presumably because even discussing them was seen as a threat to the rich and powerful who increasingly run health care.  Those involved in the leadership and governance of health care organizations and their cronies also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.   

 But as we discussed here, the major issues we discussed prior to 2015 gave way to a new normal with the advent of Trump as a presidential candidate and the MAGA movement as a major force in US politics.  In that 2020 discussion, we noted how the Trump administration acted to squelch discussion of scientific topics that did not fit in with its ideology, despite constitutional guarantees of speech and press free from government control (look here).

Now it appears that the most striking example of the anechoic effect involves discussion of the underlying causes of the anti-democratic turn in the US that threatens the system that permits public discussion, and the possibility of reforming health care dysfunction among other issues.  We continue to see bits of evidence made public about how democracy is threatened by the influence of hostile foreign powers, especially Russia, on US politics, especially elections.  Yet the evidence produces few echoes.

Here are some of the more striking bits of evidence that appeared in just the last two weeks about Russia's malign influence on US democracy.

Russia's Malign Strategy and Tactics

-The April 2023 Indictment for Russian Election Interference and Threats to U.S. Democracy "The Kremlin’s Strategy: Exploiting far left and far right fringes; Exploiting the racial divide; Going local"
https://www.justsecurity.org/86424/the-april-2023-indictment-for-russian-election-interference-and-threats-to-u-s-democracy/

Racism as a National Security Threat "the one big thru-line from the Cold War to today in terms of the  most exploitable vulnerability Russia can weaponize against us:  America’s racial divisions"
https://open.substack.com/pub/asharangappa/p/class-15-racism-as-a-national-security

Evidence of widespread Russian election meddling in other countries: "Kemal Kilicdaroglu, main challenger of Turkish President Tayyip Erdogan,  said ... his party has concrete evidence of Russia's  responsibility for the release of 'deep fake' online content"
https://www.reuters.com/world/middle-east/erdogan-rival-says-has-evidence-russias-online-campaign-ahead-turkey-vote-2023-05-12/

Linkages of Trump and Supporters to Russia

 US Trumpists are increasingly part of a new global fascist axis: "far-right populism of Hungary’s prime minister is helping to inspire  U.S. Republicans' agenda for 2024, a game plan that targets  immigration, LGBTQ rights and... the war in Ukraine"
https://www.axios.com/2023/05/08/gop-hungary-connection-shaping-2024-campaign

Reminder that Trump "is Putin's puppet": He was "repeatedly asked by CNN host Kaitlan Collins if he backed Ukraine in its 15-month conflict with Vladimir Putin’s forces, and repeatedly dodged the question"
https://www.independent.co.uk/news/world/americas/us-politics/putin-ukraine-war-trump-cnn-b2336935.html

Follow the money: Trump Media got financing from Paxum Bank, which "promoted itself...as a way for video streamers of adult content  to coordinate financial transactions across international borders" and is owned by a sketchy Russian businessman
https://www.washingtonpost.com/technology/2023/05/13/trump-truth-social-loan-questions/

[Another Trump-Russia connection?] FBI agents raid condo unit owned by Russians at Trump Towers in Sunny Isles
https://www.miamiherald.com/news/local/article275358451.html

The FBI raided a condo in Trump Tower III in Sunny Isles Beach, FL because its "owner was being arrested... on  charges of illegally selling airplane parts to Russian airline  companies"  
https://www.yahoo.com/lifestyle/days-mysterious-fbi-raid-russians-225454222.html

Putting another Russian asset in the WH: In call to ReAwaken America rally, Trump said he would give Michael Flynn a WH position.  Flynn "entered, then withdrew, a guilty plea of making false statements to the F.B.I" and hung out with Putin in Russia
https://www.thedailybeast.com/trumps-call-in-to-michael-flynns-far-right-roadshow-is-red-meat-for-christian-nationalists

Reminder: "next to Putin at the head table, in the seat of honor, was an American.  Retired Lt. Gen. Michael Flynn, who would later become Donald Trump's  national security adviser"
https://www.nbcnews.com/news/world/guess-who-came-dinner-flynn-putin-n742696

Trump and Supporters' Techniques to Downplay their Connections to Russia: The Durham Investigation 

It was supposed to show how the investigation of Trump/Russia was a witch hunt.  It didn't

Not with a bang.... Trump fans hyped the Durham investigation. Trump fans will likely keep spinning it, but it "delivered underwhelming results... securing a guilty plea from a little-known FBI employee [and] ...losing ...2 criminal cases"
https://apnews.com/article/durham-trump-russia-probe-7e84f94ca9cf7905cbc5eddc108575b3

"Durham’s...report revealed little substantial new information  about the inquiry...failed to  produce the kinds of blockbuster revelations... that...Trump  and his allies suggested Mr. Durham would uncover"
https://www.nytimes.com/2023/05/15/us/politics/trump-russia-investigation-durham.html

"Durham...scolded the F.B.I. but failed to... uncover a politically motivated 'deep state' conspiracy.... charged no  high-level F.B.I. or intelligence official with a crime and acknowledged...Clinton’s 2016 presidential campaign did  nothing prosecutable"
https://www.nytimes.com/2023/05/17/us/politics/durham-report-trump-russia.html

