January 31, 2025
Dear Interested Readers,
Trump’s Campaign of Strategic Chaos Continues: Implications For Healthcare
Over the last week, President Trump has challenged Democrats to a game of political “Whack-a-Mole” with a flurry of outrageous executive order announcements. Wikipedia gives us a good description of the game for children and a definition of the colloquial use of the term.
The term “whac-a-mole” (or “whack-a-mole”) is often used colloquially to refer to a situation characterized by a series of futile, Sisyphean tasks, where the successful completion of one just yields another popping up elsewhere…
Another analysis of what we are experiencing is the “flood the zone” strategy. This is a tactic that former Trump acolyte and advisor Steve Bannon favors. The current version may be the brainchild of Stephen Miller, deputy chief of staff, with oversight of domestic policy, and homeland security adviser. A New York Times article this week written by Luke Broadwater gives us some insight into the programmed chaos of this last week:
The strategy has existed since at least 2018, when the former Trump administration strategist Stephen K. Bannon boasted of the ability to overwhelm Democrats and any media opposition through a determined effort to “flood the zone” with initiatives.
This time, the flood is bigger, wider and more brutally efficient. As President Trump begins his second term, he has enacted his agenda at breakneck speed as part of an intentional plan to knock his opponents off balance and dilute their response.
Firing inspectors general. Sweeping clemency for Jan. 6 defendants. Investigations of perceived enemies. A federal hiring freeze. Moving to end birthright citizenship. An immigration crackdown. Terminating diversity, equity and inclusion programs. Revoking security clearances.
On Tuesday, just when Democrats thought they might come up for air, news broke that Mr. Trump had ordered a freeze on trillions of dollars in federal grants and loans, prompting a new round of outrage.
I think that Trump’s nominations for cabinet and other positions are also another example of this strategy. If most of his nominations had gone to mainstream candidates like Marco Rubio for Secretary of State, a single aberrant nominee like Robert F. Kennedy, Jr. for Secretary of Health and Human Services might have been more easily rejected. When Kennedy is just one of several nominees who lack the experience or integrity for office then it becomes unlikely that there would be enough political energy to reject all of them and most are likely to be confirmed. I don’t think it is out of the question to realize that nominating Matt Gaetz for Attorney General might have been a strategy that gave many senators a sense that making it clear that he would not be confirmed then opened the door for all the other marginal nominations.
The Trump of 2025 appears to be much more strategic than the Trump of 2017. The pace of the events of his first week in office may look like undisciplined chaos, but I fear that it has been well organized and planned, not by Trump himself, but by a very disciplined core of operatives who do have an agenda and a well-developed strategy to achieve that agenda. If you are a regular reader of these notes, you will remember that before the election I wrote a lot about the healthcare perils of Project 2025 even as Trump claimed that he knew nothing about it. Since the election, it has become increasingly clear that a core strategy of the project is to increase the power of the president, neutralize the influence of Congress, and use the Supreme Court as a preprogrammed ally in the transformation.
Russell Vought is a principal author of Project 2025 and has now been nominated to return to the position of Director of the Office of Management and Budget. The Hill reports that the alarming executive order to suspend many of the payments to publicly funded programs like Head Start and Federal Qualified Heath Centers emerged from OMB and has led Democrats to seek to stall Vought’s confirmation. Donald Trump may have been telling the truth that he was not behind nor was he familiar with Project 2025, but he is in the process of putting into office many of its authors and supporters which include both Vought and Vice President J.D. Vance. This week, Politico published an article written by Megan Messerly entitled “Project 2025 is already massively reshaping America: The OMB memo is the boldest, and clearest example of how the administration is employing Project 2025’s strategies.”She writes:
Monday’s memo from Trump’s Office of Management and Budget ordering a sweeping freeze of federal financial assistance is the boldest, and clearest example of the administration not only leaning on the people who wrote Project 2025 but employing its strategies.
The memo, which throws into jeopardy billions of federal assistance for programs like providing school meals and supporting homeless veterans, hews closely to the strategy Trump’s pick for OMB director Russell Vought sketched out for bringing the federal bureaucracy to heel in Project 2025’s second chapter. That includes ensuring that the executive branch’s spending aligns with the president’s priorities — regardless of what Congress decides. And it tees up a constitutional fight over the separation of powers, with Vought long arguing that a federal law that prohibits the executive branch from withholding dollars appropriated by Congress is unconstitutional.
