By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Cross posted from the Health Care Renewal website
Health Care Renewal is officially non-partisan. We do not endorse candidates for office, or political parties. That does not prevent us from commenting on policy issues, and on pronouncements and actions by politicians and government officials when they relate to the issues that interest us.
So, we have criticized excessive coziness among politicians and government officials on one hand, and big health care organizations and their leaders on the other. We have noted conflicts of interest affecting politicians, particularly the revolving door, and other shadings towards corporatism. We have noted how health care policy discussions may focus on health care financing, while ignoring some of the bigger issues we discuss (For example, see our discussions of health care reform, and particularly this one of the then new US Affordable Care Act). These include: leadership of health care organizations by generic managers (managerialists) who are unsympathetic or even hostile to the health care mission; deceptive practices involving marketing, the manipulation and suppression of research, stealth health policy advocacy, stealth lobbying, etc; and timidity in regulation and law enforcement, leading to outright impunity of health care leaders.
We have criticized politicians and government leaders of all parties and from all sides of the political spectrum. For example, in retrospect we criticized the (Democratic) Clinton administration’s laissez faire attitude to conflicts of interest at the National Institutes of Health (see summary here and links to older posts). We criticized flagrant examples of the revolving door involving top Bush adminstration officials (e.g., most recently here), and yet more involving Obama administration officials (e.g., most recently here).
Yet we also acknowledge that most policy discussions by political and government figures are at least well-intended and based in some degree on the facts and knowledge of the health care context (even if we think the results might be misguided, wrong-headed, or tangential.) So, while health care is not so far the most important issue in the tumultuous 2016 US presidential race, there has been considerable discussion of it. Most major candidates have staked out health care positions that again appear well-intended and based to some degree on the facts and context (although my point is not to comment on their
But there has been one major exception.
The Leading Candidate with No Health Care Plan
Donald Trump currently seems to be the leading Republican presidential candidate. As reported by the Minnesota Post,
Trump doesn’t have a health care plan. Go to the issues section of his campaign. Really, go there, you won’t believe what you see. A typical campaign website has position papers. Trump has none. The link to ‘Issues’ takes you to a pretty frightening page of short embedded videos of Trump himself summarizing his positions at a level of detail that you should find insulting.
But he doesn’t even have one of those on health care.
In addition to ‘Issues,’ the site’s homepage has a pulldown menu called ‘Positions.’ I don’t get the difference, but who cares? “Positions” are actual written-out position statements, not videos, but only on five issues, none of which are remotely related to health care (nor many other major issues).
So for Trump’s health-care thinking, we have to rely on what he says in debates and speeches and, I suppose, tweets, some of which have been controversial.
The Candidate with No Health Care Policy Advisers
On February 20, 2016, Politico reported that Mr Trump’s campaign also apparently has no health policy advisers. The article noted that Mr Trump had written in one of his books that he would
Lock the best health care policy minds in a room – and don’t let them out until they’ve crafted a plan for providing terrific coverage for everyone.
But he has not said who those advisers might be. Furthermore, the reporter was unable to determine who, if anyone, is currently advising Mr Trump about health care,
Sam Clovis, Trump’s national policy adviser, insists the campaign is talking with lots of health care experts – but declined to name any of those advisers.
‘We have experts around the world who help us on these various topics,’ Clovis said in an interview with POLITICO. ‘We get very frank and honest input if we do not expose these people to the scrutiny of the press. … As we get further along they might want to come out of the shadows.’
POLITICO scoured the landscape of notable policy wonks – from academics to lobbyists to congressional staffers to think tank fellows – but was unable to find anyone, on either side of the political divide, who acknowledged whispering health care policy tips in the billionaire’s ear. Or for that matter, of hearing of anyone who had talked to his campaign.
‘He seems to be a one-man policy shop,’ said Michael Cannon, director of health policy studies at the libertarian Cato Institute, and a leading critic of Obamacare.
So Mr Trump has no clear health care plan, and apparently no health care advisers. Furthermore, reports of what this candidate has said about health care reveals some anomalies, to say the least.
Reducing Pharmaceutical Costs to Zero?
The Washington Post in a “Fact Checker” feature on February 18, 2016, entitled, “Trump’s truly absurd claim he would save $300 billion a year on prescription drugs,” quoted Mr Trump three times on the costs of pharmaceuticals,
‘We are not allowed to negotiate drug prices. Can you believe it? We pay about $300 billion more than we are supposed to, than if we negotiated the price. So there’s $300 billion on day one we solve.’
–Donald Trump, remarks at Plymouth State University, Holderness, N.H., Feb. 7, 2016
‘So I said to myself wow, let me do some numbers. If we competitively bid drugs in the United States, we can save as much as $300 billion a year.’