Despite the failure of the Durham investigation to find any important misconduct much less "deep state" politicization of the Trump-Russia investigation, to Trump fans it  "was Watergate times 10, or 100"
https://www.nytimes.com/2023/05/16/us/politics/durham-report-conservative-reaction.html

Russia, Trump and the 2016 election "Russia tried to swing the 2016 election to Trump; FBI had reason to investigate a tip suggesting Trump campaign involvement; Trump campaign welcomed help from Russia:  ‘Steele dossier’ proved to be a red herring"  
https://www.washingtonpost.com/politics/2023/05/17/truth-about-russia-trump-2016-election/

Russian Propaganda and Disinformation

"hate crimes in America are often influenced by online chatter that's  increasingly linked to Russian sites or pro-Russian narratives on more  obscure parts of the internet. The Kremlin doesn't seem to mind"  
https://www.axios.com/2023/05/09/american-extremists-russian-sites-shootings

Conflicts of Interest, Corruption, Crime

Since 2015, we have asked (here) how the US (and the world) can possibly reduce health care corruption, a major cause of global health care dysfunction, under a thoroughly conflicted and corrupt Trump administration.  Since the end of that administration, Trump has campaigned to be president again.  Meanwhile, the evidence of his and his supporters' conflicts of interest, corruption, and criminality continue to grow.  Recent examples include:

Trump's Conflicts, Crimes, and Corruption

Jury finds Trump liable for sexual abuse, awards accuser $5M [When real, reasonable people get to review Trump's conduct while free of his intimidation and bluster they may tend to do so harshly]
https://www.sfgate.com/news/article/jury-to-start-deliberations-in-suit-accusing-18087335.php

"Trump admitted more directly than before on Wednesday that he knowingly  removed government records from the White House and claimed that he was  allowed to take anything he wanted with him as personal records" Confessing to a crime?  
https://www.nytimes.com/2023/05/11/us/politics/trump-documents-white-house.html

He just can't help himself: in his CNN Town Hall appearance, Trump appeared to defame E Jean Carroll again, just days after she won a lawsuit against him for his previous defamation
https://www.nytimes.com/2023/05/11/nyregion/e-jean-carroll-trump-defamation.html

[Even more accusations of sexual misconduct by Trump, even involving his own White House staff] Top aides reveal Trump’s alleged inappropriate conduct towards female staffers
https://www.independent.co.uk/news/world/americas/us-politics/donald-trump-white-house-aides-abuse-b2337881.html

Attacking the rule of law, eve obstruction of justice? - Trump fan politicians go after prosecutors who are investigating or otherwise legally pursuing Trump, including Manhattan DA Bragg, Special Counsel Smith, Fulton County GA DA Willis
https://www.theguardian.com/us-news/2023/may/17/donald-trump-republican-allies-prosecutors-investigations

There is apparently evidence that Trump knew he was committing a crime by walking off with classified presidential records despite his later claims that doing so was legal
https://www.independent.co.uk/news/world/americas/us-politics/trump-mar-a-lago-classified-documents-evidence-b2342010.html

The Conflicts, Crimes and Corruption of Trumpist and/or Far Right Politicians

[Noticing this glaring conflict of interest] Judge to order Wisconsin Elections Commission to reconsider fake elector complaint without the commissioner who joined the scheme
https://www.jsonline.com/story/news/politics/2023/05/08/wisconsin-elections-commission-must-reconsider-fake-elector-case/70195092007/

Are they all sleazy or criminal? Republican "Rep. Bryan Slaton resigned from the Texas House on Monday after an investigation determined that he had an inappropriate sexual relationship with a 19-year-old woman on his staff"  
https://www.chron.com/politics/article/bryan-slaton-pressure-resign-texas-house-18086307.php

TX rep Slaton "proposed banning children from attending drag shows to supposedly shield them from being groomed... resigned after he was found to have engaged in inappopriate sexual  conduct with a 19-year-old intern" Fake morality of the culture warriors
https://www.theguardian.com/us-news/2023/may/09/republican-drag-shows-danger-for-kids-resigns-misconduct-intern

[Again, are they all crooks?] Rep Santos [(R-NY) is accused of using illicit campaign contributions for personal expenses "indictment accusing him of wire fraud, money laundering,  stealing public funds and lying in federal disclosure forms"
https://www.nytimes.com/live/2023/05/10/nyregion/george-santos-charges-news/santos-had-been-under-investigation-for-his-campaign-finances-and-other-activities

Rep George Santos confesses to theft in Brazil to avoid prosecution
https://www.washingtonpost.com/world/2023/05/11/george-santos-brazil-case-theft/

Follow the money: "conservative operatives using sophisticated robocalls raised  millions of dollars from donors using pro-police and pro-veteran  messages....  nearly all the  money went to pay the firms making the calls and the operatives  themselves"
https://www.nytimes.com/interactive/2023/05/14/us/politics/scam-robocalls-donations-policing-veterans.html

[And now reports of sexual misconduct by Trump's lawyer Giuliani] Rudy Giuliani accused of sexual harassment by ex-employee
https://www.bbc.com/news/world-us-canada-65606131

[Are they all thugs, if not crooks?- Louisiana] GOP Rep Clay Higgins filmed shoving activist who questioned Lauren Boebert’s divorce
https://www.independent.co.uk/news/world/americas/us-politics/clay-higgins-shoved-activist-laren-boebert-b2341682.html

Propaganda, Disinformation, Deception

We used to write about propaganda and disinformation used to promote health care goods and services (stealth marketing campaigns), and advocate for policies favorable to private health care organizations (stealth health policy advocacy and stealth lobbying).  Some stealth marketing, lobbying and policy advocacy campaigns encompass not just propaganda, but disinformation.  For example, consider the health insurance company campaign to derail the Clinton administration's attempt at health reform as described by Wendell Potter in Deadly Spin (look here).  The tactics employed in that campaign included: use of front groups and third parties (useful idiots?); use of spies; distractions to make important issues anechoic; message discipline; and entrapment (double-think).