While Vought has yet to be confirmed by the Senate, multiple people close to the administration told POLITICO that both he and Trump policy chief Stephen Miller have played key roles in the funding freeze.
Once there was a huge pushback, there was some retreat. Was it a test? Was it another example of “Whack-a-Mole”? Ms. Messerly speculates:
It’s not the only example of how Project 2025 promises are coming to fruition. The president has moved to end diversity, equity and inclusion programs, re-up his previous “Schedule F” initiative that allows him to more easily fire career employees and reinstate service members who had been dismissed for failing to receive the Covid-19 vaccine at the height of the pandemic.
I should have “bolded” It’s not the only example of how Project 2025 promises are coming to fruition. The president has moved to end diversity, equity, and inclusion programs… Diversity, Equity, and Inclusion (DEI) efforts were a major target of Project 2025, and moves to end DEI efforts in government and in industry have been objects of executive orders and some of the most shocking pronouncements Trump has made this week. Yesterday morning, I was listening to NPR’s transmissions of the president’s statement about the tragic collision between an Army Blackhawk helicopter and an American Airlines flight that was landing at Washington’s Reagan National Airport. The president started in an appropriate tone but then quickly shifted his comments to blame the efforts of the Obama and Biden administrations to promote DEI initiatives. In an article written shortly after the President’s press conference, New York Times correspondent David Sanger wrote:
President Trump’s remarks, suggesting without evidence that diversity in hiring and other Biden administration policies somehow caused the disaster, reflected his instinct to immediately frame major events through his political or ideological lens…
…Mr. Trump went back and forth between blaming diversity goals that he said were created by President Barack Obama and President Joseph R. Biden Jr., and then saying that an investigation was necessary.
His instant focus on diversity reflected his instinct to immediately frame major events through his political or ideological lens, whether the facts fit or not.
It is something he has done before: After a terrorist attack in New Orleans a month ago, he blamed illegal immigration, even though the attacker was a U.S. citizen born in Texas.
In his testimony before the Senate Finance Committee on Wednesday Robert F. Kennedy Jr. demonstrated in his inability to answer the questions about Medicare and Medicaid from Republican Senator Cassidy, a gastroenterologist, that his objective will be to implement the agenda of the president. Would that be the president’s “concepts of a plan” or the more specific healthcare recommendations contained in Project 2025 where we can also read the plans that are the basis of so many of the executive actions President Trump has taken during his first week in office?
Ironically, some of Kennedy’s ideas do deserve attention. We probably do need to more carefully examine food additives, the reasons underlying many chronic conditions, and the toxins in our environment. The way to proceed is with the scientific method and not the pursuit of Mr. Kennedy’s many biases against our research establishment. Our delivery of care needs to be overhauled, but the place to begin may be to seek ways to enhance the delivery of primary care which is the strategy of the nations that have better outcomes and longer life expectancies than we do. For guidance in our efforts to Make America Healthy Again, I would not look to think tanks like the Heritage Foundation, the creators of Project 2025, but I would look at the recommendation of an organization like the Commonwealth Fund that has carefully studied our failures in relationship to other economies and at the states here with the best outcomes. Those last two articles deserve your attention and the attention of Robert F. Kennedy. I will not spoil your reading experience if I tell you that our problem is not our efforts to support DEI.
Whether it is a “Whack-a-Mole” strategy, “flood the plane” tactic, “alternative facts” or just plain old lies, I fear that misinformation will continue to be a major challenge over the next four years. What I do believe that is not misinformation, is that the outline for healthcare policy that we find in Project 2025 will be the initial healthcare strategy of this administration. Some time ago I asked ChatGPT, which we have learned this week is inferior to Chinese ChatBots, to review the healthcare recommendations of Project 2025. The answer that I got fits well with what we have seen so far. So, I will repeat what ChatGPT said:
Alignment with Project 2025
Trump’s healthcare team aligns with conservative policy goals outlined in Project 2025, a strategic roadmap developed by Republican think tanks. Key recommendations include reducing federal control over healthcare, scaling back ACA provisions, and promoting state-led innovations in public health. Kennedy and Oz’s appointments could further these goals by emphasizing market-driven solutions, deregulation, and alternative health practices.
