TheEconomistFebruary 8th 2020 211I
f youronly source of information on Do-
nald Trump’s record on health care was
his state-of-the-union address, you would
conclude that the president is hellbent on
three things. The first is protecting patients
with pre-existing medical conditions from
insurers who would like to be rid of them.
The second is making sure that illegal im-
migrants do not have access to subsidised
health care. The third is bringing down the
cost of prescription drugs.
But the president’s own words are not
always the best guide to what the president
does. He came to office promising to repeal
Obamacare but failed to do so, and then lost
control of the House of Representatives,
and with it the opportunity to have another
go. That does not mean his administration
has done nothing, though. Presidents can
have a lot of influence over American
health care through the Department of
Health and Human Services (hhs), an orga-
nisation that is much more interesting
than it sounds.
Observers of American politics oftenforget that the distinction of having the
biggest budget in Washington goes not to
the defence department, but to hhs. In
2019, America spent a mere $685bn on de-
fence compared to the $1.2trn spent at
hhs—most of it on Medicare, the govern-
ment health-insurance programme for the
elderly, and Medicaid, the programme for
the very poor. In addition to covering 109m
Americans through these schemes, hhs
has a sprawling mandate—to regulate the
safety of food and drugs, to monitor epi-
demics, combat opioid addiction, provide
direct health care for Native Americans liv-
ing on reservations and take care of unac-
companied migrant children when they ar-
rive at the border.
The first health secretary Mr Trump ap-
pointed to carry out these weighty tasks,
Tom Price, had to leave after eight months,
when a scandal about his use of private
planes at taxpayer expense earned him the
sack. His successor at the department, Alex
Azar—who had been both an executive at
Eli Lilly, a pharmaceutical giant, and a dep-uty secretary of the department in previous
lives—has kept the job since and avoided
much public notice or outrage. That is the
result both of his better judgment and his
rather ineffectual tenure. The sensible
policies that Mr Azar has pushed—those
aimed at reducing the price of prescription
drugs—have gone nowhere.
Those changes that the department has
successfully pushed through point in a dif-
ferent direction. hhshas set about destabi-
lising the insurance markets set up under
the Affordable Care Act (aca), formally
known as Obamacare, after Republicans
failed to repeal it in Congress. It has also set
about paring back Medicaid, the safety-net
health-insurance programme. And it has
tried to curb the work of abortion clinics.
The first of these tasks illustrates the
strangeness of the Trump administration
as it actually exists. Though unable to re-
peal the law, Congress got rid of the tax
penalty for those who refuse to buy health
insurance. The law used sticks and carrots
to induce people to buy health insurance
and Congress threw the main stick away.
That development led Republican state at-
torneys-general to sue, arguing that the ef-
fective elimination of the individual man-
date made the rest of the law invalid.
At first the Department of Justice de-
clined to defend the main provisions of the
law, leading one of its senior lawyers to re-
sign. Later it hardened its position, and an-
nounced that the department agreed thatDonald Trump’s recordWhat he did, not what he said
WASHINGTON, DC
In the first of a series on what the president has done, we look at how he has
used the agency with the biggest budget in WashingtonUnited States
22 NewHampshire’sturn
23 Testingandcollegeadmissions
24 Governmentarchitecture
25 LA’strains
26 Lexington: Trump unboundAlso in this section