But back in the day, the notion of propaganda and disinformation as a real threat to health care, much less our democratic process and society as a whole, was pretty radical.  That was then.  By 2019 we were writing about a  a new (ab)normal that includes propaganda and disinformation in the service of hostile authoritarian foreign states meant to disrupt more democratic governments, whatever the cost in human health and lives.

 It is important to better understand the techniques of the propagandists and disinformationists, so:

Propagandists' and Disinformationists' Toolbox

Reflexive control "Using the name scholars have given to this area of research to  frame the debate baits Rufo’s opponents into arguing about what CRT is and isn’t, which... keeps the exact three words he wants (and  their attendant connotations) in circulation"  
https://open.substack.com/pub/asharangappa/p/erasing-memory

"How can we really engage in these conversations, when the tension is  there before you even pick up the book and open the topic?" [It's hard to  have a rational argument when fanatics are screaming at you]
https://www.axios.com/2023/05/04/us-history-test-results-civics-covid

The Flood the Zone with BS Technique:
[The old-time fast talking snake oil salesman in the internet age] Donald Trump steamrolls CNN’s town hall [It's easier to lie than to rebut a lie.  If someone lies very quickly, you can't respond in real time]
https://www.washingtonpost.com/opinions/2023/05/10/cnn-trump-town-hall-lies/

'"You can’t keep saying that all night long'....[so one]  can rebut him, correct him, interrupt him and otherwise battle with him  over every point, but that’s no match for ceaseless mendacity....'We don’t have time to fact-check every lie'"
https://www.washingtonpost.com/opinions/2023/05/10/cnn-trump-town-hall-lies/

It's the old Steve Bannon (and Russian) tactic: flood the zone with BS. "CNN hasn’t figured this thing out, and it’s a good bet its competitors have no better ideas" It's clear society needs a better solution to the flood the zone tactic.
https://www.washingtonpost.com/opinions/2023/05/10/cnn-trump-town-hall-lies/

"fear is weaponized even more than hate by leaders who seek to spark violence. Hate is often part of the equation...but fear is  almost always the key ingredient when people feel they must lash out to  defend themselves.
https://www.nytimes.com/2023/05/06/opinion/fear-speech-social-media.html

Ways to Combat Propaganda and Disinformation

Ending false equivalence in choice of editorial voices: "will the  newspaper raise the bar for those local or syndicated [supposedly conservative] voices — i.e.,  requiring the commentary to actually engage in a truthful semblance of a  given issue?
https://www.sltrib.com/opinion/commentary/2023/05/08/commentary-will-we-see-honest/

How the media can cover Trump better this time "Focus on 'the stakes' of the 2024 election, not 'the odds'; Explain Trump’s probable agenda;  Don’t make getting access to Republican politicians or projecting 'neutrality and 'objectivity' a main goal"
https://www.washingtonpost.com/opinions/2023/05/09/trump-2024-cnn-town-hall-media-coverage/

Christian Nationalism Threatens Health Care Professionals, Medicine, Health Care, and Public Health

Much of the "culture war" is about attacking particular patient groups (eg, transgender patients, women seeking abortions, needing birth control or care for such conditions as ectopic pregnancy and miscarriage) and the health care professionals who care for them, or about attacking public health professionals (eg, those involved in pandemic policy) or creating phony public health problems, eg, pornography.

Furthermore, while these attacks are often framed in a biomedical, health care or public health context, the motivation behind them seems to come from extreme sectarianism, particularly Christian nationalism.

Leaked data on right-wing physicians group shows its support of extreme sectarian religious beliefs, recruiting "doctors and medical school students seen as holding Christian views," returning US to a time when "evangelical Christian beliefs" were favored
https://www.wired.com/story/american-college-pediatricians-google-drive-leak/

The state's near-total abortion ban is forcing providers to leave the state "she had to tell a patient that her  pregnancy had a significant fetal abnormality.... her hands were tied. She  couldn’t offer any more care- they had to go elsewhere"
https://www.huffpost.com/entry/idaho-abortion-ban-crisis_n_6446c837e4b011a819c2f792

[Attempting intimidation for taking care of patients] Texas AG Ken Paxton probing Austin children’s hospital [but] "It’s not clear what law Paxton believes Dell Children’s has broken;  Texas does not currently have age limits on gender-affirming care"
https://www.texastribune.org/2023/05/05/ken-paxton-trans-care-investigation-dell-childrens/

Fearing legal repercussions, doctors in Texas say they are risking grave patient harm to comply with new abortion restrictions [abortion bans'  adverse effects:  Extreme sectarian based medicine hurts patients]  
https://www.newyorker.com/news/dispatch/in-the-post-roe-era-letting-pregnant-patients-get-sicker-by-design