Overall, while Trump’s healthcare policies aim to reduce costs and expand choice, potential challenges include increased uninsured rates, weakened public health protections, and strained safety-net programs. The coming months will reveal how effectively these priorities can be implemented amidst political and public health pressures.
It is clear that efforts to improve the social determinants of health will probably suffer the same fate as DEI initiatives. The promises of the Triple Aim are slip-slidin’ away. If the president wants to Make America Healthy Again, he is off to a poor start. I feel bad for all of those red state voters who enthusiastically fell for the showmanship of Trump and will soon discover that their access to the healthcare they need has evaporated as the financial mechanisms of Medicaid are changed. Robert F. Kennedy, Jr. is unlikely to be the person who can successfully lead an effort to improve the health of the nation, but he is the perfect tool to implement the regressive formula for healthcare outlined in Project 2025.
I suspect that other Republican senators will not listen to Senator Cassidy, the gastroenterologist, and they will confirm RFK, Jr. as the new Secretary of HHS. Indeed, Cassidy himself is likely to vote to confirm Kennedy because he is facing reelection and is already being challenged because in 2021 he voted to impeach Trump. When the process of Senate confirmation is over, we will likely be subjected to the continuing biases that there are “market solutions” to our healthcare woes. I hope that I am wrong. After the confirmation of Pete Hegseth as Secretary of Defense, despite his obvious flaws, we will soon be hearing Kennedy referred to as “Mr. Secretary.” Heaven help us.
It’s Still Winter, But I Am Feeling Cheery
We continue to have very cold weather although we have had a couple of days when we got above 32. Today’s header is from one of my favorite scenic spots on my walk along the shore of our lake. For most of my walk, there are woods or houses between the road and the lake, but in a few places, there is an unobstructed view of the broad expanse of ice. This scene is exactly 1.25 miles from my door. I have missed this scene until last week when I was able to walk out and back for three miles with my crutches. My accomplishment this week was to go out and back on a two-mile walk while carrying for safety, but not using, my crutches. I am delighted with the progress that I am making.
My biggest reason for feeling cheery is that after two denials I was finally approved for Vyndamax (tefamidis) treatment for my potentially fatal cardiac amyloidosis and peripheral neuropathy. I was startled when I was told that 30 capsules would cost $25,000 retail. When I was approved the good news was that the price was only $21,000 and my copay would be $6000. Unfortunately, my income was too high to qualify for the “charity” discounts.
My wife was a nurse practitioner in cardiology at the VA Hospital in West Roxbury, Massachusetts. When she retired we elected to go with the Blue Cross Federal Retirees Health Insurance program rather than Medicare Part B with a “wrap-around,” or a Medicare Advantage option. As the annual out-of-pocket deductibles and premiums have risen, we have frequently questioned our decision, but have stayed with the program rather than pay penalties and switch to Medicare B.
I was willing to pay the $6000 copay if in fact that would cover all of my out-of-pocket expenses for the year. When I called to confirm whether I would need to pay $6000 or $12,000 since the policy covers both of us I was directed to the CVS Caremark Specialty Pharmacy where I learned that I could get the medicine mailed to me for $65.00 a month! Who knew? That was not the end of the good news because I learned that I could get my prescription for Farxiga (dapagliflozin) filled for 90 days for $40. I had just paid a copay of $74 for a one-month supply at my local pharmacy. On the Farxiga I could save $728 per year. Beyond all the savings, the service over the phone and online from Caremark was spectacular.
I am amazed at my good fortune, but I must wonder why the path to getting what I needed for such a significant medical issue was so difficult and obscure. I shudder to think that I came close to writing a check for $6000 for a month of a medicine which research shows will improve my symptoms and lengthen my life expectancy. I believe that as great as my experience was in the end, I suffered many weeks of uncertainty which seems to be my personal experience with the strategy of “delay, deny, defend.” I don’t know why a medicine that has been in use in Europe for ten years and in America since approval in 2019 still sells for hundreds of thousands of dollars a year for a single patient.
Now that my immediate problem with access to a critical medicine seems solved, I am looking forward to taking my walks and thinking about something other than my medical challenges. I have much for which to be thankful. I wish that I could be sure that the blessings available to me are also available to everyone.
Be well.
Gene
