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Not Fake News! A Trump Administration Rule Models Government Civility

By MICHAEL L. MILLENSON Michael Millenson

A Trump administration regulation issued just hours before the partial federal shutdown offers quiet hope for civility in government.

What happened, on its face, was simple: an update of the rules governing a particular Medicare program. In today’s dyspeptic political climate, however, what didn’t happen along the way was truly remarkable – and may even offer some lessons for surviving the roller-coaster year ahead.

A regulatory process directly connected to Obamacare and billions in federal spending played out with ideological rhetoric completely absent. And while there were fervid objections to the draft rule from those affected, the final version reflected something that used to be commonplace: compromise.

Think of it as Survivor being replaced by Mr. Smith Goes to Washington. Or, perhaps, a small opening in the wall of partisan conflict.

More on that in a moment. First, let’s briefly examine the specifics.

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What Does Congressional Gridlock Mean for the Rest of the Country?

By AMY LONG and JOE MOLLOY Joe Molloy, health policy, Congressional gridlock

Often, a Congressional gridlock is essentially good. This is because the executive arm of government is forced to consider a bipartisan approach to issues if it’s to secure the approval of both Democrats and Republicans in Congress.

The outcome of the midterm elections indicates that the Republicans have managed to retain their control of the Senate, while Democrats have secured control of the House of Representatives.

Health a Central Issue During the Midterms

According to a survey by Health Research Incorporated, the three top issues of concern during the midterm elections were health, followed by Social Security and Medicare, with 59% of the respondents irrespective of age, race or geography citing health as the most significant.

Among Trump’s electoral promises was a complete repeal and replacement of Obamacare under the Affordable Care Act (ACA) with a policy that was apparently less expensive and more effective. On his first day of office, Trump signed an executive order instructing federal agencies “to take all reasonable measures that minimize the economic burden of the law, including actions to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act.”

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Iowa Race Questions Logic of Significance of Health Policy Debate

By AMY LONG and JOE MOLLOY Joy Molloy talking about Health Policy Debate

According to the Democrats, their success across the country in the midterm elections has largely been due to the party running on healthcare. Indeed, surveys such as the one conducted by Health Research Incorporated indicated that health was the number one concern for voters during the midterms. In the three states where Medicaid expansion was on the ballot, voters were in favor of it. We’ve been wondering about that, so we took a look at how Iowa voted.

It’s one thing for voters to support healthcare on its own. It’s another for an issue to outweigh all others. Did healthcare really beat every other concern a voter thinks about when picking a candidate during the midterms?

Congressional and Statewide Races

Democrats took 3 of the Iowa’s 4 seats, unseating 2 Republican incumbents. They had a sizeable majority of the votes cast, so things looked good for the Democrats. If the theory holds up, the focus the Democrats kept on healthcare throughout the race would pay off. And it would seem it worked, right?

There’s a big problem here. If Democrats had made gains in Iowa because of healthcare issues, we should expect them to have a pretty resounding victory in the gubernatorial race and in the statehouse.

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Health in 2 point 00, Episode 23

In this start your weekend off right edition, Jessica DaMassa asks me about Andy Slavitt’s new Town Hall venture fund announced at HLTH, the ATHN buyout, Novartis paying Michael Cohen, Trump’s drug price speech & Lyra Health’s $45m raise….all in 2 minutes–Matthew Holt

THCB Exclusive–Trump appoints Holt to run VA

Today Donald Trump pulled a big surprise. He changed the much criticized appointment for his new VA head from over-effusive physician Rear Adm. Ronny Jackson to well known lefty health blogger Matthew Holt. When asked why he wanted Holt to run the VA Trump said, “Look, I’m pretty smart and I’ve appointed now only the best people like John Bolton and Mike Pompeo to run our foreign policy. If I appoint someone else I like, how can I fire him quickly? That Holt guy seems to hate me, and he’s never stayed in one of my hotels, so he’s perfect for the VA–I hear that the accommodation is a bit rough, not exactly a ten.”