Reminder that movement against abortion imposes extreme sectarian religious beliefs on those of other faiths: "Jewish law dating back to the Torah has established that abortion is not murder."
https://www.charlotteobserver.com/opinion/article275261916.html

Confluence of far-right politics and health care nonsense: After DeSantis' coup, New College will host Dr Scott Atlas as commencement speaker. He was a  member of the Trump administration who promoted herd immunity as solution to COVID
https://www.tampabay.com/news/education/2023/05/09/new-college-picks-trump-covid-adviser-scott-atlas-commencement-speaker/

[How sectarianism and superstition creeps into public health] Ladapo's wife who "studied traditional naturopathy, plant and herbal medicine, and shamanism" convinced Ladapo to go to  counseling that that caused him to believe he was following "God’s plan"  
https://www.orlandosentinel.com/2023/05/13/joseph-ladapo-says-anti-vaccine-crusade-was-gods-plan-it-cost-him-his-peers-trust-2/

[More threats to health care] Abortion Clinics Are Dealing with More Arson, Stalking, and Anthrax Threats Now-  Abortion providers feared they’d see an increase in harassment and threats if Roe v Wade was overturned. They were right.
https://www.vice.com/en/article/v7bday/rise-in-abortion-clinic-harassment-after-roe

[Turning sexual hangups into policy? Theocrats go after porn as a public health threat, and...] There’s ‘nothing more timid’ than a man watching porn, Josh Hawley says "There is no risk involved, no exposure to hardship or danger in the least" Promoting sex and relationships that are risky, difficult, dangerous?
https://www.kansascity.com/news/politics-government/article275458201.html

KS Republican county chair says LGBTQ friendly pastors "signed a contract with Satan," plans to "make it hostile to that group of people...small sliver of society...have them move elsewhere, that does a huge amount to shut this  down,”
https://themercury.com/news/republicans-revel-in-divine-plan-to-turn-kansas-into-conservative-sanctuary/article_4a9bbd54-a6fd-5d05-b06f-41785cf4eff6.html

Apparently afraid of prosecution under anti-abortion laws, doctors told patient threatened with a miscarriage "at high risk of life-threatening complications" they could do nothing.  Violating law requiring hospitals to treat patients in emergencies?
So anti-abortion laws make doctors damned if they do (abort pregnancy for patient facing high risk of severe complications) and damned if they don't (by failing to provide emergent care).
https://www.propublica.org/article/two-hospitals-denied-abortion-miscarrying-patient-breaking-federal-law

[More physicians driven away by bans on caring for patients demonized by sectarian extremists] Austin doctors who treated trans kids leaving Dell Children’s clinic after AG Paxton announces investigation
https://www.chron.com/news/houston-texas/article/talk-investigation-forces-tx-doctors-treat-trans-18098101.php

After quacky COVID herd immunity proponent and former Trump administration staffer Dr Scott Atlas invited to speak at DeSantis transformed New College commencement, students raise money to support alternative event
https://wusfnews.wusf.usf.edu/education/2023-05-10/with-former-trump-appointee-speaking-at-their-graduation-new-college-students-plan-alternative-commencement

Doctors forced out by laws restricting treatment of patients with pregnancy complications pushed by extreme sectarians: "Doctors... fleeing the state due to new abortion restrictions....[fearing] 'Being tried as a felon simply for saving someone’s life'"  
https://www.cnn.com/2023/05/13/us/idaho-abortion-doctors-drain

[Reminder: laws based on extreme sectarian religious views impose them on those of other faiths, and harm doctors and patients] Texas doctors depart as attorney general investigates hospital’s gender-affirming care
https://www.theguardian.com/us-news/2023/may/18/texas-hospital-inquiry-doctor-exodus

Follow the Money: Who Funds Attacks on Democracy

It's not just Russia and hostile foreign powers who threaten democracy behind the scenes.  Domestic greed is still a factor. 

Another example of how big national right-wing dark money came to small town to finance local school board candidates who wanted to ban books. We need to figure out who is paying for this, and what's in it for them  
https://www.bostonglobe.com/2023/05/06/nation/how-school-board-race-blue-state-illinois-became-nationally-funded-cage-match/

"Republicans...play this...game of supporting the  wealthy and big business behind the scenes... but making it appear...that they're on the side of the little person....going after the wokeness is a good way to do it...that's not  a bread and butter issue"
https://www.bbc.com/news/business-65428204

[One big corporation refuses to bow down to DeSantis' anti-woke threats.  Will others realize pumping money into extremists' political coffers is bad for business?] Disney Pulls Plug on $1 Billion Development in Florida
https://www.nytimes.com/2023/05/18/business/disney-ron-desantis-florida.html

 

 

Haunted by the Impunity of Rich Business Leaders - Will One Criminal Conviction make a Difference? The Trump Organization Chief Financial Officer Pleads Guilty

 Impunity: an Introduction

We believe that unaccountable leadership is a major cause of health care dysfunction.  Impunity is an extreme form of unaccountable leadership.

We have noted that despite numerous legal settlements made by health care organizations of allegations like fraud, bribery, and kickbacks, almost never do top leaders who presided over these actions face any negative consequences.  Lack of deterrence caused by such impunity appears to be a major cause of  the epidemic of continuing unethical behavior, crime and corruption on the part of large health care organizations. How executives got to the point of having such impunity has never been clear.