–Trump, remarks in Manchester, N.H., Feb. 8
‘We’re the largest drug buyer in the world. We don’t negotiate. We don’t negotiate. You pay practically the same for the country as if you go into a drug store and buy the drugs. If we negotiated the price of drugs, Joe, we’d save $300 billion a year.’
–Trump, interview on MSNBC, Feb. 17
The problem here is that the $300 billion figure turns out to be ridiculous. The Post article noted,
To put Trump’s $300-billion-a-year claim in perspective, let’s first note that Sanders cites a 2013 estimate from the Center for Economic and Policy Research that negotiated drug prices would result in savings to Medicare of between $230 billion to $541 billion over 10 years.
So for virtually the same policy, Sanders is claiming savings averaging $38 billion a year — and Trump is promising a figure eight times larger. (Clinton offers no estimated savings.)
What’s going on here? It’s unclear, because as usual the Trump campaign refuses to respond to any queries about Trump’s numbers.
total spending in Medicare Part D (prescription drugs) in 2014 was $78 billion. So Trump, in effect, is claiming to save $300 billion a year on a $78 billion program. That’s like turning water into wine.
It’s possible that Trump is being sloppy and when he discusses Medicare, he really means to say he would force government-led pricing on all prescription drugs. But the numbers don’t add up that way either.
In fact, depending on the source you consult, total annual spending on prescription drugs in the United States is between $298 billion a year to $423 billion. So that would mean Trump is claiming that he can eliminate virtually any cost to prescription drugs. It would suddenly be free!
So Mr Trump’s claims made on at least three occasions about the magnitude of savings that would result from his (unoriginal) proposal to have the government negotiate drug prices were mathematically implausible, if not impossible.
“Word Salad” about the Mandate
Rather right-wing columnist Jennifer Rubin, writing in the Washington Post on February 22, 2016, provided two sets of quotes from interviews with Mr Trump about his position on the “mandate” within the Affordable Care Act (ACA). Note that the mandate imposes a (relatively modest) extra tax on people who do not have health insurance, providing an incentive to have such insurance. For example, on “Meet the Press,”
DONALD TRUMP: Well, on the mandate, if you look at the mandate, we had a situation where we were, Anderson Cooper, who’s terrific, by the way, and did a terrific job, but we were talking over each other. Look, I want, we’re going to repeal and replace Obamacare. Obamacare is a total and complete disaster. It’s going to be gone. We’re going to come up with a great healthcare plan, whether it’s healthcare savings accounts, we have a lot of different things. We’re going to get rid of the lines between states, we’re going to have great competitive bidding. But I say all the time, you can call it anything you want. People are not going to die in the middle of the street. People are not going to die on the sidewalk if I’m president, okay?
CHUCK TODD: Well, let me get something definitive from you on this.
DONALD TRUMP: But Chuck, I say that, excuse me, I say that to packed houses with thousands and thousands of people, Republicans mostly, and I get standing ovations. I’m not going to let that happen. If I’m president, we’re not going to have people dying on the streets. So you can call it whatever you want. I don’t call it a mandate, I just say it’s common sense.
CHUCK TODD: No, I understand that. Well, let me ask you this. Do you think that it should be a law that anybody who can afford health insurance has to have it?
DONALD TRUMP: I think, no, I think it’s going to be up to them, okay? I want it to be up to them. But I’m really talking about people that can’t afford it. We’re not going to let people die in squalor because we are Republicans, okay? That’s part of the problem with the Republicans, where somehow they got fed into this horrible position. We’re going to take care of people. But no, people don’t have to have it. We’re going to have great plans, they’re going to be a lot less expensive than Obamacare. They’re going to be private. There are going to be lots of different options. We’re going to have a lot of different options. Right now you have no options. You know why? Because the insurance company controlled Obama because they gave him a lot of money. That’s why you have lines around the states. And you can’t get competitive bidding.
Her summary was:
He insists whatever inanity he said earlier was a mistake, denies he took or takes a liberal position and declares there will not be people ‘dying in the streets.’ (Does he understand there is a duty now to treat people, but what we are debating is insurance?) Then he ends with assurances he is loved by crowds. Superlatives by the bushel may be funny, but they also substitute for concrete answers.
It may seem like a word salad or stream of consciousness at first glance, but it is a salad he tosses up over and over again, each time avoiding close scrutiny.
An article on February 22, 2016, in the left leaning MotherJones stated that Mr Trump had already contradicted his previous approval of the “mandate,”
Trump has now made clear that he doesn’t like the individual mandate
after all—he just misspoke when he said that to Anderson Cooper a few
So while Mr Trump has drawn attention to his position on the mandate, that position seems hopelessly incoherent, or as Ms Rubin called it, “word salad.”