When THCB asked Holt why he agreed to take the job running the VA, he suggested that it had a lot to do with his English roots. “As most of my followers know I grew up in England and like the concept of everyone suffering together in a government funded and provided socialized National Health System. The VA and its fellow traveler the DOD is the only health system like that in America and it’s a brilliant place to start”. When asked about his likely future polices for the VA, Holt suggested that massive expansion was the key initiative. In a written statement, his VA spokesman noted “Given the utter lunacy of the Trump Administration and the crazy warmongers now running the show, the chances of total war versus North Korea and Iran are very high. So essentially everyone in the country will soon be called up to the military, which means that soon eventually everyone will be a Veteran. And if Trump loses in 2020, by 2021 we’ll be at war with the Russians so either way my theory pays off.”

Holt was on the Charlie Rose show last week when he told Rose about his philosophy for the future. “When everyone in the country is part of the VA, we can shut down that ineffective and expensive private health system, and instead everyone can get their care the way I think is best. And if they don’t like it Rasu Shrestha will send them their records using the Lighthouse Blue Button Carrier Pigeon system, and we’ll give them a row boat to head to Nepal or somewhere.

When TCHB reached him for comment, Cato health spokesman Michael Cannon said, “if you are going to expand this universal health care stuff, you might as well give it a real go. Lucky for me, I have bone spurs…”

Global Risk Report: Davos, Trump and Climate Change

During the recent World Economic Forum in Davos, Switzerland, President Trump once again noted his objection to the Paris climate accord.  In an interview with Piers Morgan, Trump again called it a “horrible deal” because, as has been widely reported, climate change or global warming is, per the president, a “hoax” perpetrated by the Chinese.  “There is cooling and there’s a heating – I mean look,” Trump explained to Morgan, “it use to not be climate change.  It used to be global warming.  That wasn’t working too well because it was getting too cold all over the place.  The ice caps were going to melt.  They were going to be gone by now, but now they’re setting records, okay?” 

Trump was asked about climate change because the topic was on the Forum’s agenda.  Not surprisingly, in the days leading up to the confab, climate scientists once again found the proceeding calendar year one of the warmest on record.  NASA ranked 2017 the second warmest since 1880 (or since reliable record keeping began), or after 2016.  NOAA, using a slightly different methodology, ranked it the third warmest after 2016 and 2015 respectively.  Not only were the last three years the warmest on record, the five warmest years on record have occurred since 2010, 17 of the 18 warmest since 2001 and last year marked the 21st consecutive year the contiguous United States had above average temperatures.  Record 2017 temperatures were somewhat unanticipated however because of the lack of an El Niño (or Pacific trade wind), effect that is associated with increased global temperatures.  Because air temperatures are largely determined by ocean temperatures, also not surprisingly the five warmest ocean temperature years recorder have been 2017, 2015, 2016, 2014 and 2013 respectively.  Ocean temperatures in 2017 were exceptionally warm.  Measured as heat energy in Joules, 2017 ocean temperatures exceeded 2015 by 1.51 x 10^22 Joules, or the amount of electrical energy China produces annually.

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The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President

The resurgent debate about President Trump’s mental health prompts me to update a piece I wrote for THCB last June. That piece drew lively comments and debate.

It’s also the one-year mark of the Trump presidency.

As The New York Times editorial page recently asked, bluntly, on Jan. 11: “Is Mr. Trump Nuts?”

Since last summer, that question has gained more traction and spurred more earnest debate. The results from Trump’s medical and “cognitive” exam on Jan 12 are unlikely to quell concern.   (More about those results below.)

Nearly every major newspaper and magazine has run stories. Print media columnists and TV commentators dwell on it constantly.   It’s catnip for late night comedians. It’s been a trending topic on social media for months.   And, of course, it’s a topic of discussion and banter almost everywhere you go.