But consider two important cases.  

Columbia/HCA CEO Not Held Responsible for Defrauding the Federal Government in 2003

 In 2010, we described the case of early dominant for-profit hospital system Columbia/HCA, which, after investigations beginning in the late 1990s, settled charges of defrauding the federal government.  The company paid a fine of $1.7 billion, a record amount at that time, but did not admit guilt.  More importantly, the company CEO, Rick Scott, was not charged with anything, suffered no negative consequences even though it was on his watch that the company was involved in apparently fraudulent behavior, and retired with a large golden parachute.  

Mr Scott then went on to be elected Governor of, then Senator from Florida as a Republican.  He is still in the Senate, and has become a big supporter for former President Trump.

In 2010 we wrote:

we have noted a parade of legal settlements involving and guilty pleas and criminal convictions by  health care organizations, (or often just subsidiaries conveniently available to take the rap).  As we have noted, resulting fines may be just be treated as costs of doing business by health care leaders.  Almost never have the people who authorized, directed, or implemented wrong-doing almost never suffer negative consequences.

Instead, they may just continue to haunt health care and society at large

.

and

as I have repeated seemingly infinitum, we will not deter unethical behavior by health care organizations until the people who authorize, direct or implement bad behavior fear some meaningfully negative consequences. Real health care reform needs to make health care leaders accountable, and especially accountable for the bad behavior that helped make them rich.

Purdue Pharma Executives Convicted in 2007

In 2007, we made quite a lot about criminal convictions for Purdue Pharma, and of three of its executives for the "misbranding" of Oxycontin.  (That was just the beginning of the legal problems for Purdue, and other manufacturers and distributors of "legal" narcotics and their contribution to the epidemic of narcotic abuse.)  At the time, we marveled that

At least in the Purdue Pharma/ Oxycontin case top company leaders were prosecuted, plead guilty, and will personally have to pay substantial financial penalties. Maybe this will convince the leaders of health care organizations that deceptive marketing practices may not be in their long term interests.

Of course, at the time we did not realize that Purdue Pharma was a privately held corporation run largely by the family that owned it, the Sacklers.  While the three executives had some responsibility for company operations, they were not as powerful as the top executives of publicly held health care companies, and so their convictions did not really end the impunity even of the top leaders of even one important health care corporation.

Trump Organization CFO to Plead Guilty of 15 Felonies Involving Tax Cheating in New York Court

Today, as the New York Times reported:

 One of Donald J. Trump’s most trusted executives stood before a judge on Thursday and pleaded guilty to 15 felonies, admitting that he conspired with Mr. Trump’s company to carry out a scheme to avoid paying taxes on lavish perks — even while refusing to implicate the former president himself.

As part of the plea deal with the Manhattan district attorney’s office, the executive, Allen H. Weisselberg, is required to testify at the company’s trial if prosecutors choose to call on him, and to admit his role in conspiring with Mr. Trump’s company to carry out the tax scheme. That testimony could tilt the scales against the company, the Trump Organization, as it prepares for an October trial related to the same accusations. 

This demonstrates that in 2022, it is still big news if an apparently top corporate executive is convicted of a crime involving his management of the corporation.  We have progressed so little.

In particular, we certainly have not yet progressed to the point at which the actual top leaders of big corporations are held accountable for their misbehavior.  The Trump Organization is a closely held private corporation.  Its top leader is generally acknowledged as Donald J Trump, and its other top leaders are likely his children.  None of them so far have been charged in this case.

Donald J Trump as leader of the Trump Organization had a very long record of impunity as leader of the Trump Organization (look here).  It is possible that had he been held to account for his earlier actions, we might never have run for President of the United States.  Trump as President was accused of a long list of conflicts of interest and corrupt acts (look here).  He has denounced the 2020 election, which he lost, as "rigged" despite no evidence in support of that.  He currently is under investigation for leading an insurrection to overturn the election and stage an auto-coup.

Conclusion

We are still haunted, now dangerously haunted, for our failures as a society to hold rich, top business leaders accountable for their actions.

When will we ever learn? Will be learn before it is too late?

 

The Plot Thickens - How Corrupt was the Trump Administration Under Which Health Care (and the Rest of the US) Operated from 2017 - 2021?

This week, reports appeared that former US President Donald Trump, the Trump Organization of which he is the principal owner, and other people connected to the Trump Organization are the subjects of a special grand jury investigation going on in New York City.  As the Washington Post reported,

 Manhattan's district attorney has convened the grand jury that is expected to decide whether to indict former president Donald Trump, other executives at his company or the business itself, should prosecutors present the panel with criminal charges, according to two people familiar with the development.

Furthermore,

 The move indicates that District Attorney Cyrus R. Vance Jr.’s investigation of the former president and his business has reached an advanced stage after more than two years. It suggests, too, that Vance thinks he has found evidence of a crime — if not by Trump, by someone potentially close to him or by his company.

Vance’s investigation is expansive, according to people familiar with the probe and public disclosures made during related litigation. His investigators are scrutinizing Trump’s business practices before he was president, including whether the value of specific properties in the Trump Organization’s real estate portfolio were manipulated in a way that defrauded banks and insurance companies, and if any tax benefits were obtained illegally through unscrupulous asset valuation.

The district attorney also is examining the compensation provided to top Trump Organization executives, people familiar with the matter have said.