The Minnesota Post article also noted,
When asked Thursday night under Rubio’s prodding to describe his plan for health care, he said, as he always does, that he wants to repeal the Affordable Care Act and replace it with something ‘much better.’ Then he says (and this is a direct quote from the debate transcript): ‘I want to keep pre-existing conditions. I think we need it. I think it’s a modern age. And I think we have to have it.’
This is gibberish, especially the explanation that ‘I think it’s a modern age,’ which may have some meaning but I can’t imagine what.
In addition, in the most recent debate, Mr Trump did emphasize that he wanted insurance companies to be able to sell policies across state lines, although his wording was not so clear,
That weird and confusing phrasing — about ‘getting rid of the lines around the states,’ which Rubio mocked — as best as anyone can tell means that Trump wants national health insurers to be able to offer standardized plans all over the country, instead of having to meet the particular standards and requirements imposed by individual states. Different states require different things of health insurers, which prevents national firms from offering plans in all states.
As the article noted, this is not a new idea, and how much difference this change would make is not clear. Nonetheless, even after being badgered repeatedly, Mr Trump could not add more substance to his health care plan, nor explain how he might get more substance.
With Rubio pressing in and badgering Trump from the sidelines — the same way Rubio was badgered a few weeks ago by Chris Christie and the way Trump often badgers other candidates — and with CNN’s Dana Bash following up, Trump said his three things: Repeal Obamacare and replace it with something much better, get rid of the lines around the states, and don’t let people die in streets. I always assumed that there was more to his plan, but I never came across the details. And, during the exchange Thursday night, it came out that there is no more. Here’s that chunk of the transcript so you can decide for yourself if I’m missing something. (I’ve done a tiny bit of editing for flow.)[italics added for emphasis- Ed]
BASH: Mr. Trump, Senator Rubio just said that you support the individual mandate. Would you respond?
TRUMP: I just want to say, I agree with that 100 percent, except pre-existing conditions, I would absolutely get rid of Obamacare. We’re going to have something much better, but pre-existing conditions, when I’m referring to that, and I was referring to that very strongly on the show with Anderson Cooper, I want to keep pre-existing conditions. I think we need it. I think it’s a modern age. And I think we have to have it. (APPLAUSE)
BASH: OK, so let’s talk about pre-existing conditions. What the insurance companies say is that the only way that they can cover people [who have pre-existing conditions and would be more expensive to cover] is to have a mandate requiring everybody purchase health insurance. Are they wrong?
TRUMP: I think they’re wrong 100 percent. What we need — look, the insurance companies take care of the politicians. The insurance companies get what they want. We should have gotten rid of the lines around each state so we can have real competition. We thought that was gone, we thought those lines were going to be gone, so something happened at the last moment where Obamacare got approved, and all of that was thrown out the window.
The reason is some of the people in the audience are insurance people and insurance lobbyists and special interests. They got — I’m not going to point to these gentlemen, of course, they’re part of the problem, other than Ben [Carson], in all fairness. And, actually, the governor [John Kasich], too. Let’s just talk about these two, OK? Because I don’t think the governor had too much to do with this.
But, we should have gotten rid of the borders, we should have gotten rid of the lines around the states so there’s great competition. The insurance companies are making a fortune on every single thing they do. I’m self-funding my campaign. I’m the only one in either party self-funding my campaign. I’m going to do what’s right. We have to get rid of the lines around the states so that there’s serious, serious competition. And you’re going to see — excuse me. You’re going to see pre-existing conditions and everything else be part of it, but the price will be down, and the insurance companies can pay. Right now they’re making a fortune. (APPLAUSE)
BASH: But just to be specific here, what you’re saying is getting rid of the barriers between states, that is going to solve the problem…
TRUMP: That’s going to solve the problem. And the insurance companies are going to say that they want to keep it. They want to say — they say whatever they have to say to keep it the way it is. I know the insurance companies, they’re friends of mine. The top guys, they’re friends of mine. I shouldn’t tell you guys, you’ll say it’s terrible, I have a conflict of interest. They’re friends of mine, there’s some right in the audience. One of them was just waving to me, he was laughing and smiling. He’s not laughing so much anymore. Hi.
Look, the insurance companies are making an absolute fortune. Yes, they will keep pre-existing conditions, and that would be a great thing. Get rid of Obamacare, we’ll come up with new plans. But we should keep pre-existing conditions.
RUBIO: Dana, I was mentioned in his response, so if I may about the insurance companies…
BASH: Go ahead.
RUBIO: You may not be aware of this, Donald, because you don’t follow this stuff very closely, but here’s what happened. When they passed Obamacare they put a bailout fund in Obamacare. All these lobbyists you keep talking about, they put a bailout fund in the law that would allow public money to be used, taxpayer money, to bail out companies when they lost money. And we led the effort and wiped out that bailout fund. The insurance companies are not in favor of me, they hate that. They’re suing right now to get that bailout money put back in.