Lawmakers have finally joined in, too, after reluctance for the better part of 2017. Some even render an opinion publicly.

Articles have begun to pop up in medical journals, too—most recently Dr. Claire Pouncey’s piece in the New England Journal of Medicine (Dec. 27, 2017).

And then there’s the book, which sparked Dr. Pouncey’s piece as well other articles and reviews since it came out last fall.   I’m not talking about Fire and Fury: Inside the Trump White House by Michael Wolff—although that book is certainly relevant in this context.

Rather, I’m talking about The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President, edited by Dr. Bandy X. Lee, a specialist in law and psychiatry at the Yale School of Medicine.

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The Individual Mandate’s Dead. What Happens Next?

The demise of the ACA individual mandate, along with Trump’s and Republicans’ efforts to repeal Obamacare in 2017, will trigger in election year 2018 a new phase of the long-running, bitter battle over the fate of ACA, the insurance marketplaces, and the direction of health reform in general.

Surprisingly, the Democrats appear to have the upper hand for the moment.   Republican efforts to repeal the ACA in 2017 were deeply unpopular—only about 20 percent of the U.S. population supported them. Independents and moderate Republicans, in Congress and among voters, were notably opposed. And in the Senate, moderates killed the various ACA repeal bills (albeit by narrow margins).

The Republican tax bill is also unpopular.

Recent special election results in Virginia and Alabama—put Republicans off-balance and on-notice as well. In particular, the Alabama result bends the vote math in the Senate against any repeat ACA repeal efforts in 2018, and very likely beyond.

But, perhaps most surprising, the resurgence of interest in “coverage for all,” universal coverage, and “health care as a right” that started with Bernie Sander’s campaign in 2016 has continued to gain traction, even among some conservatives.

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I Finally Understand US Health Policy

The following exchange occurred during an interview of President Trump with journalists of the NYT:

HABERMAN: That’s been the thing for four years. When you win an entitlement, you can’t take it back.

TRUMP: But what it does, Maggie, it means it gets tougher and tougher. As they get something, it gets tougher. Because politically, you can’t give it away. So pre-existing conditions are a tough deal. Because you are basically saying from the moment the insurance, you’re 21 years old, you start working and you’re paying $12 a year for insurance, and by the time you’re 70, you get a nice plan. Here’s something where you walk up and say, “I want my insurance.” It’s a very tough deal, but it is something that we’re doing a good job of.

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The Entertainment Presidency: A Primer For Health Care Professionals

Many physicians have expressed dismay at the conduct of US president Donald Trump.  But whether colleagues find his politics objectionable or congenial, his conduct bold or vulgar, and the man himself an imbecile or a genius, it is important for healthcare professionals to understand that the Trump presidency is a predictable consequence of our times.  In particular, it is an entirely natural outgrowth of the forms of media that characterize our age.

The Medium Becomes the Message

In 1964, media theorist Marshall McLuhan famously declared the medium the message.  McLuhan argued that the consciousness of a people is more profoundly shaped by media themselves – for example, Gutenberg’s movable print, radio, or television – than by the content they convey.  To understand the character of a presidency, McLuhan would argue, we need to shift our attention from specific policies to the media by which the president operates.

When candidates Abraham Lincoln and Stephen Douglas engaged in their famous 1858 debates for an Illinois Senate seat, broadcast media had not yet been invented, and the newspaper dominated.  As print media, newspaper articles could examine a candidate’s position on an issue in great depth, and 19th century debate audiences expected candidates to develop real arguments for their policies.  As a result, each of the Lincoln-Douglas debates was formatted to last three hours.

Today’s media prefer sound bites.  In fact, McLuhan argued that the medium of television operates “at the speed of light.”  It permits “no continuity” and “no connection.”  Instead, he said, with television, “It’s all just a surprise.”   In contrast to the time Lincoln took to carefully craft his arguments, a television president might be expected to rely less on argument than on astonishment, not taking the time to trouble himself over non-sequiturs and contradictions.

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