To my knowledge, even though the grand jury could return no indictments, such an investigation of a former president and his business is unprecedented in modern times.  It suggests the possibility that this particular president was more unethical and corrupt than any other, and that he might turn out to be the only actually criminal president.  Thus it suggests that all our concerns about unethical practices, conflicts of interest, and corruption of the Trump administration, and their effects on corruption in other sectors, particularly health care, were not unfounded.

Thus, I will take this opportunity to review these concerns.

  Background: Health Care Corruption

As we wrote in August, 2017, Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.

the scale of corruption is vast in both rich and poor countries.

 

Also,

Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.

 

The report got little attention.  Health care corruption has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,

However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

Presumably the leaders of other kinds of corrupt organizations can do the same. 

When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects some other places, mainly  presumably benighted less developed countries.  At best, the corruption in developed countries that gets discussed is at low levels.  In the US, frequent examples are the "pill mills"  and various cheating of government and private insurance programs by practitioners and patients.  Lately these have gotten even more attention as they are decried as a cause of the narcotics (opioids) crisis (e.g., look here).  In contrast, the US government has been less inclined to address the activities of the leaders of the pharmaceutical companies who have pushed legal narcotics (e.g., see this post). 

However, Health Care Renewal has stressed "grand corruption," or the corruption of health care leaders.  We have noted the continuing impunity of top health care corporate managers.  Health care corporations have allegedly used kickbacks and fraud to enhance their revenue, but at best such corporations have been able to make legal settlements that result in fines that small relative to their  multi-billion revenues without admitting guilt.  Almost never are top corporate managers subject to any negative consequences.

We have been posting about this for years at Health Care Renewal, while seeing little progress on this issue.

 Health Care Corruption in the Context of a Corrupt Government

Instead, things from 2017 - 2021 only seemed to be getting worse, given the increasing evidence that the Trump administration was corrupt at the highest levels.   In January, 2018, we first raised the question about how health care corruption could be pursued under a corrupt regime.  We noted sources that summarized Trump's. the Trump family's, and the Trump administration's corruption..  These included a website, entitled "Tracking Trump's Conflicts of Interest" published by the Sunlight Foundation, and two articles published in the Washington Monthly in January, 2018. "Commander-in-Thief," categorized Mr Trump's conflicted and corrupt behavior.  A Year in Trump Corruption," was a catalog of the most salient cases in these categories in 2017.

In July, 2018, we addressed the Trump regime's corruption again  By then, more summaries of Trump et al corruption had appeared.   In April, 2018, New York Magazine published "501 Days in Swampland," a time-line of  starting just after the 2016 presidential election. In June, 2018, ProPublica reviewed questionable spending amounting to $16.1 million since the beginning of Trump's candidacy for president at Trump properties by the US government, and by Trump's campaign, and by state and local governments. Meanwhile, Public Citizen released a report on money spent at Trump's hospitality properties.

In October, 2018, we summarized the content of the voluminous Tracking Corruption and Conflicts of Interest in the Trump Administration summary appearing in the Global Anti-Corruption Blog. The blog organized corrupt activities within the Trump administration into the following categories:

1. U.S. Government Payments to the Trump Organization

2. Use of the Power of the Presidency to Promote Trump Brands

3. U.S. Government Regulatory and Policy Decisions that Benefit Business Interests of the Trump Family and Senior Advisors

4. Private and Foreign Interests Seeking to Influence the Trump Administration Through Dealings with Trump Businesses

Not only was the report voluminous, the October, 2018, version of the report requiring 26 pages to print, it suggested that many examples of corruption by Trump et al were not one-offs, but were long-term activities.  For example, every time President Trump travels to on of the properties he owns through the Trump Organization, for example, has Mar-a-Lago resort in Florida, the US government is obligated to pay Trump himself through that organization for various expenses, e.g., the Secret Service renting golf carts at Mar-a-Lago.  Each time that happens it seems to violate the "domestic emolument clause" of the US Constitution, which prohibits state or US government payments to a President for anything other than his salary.  Also, foreign governments and corporations seeking to promote specific government policies in their self-interest, similarly seeking favorable regulations, or other seeking to influence government actions in their favor are making periodic payments to the Trump Organization, such as buying accommodations or paying for events at Trump properties.  When foreign governments do so, that appears to violate the "foreign emoluments clause" of  the US Constitution, which prohibits payments by a foreign government to the US President.

Further reports on Trump and associates' conflicts of interest and corruption appeared through 2019, as further documented in this post.

Discussion

We noted in our last summary post on conflicts of interest and corruption in the Trump administration that the topics of corruption, health care corruption, and the likely corruption of the Trump administration remained largely anechoic.   

Despite the extensive and ever-increasing list of apparently corrupt acts by the Trump and cronies, grand corruption at the top of US government, with its potential to corrupt not just health care, but the entire country and society, still seems like a taboo topic.  The US news media continues to tip-toe around the topic of corruption, in health care, of top health care leaders, and in government, including the top of the US executive branch.  As long as such discussion seems taboo, how can we ever address, much less reduce the scourge of corruption?  The first step against health care corruption is to be able to say or write the words, health care corruption.