Here’s what you didn’t hear in that answer, and this is important, guys, this is an important thing. What is your plan? I understand the lines around the state, whatever that means. This is not a game where you draw maps…
TRUMP:…And you don’t know what it means?
RUBIO: What is your plan, Mr. Trump? What is your plan on health care?
TRUMP: You don’t know. The biggest problem…
RUBIO: …What’s your plan?
TRUMP: … You know, I watched him melt down two weeks ago with Chris Christie. I got to tell you, the biggest problem he’s got is he really doesn’t know about the lines. The biggest thing we’ve got, and the reason we’ve got no competition, is because we have lines around the state, and you have essentially….
RUBIO: …You already mentioned that [inaudible] plan. I know what that is, but what else is part of your plan?…
TRUMP: …You don’t know much…
RUBIO: …So, you’re only thing is to get rid of the lines around the states. What else is part of your health-care plan?…
TRUMP: …The lines around the states...
RUBIO: …That’s your only plan…
TRUMP … Excuse me. Excuse me.
RUBIO: … His plan. That was the plan?…
TRUMP:…You get rid of the lines, it brings in competition. So, instead of having one insurance company taking care of New York or Texas, you’ll have many. They’ll compete, and it’ll be a beautiful thing.
RUBIO: Alright…So that’s the only part of the plan? Just the lines?
TRUMP: The nice part of the plan — you’ll have many different plans. You’ll have competition, you’ll have so many different plans.
RUBIO: Now he’s repeating himself.
TRUMP: No, no, no. I watched him repeat himself five times four weeks ago…
RUBIO:… I just watched you repeat yourself five times five seconds ago…
TRUMP: I watched him meltdown on the stage like that, I’ve never seen it in anybody…
BASH:…Let’s stay focused on the subject…
TRUMP:…I thought he came out of the swimming pool…
RUBIO:…I see him repeat himself every night, he says five things: Everyone’s dumb, he’s gonna make America great again…We’re going to win, win win. He’s winning in the polls…And the lines around the state. (APPLAUSE)
BASH: Senator Rubio, you will have time to respond if you would just let Mr. Trump respond to what you’ve just posed to him…
RUBIO: … Yeah, he’s going to give us his plan now, right? OK…
BASH [to Trump]:…If you could talk a little bit more about your plan. I know you talked about…Can you be a little specific?…
TRUMP: … We’re going to have many different plans because… competition…
RUBIO: … He’s done it again.
TRUMP: There is going to be competition among all of the states, and the insurance companies. They’re going to have many, many different plans.
BASH: Is there anything else you would like to add to that…
TRUMP: No, there’s nothing to add. What is to add?
After being repeatedly asked about the substance of his health care policy agenda, Mr Trump only seems to have repeated the notion of selling health insurance across state lines to increase competition, interrupted by non sequiturs insulting Senator Rubio and insurance executives. The Minnesota Post writer and I could find absolutely no other content in Mr Trump’s , despite repeated inquiries about the substance of his health care plan.
It does seem reasonable to describe Mr Trump’s health care policy ideas as gibberish.
Health care and public health affect all Americans, and all people around the world. Health care in the US is more expensive and less accessible than it is in many other developed countries. For all the money the country spends, there is no clear evidence that the quality of patient care, or patients’ outcomes are better than, or sometimes even comparable to those of other countries The reforms embodied in the Affordable Care Act (ACA, PPACA, “Obamacare’) have increased the proportion of insured patients, but insurance remains expensive for many, and insurance coverage now often has major gaps that mean a major illness can bankrupt a middle-class patient.
Furthermore, the law has done nothing to reduce concentration of power in health care. It has done nothing to make health care leaders more accountable, especially for their organization’s unethical or even criminal behavior, decrease their ability to line their pockets regardless of such behavior, and thus reduce their impunity. It will not obviously decrease conflicts of interest affecting those who make decisions about patient care or health policy, lock the revolving door between government and the health care industry, end manipulation of clinical research to serve vested interests, or suppression of research whose results offend such interests, etc, etc.
So health care policy is increasingly important, and increasingly demands serious discussion. A US presidential campaign ought to provide some impetus for such discussion, although health care policy is certainly not the only thing that needs to be discussed.
Most presidential candidates have at least attempted a serious discussion of health policy, if not in person, then in position papers or on their web-sites.
However, the currently leading candidate for the Republican nomination does not seem to have serious ideas about health care. Yet he has said “We’re going to come up with a great healthcare plan.” To substantiate such claims, he has repeated a few vague talking points, and when challenged, seems unable to manage any substantive conversation beyond them. Some of his verbal pronouncements have been nothing short of ridiculous.
“in the big lie there is always a certain force of credibility….” said a 20th century world leader who inspired adulation, and led to disaster.
We live in perilous times when a candidate with such reckless approaches to critical problems continues to attract adulation.