Once Trump left office, there has not been much more discussion.  There have been brief reports in the media that many investigations of Trump and cronies are ongoing.  For example, an article in the
Washington Post in March 2021 noted "the [NY] state attorney general has subpoenaed his lawyers, his bankers, his chief financial officer — even one of his sons.... Former president Donald Trump is also facing criminal investigations in Georgia and the District of Columbia related to his efforts to overturn the 2020 election."  Also, "In Washington, D.C. Attorney General Karl A. Racine (D) has also opened a criminal investigation into Trump’s actions on Jan. 6" and "the Justice Department, in the meantime, is conducting a broad investigation of the Jan. 6 Capitol attack."  Yet, as we documented here, prior to becoming president, Trump and his associates enjoyed practical impunity, escaping convictions and penalties multiple times. There is no certainty he will not maintain his impunity in the future.

Trump is no longer president, but he enjoys continuing support from many in his party, and has suggested he might run again.  How will we ever make a meaningful dent in health care corruption if we cannot end the impunity of our top political leadership? 

Update: State of Play in US Health Care Dysfunction Prior to the Coronavirus Pandemic

 Introduction: the Sorry History of US Health Care Dysfunction

We have been talking about health care dysfunction for a very long time, starting with a publication in 2003.

To better understand health care dysfunction, I interviewed doctors and health professionals, and published the results in Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here).  In that article, I postulated that US physicians were demoralized because their core values were under threat, and identified five concerns:

1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3.  perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5.  attacks on the scientific basis of medicine, including manipulation and suppression of clinical research studies

After that my colleagues and I have tried to raise awareness of these and related issues, now mainly through the Health Care Renewal blog.  We also set up FIRM - the Foundation for Integrity and Responsibility in Medicine,  a US non-profit organization, to try to provide some financial support for the blog.

It has been a slog.  For years  health care dysfunction, at least we we defined and discussed it, was practically a taboo topic.  From 2003 through 2016 we felt there were only a few incremental improvement in some aspects.  However, the advent of Donald Trump and his "base," and the first years of the Trump presidency expanded the scope and increased the intensity of health care dysfunction.  It got bad enough that the phrase "health care dysfunction" actually made it to a presidential debate, albeit a Democratic primary debate, in November, 2019.  On that occasion we summarized what we thought were the ongoing issues. 

Since then, things have only gotten worse. Then in 2020 the coronavirus pandemic spread around the globe.  That only provided more opportunities for the Trump administration to amplify dysfunction.

Now, on the occasion of the Trump administration's apparent defeat in the presidential election (setting aside for the  moment any legal or extra-legal challenges to the results), I will update what the state of play in health care dysfunction was prior the pandemic.  At a later time we will discuss how the pandemic gave Trump et al an opportunity to supercharge health care dysfunction.

The Multiple Dimensions of Health Care Dysfunction Pre-Pandemic

Since 2003 we have broadened our thinking about what constitutes and causes US (and more global) health care dysfunction. Early on we noticed a number of factors that seemed to enable increasing dysfunction, but were not much discussed.  These factors notably distorted how medical and health care decisions were made, leading to overuse of excessively expensive tests and treatments that provided minimal or no benefits to outweigh their harms.  The more we looked, the more complex this web of bad influences seemed.  Furthermore, some aspects of it seemed to grow in scope during the Trump administration.

A brisk summary of these often complex issues follows.

 Threats to the Integrity of the Clinical Evidence Base

The clinical evidence has been increasingly affected by manipulation of research studies.  Such manipulation may benefit research sponsors, now often corporations who seek to sell products like drugs and devices and health care services.  Manipulation may be more likely when research is done by for-profit contract research organizations (CROs). When research manipulation failed to produce results to sponsors' liking, research studies could simply be suppressed or hidden.  The distorted research that was thus selectively produced was further enhanced by biased research dissemination, including ghost-written articles ghost-managed by for-profit medical education and communications companies (MECCs). Furthermore, manipulation and suppression of clinical research may be facilitated by health care professionals and academics conflicted by financial ties to research sponsors.

These issues did not get much attention since November, 2019, during the Trump presidency, pushed aside by the administration's "flooding of the zone" with distractions.

 Deceptive Marketing

The distorted evidence base was an ingredient that proved useful in deceptive marketing of health care products and services. Stealth marketing campaigns became ultimate examples of decpetive marketing.  Deceptive marketing was further enabled by the use of health care professionals paid as marketers by health care corporations, but disguised as unbiased key opinion leaders, another example of the perils of deliberate generation of  conflicts of interest affecting health care professionals and academics.

These issues also did not get much attention since November, 2019.

Distortion of Health Care Regulation and Policy Making

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

More recently,  as we noted here, we became aware of efforts by foreign powers to spread such disinformation for political, not just financial gain, e.g., in April, 2019, we discussed evidence that Russia had orchestrated a systemic disinformation campaign meant to discredit childhood vaccinations, particularly for the measles, which was likely partly responsible for the 2019 measles outbreak

Furthermore, companies selling health care products and services further enhanced their positions through regulatory capture, that is, through their excessive influence on government regulators and law enforcement.  Their efforts to skew policy were additionally enabled by the revolving door, a species of conflict of interest in which people freely transitioned between health care corporate and government leadership positions.

In the Trump era, we saw a remarkable increase in the incoming revolving door, people with significant leadership positions in health care corporations or related groups attaining leadership positions in government agencies whose regulations or policies could affect their former employers (look here).   We found multiple managers from and lobbyists for big health care corporations being put in charge of regulation of and policy affecting - wait for it - big health care corporations, a staggering intensification of the problem of the revolving door.

Since November, 2019, cases of US government officials traversing the revolving door continued (look here).

Bad Leadership and Governance

Health care leadership was often ill-informed.  More and more people leading non-profit, for-profit and government have had no training or experience in actually caring for patients, or in biomedical, clinical or public health research.  Lately, during the Trump administration, we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics look here).  We had not previously expected leaders of government to be personally knowledgeable about health related topics, but traditionally they consulted with experts before making pronouncements.

Health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values. Often business trained leaders put short-term revenue ahead of patients' or the public's health.  In addition, we began to see evidence that leaders of health care corporations were using their power for partisan purposes, perhaps favoring their personal political beliefs over their stated corporate missions, patients' and the public's health, and even  corporate revenues. Then, we started seeing appointed government health care leaders who lacked medical, health care or public health background or expertise but also whose agenda also seemed to be overtly religious or ideological, without even a nod to patients' or the public' health (look here).
 
Leaders of health care organizations increasingly have conflicts of interest.  Moreover, we have found numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions, albeit usually of corporate entities, not individuals.

In the Trump administration, corrupt leadership extends from the corporate world to the highest levels of the US government.  We discussed the voluminous reports of conflicts of interest and corruption affecting top leaders in the executive branch, up to and including the president and his family (look here). 

Since November, 2019, periodic updates about the President Trump and family's extensive conflicts of interest, and particularly how some of his conflicts appear to violate the US Constitution (eg, look  here).  Not unexpectedly, the latest version of Transparency International's Corruption Perception Index showed that the public perceived the US government under Trump has a worsening corruption problem (look here). 

One cannot expect effective enforcement of ethics rules and anti-corruption laws in such an environment.

Abandonment of Health Care as a Calling

A US Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members, leading to the abandonment of traditional prohibitions on the commercial practice of medicine.  Until 1980, the US American Medical Association had  ruled that the practice of medicine should not be "commercialized, nor treated as a commodity in trade."  After then, it ceased trying to maintain this prohibition. Doctors were pushed to be businesspeople, and to give making money the same priority as upholding their oaths. Meanwhile, hospitals and other organizations that provide medical care are increasingly run as for-profit organizations. The physicians and other health care professionals they hire are thus providing care as corporate employees, resulting in the rise of the corporate physician.  These health care professionals may be further torn between their oaths, and the dictates of their corporate managers. 

 These issues also did not get much attention since November, 2019.

Perverse Incentives Put Money Ahead of Patients, Education and Research

We have extensively discussed the perverse incentives that seem to rule the leaders of health care. Financial incentives may be large enough to make leaders of health care organizations rich.  Incentives often prioritize financial results over patient care.  Some seem to originate from the shareholder value dogma promoted in business school, which de facto translates into putting current revenue ahead of all other considerations, including patient care, education and research (look here).

These issues also did not get much attention since November, 2019.

 Cult of Leadership

Health care CEOs tend now to be regarded as  exalted beings, blessed with brilliance, if not true "visionaries," deserving of ever increasing pay whatever their organizations' performance.  This phenomenon has been termed "CEO disease" (see this post).  Afflicted leaders tend to be protected from reality by their sycophantic subordinates, and thus to believe their own propaganda.

 These issues also did not get much attention since November, 2019.

Managerialism

Leadership of health care organizations by managers with no background in actual health care, public health, or biomedical science has been promoted by the doctrine of managerialism which holds that general management training is sufficient for leaders of  all organizations, regardless of their knowledge of the organizations' fundamental mission.

These issues also did not get much attention since November, 2019.

Impunity Enabling Corrupt Leadership

Most cases involving corruption in large health care organizations are resolved by legal settlements.  Such settlements may include fines paid by the corporations, but not by any individuals.  Such fines are usually small compared to the revenue generated by the corrupt behavior, and may be regarded as costs of doing business.  Sometimes the organizations have to sign deferred prosecution or corporate integrity agreements.  The former were originally meant to give young, non-violent first offenders a second chance (look here).  However, in most instances in which corruption became public, are no negative consequences ensue for the leaders of the organizations on whose watch corrupt behavior occurred, or who may have enabled, authorized, or directed the behaviors.

These issues also did not get much attention since November, 2019.

Taboos

Some of the above topics rarely appeaedr in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant. We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who personally profit from the status quo in health care.  Those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.

However,in the Trump administration,  we began to also note examples of government officials attempting to squelch discussion of scientific topics that did not fit in with its ideology, despite constitutional guarantees of speech and press free from government control (look here).

These issues also did not get much attention since November, 2019.

Discussion

In 2017, we said that it was time to consider some of the real causes of health care dysfunction that true health care reform needs to address, no matter how much that distresses those who currently most personally profit from the status quo.

Furthermore, in 2019 we asserted that all the trends we have seen since 2017 are towards tremendous government dysfunction, some of it overtly malignant, and much of it likely enabling even worse health care dysfunction.

Now that there is the prospect of a new US administration, we hope health care and public health professionals, patients, and all citizens will have a much more vigorous response to it.  US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways. As the coronavirus pandemic rages, the need to make our health care and public health less dysfunctional is increasingly apparent.  If not now, when?