Back in Office, Trump Swipes at Health Establishments

President Trump signs executive orders during his first day after returning to the White House (screenshot from PBS News Hour)

Beyond the bold promises to “end the chronic disease epidemic and keep our children safe, healthy, and disease free,” and to “reinstate any service members who were unjustly expelled from the military for objecting to the Covid vaccine mandate,” President Donald Trump said little about healthcare in his inauguration speech last week.

But during his first week back in the Oval Office, the President issued several executive orders that signal a clear intention to overturn longstanding public health precedents and undo policies established by the Biden administration.

Among them is the high-profile—and highly-controversial–order to withdraw the US from the World Health Organization. The rationale for the withdrawal, according to a White House statement, is “the organization’s mishandling of the COVID-19 pandemic that arose out of Wuhan, China, and other global health crises, its failure to adopt urgently needed reforms, and its inability to demonstrate independence from the inappropriate political influence of WHO member states.”

The administration has also issued 11 other healthcare-related executive orders, including one that rescinds President Biden’s Medicare/Medicaid drug price control models.

While many of these executive orders are more symbolic than substantive, others are likely to be very impactful across the healthcare landscape.

WHexit

Trump’s insistence on pulling the US out of the largest global public health agency is in line with several of the administration’s core themes: America First isolationism; distrust of expert consensus; and a general disregard for precautionary principles if they hinder commerce.

The president’s animosity toward the WHO is fueled in part by a broader grievance that other countries are taking advantage of America’s financial largesse, and that the US underwrites organizations, alliances, and treaties that do not serve US interests.

The executive order states: “WHO continues to demand unfairly onerous payments from the United States, far out of proportion with other countries’ assessed payments.  China, with a population of 1.4 billion, has 300 percent of the population of the United States, yet contributes nearly 90 percent less to the WHO.”  

Trump contends that the US contributes around $500 million annually to WHO, compared to China’s $40 million, despite its far smaller population.

A nation’s total annual contribution to WHO is a combination of fixed and mandatory membership dues, and voluntary contributions typically earmarked for specific programs. For all member countries, annual contributions vary year to year, depending on the emergencies, pandemics, and public health initiatives the organization undertakes.

According to the Kaiser Family Foundation, US contributions over the last decade ranged from a low of $163 million to a high of $816 million last year. Trump’s estimate of $500 million likely reflects an average. The Council on Foreign Relations estimates that  China’s peak contribution, which was in 2019,  was $86 million, plus an additional $10.2 million in voluntary contributions.

Dues and Don’ts

There’s no question that there’s a vast discrepancy between the amounts ponied up by the two countries, even if one accepts that while China’s population is far larger, its overall economy is smaller than the US’s. In 2024, the US financed roughly 18% of the WHO’s total budget.

But Trump’s contempt for WHO—and for China–go beyond spreadsheet concerns. On the campaign trail, he called the organization “a corrupt globalist scam,” viewing it as a tool of the Chinese Communist Party. The vitriolic language dovetails with his threats about tariffs and his apparent willingness to engage in trade war brinkmanship with the world’s second largest economy.

Trump’s suspicions about China are not entirely unfounded. In the earliest days of the epidemic, China’s government refused to acknowledge that a dangerous virus was on the loose. It squelched open discourse, and reprimanded concerned scientists like physician Li Wenliang, who sounded the alarm in December 2019. Dr. Li, who died from the virus months later at the age of 34, was accused by Wuhan police of “rumor-mongering” and “severely disrupting the social order.”

Once hospitals filled beyond capacity and bodies were piling in the streets, China’s government had no choice but to acknowledge the crisis, which prompted an abrupt shift from categorical denial to draconian enforcement of social distancing, stay-at-home lockdown, and masking.

In its formal declaration of the COVID-19 pandemic on January 30, 2020, the WHO tip-toed around China’s response. It chose to overlook the initial denials, and instead praised the country’s fierce efforts to contain the outbreak.

WHO’s director-general Tedros Ghebreyesus said at the time that the declaration “should be seen in the spirit of support and appreciation for China, its people, and the actions China has taken on the frontlines of this outbreak, with transparency, and, it is to be hoped, with success.” He stressed that “this declaration is not a vote of no confidence in China.”

Given that, at the time, nearly all data about this virus, its containment, and its potential treatment were coming from China, and that a global response would require diplomacy and cooperation, the WHO’s tact made some sense.

(Image: Joseph Sohm/Shuttestock)

But tact and diplomacy are not among Donald Trump’s superpowers. Throughout his first term, as the pandemic raged, he continued to refer to SARS-CoV-2 as “Chinese virus.” He consistently downplayed the seriousness of the crisis—remember, more than 1.2 million Americans have died from Covid-19, according to CDC data. He routinely redressed public health officials, making no secret of his contempt for NIH director Anthony Fauci, and he stoked rancor over hydroxychloroquine, masking, social distancing, and school closures.

Though he has loudly accused China and the WHO of mishandling the pandemic, many have accused him of the same.

Righteous or Reckless?

Trump attempted to pull the US out of the WHO back in July 2020. But it takes a full 12 months for a member country to extricate itself. During that span, Trump lost the 2020 election to Joe Biden, who nullified the exit order shortly after taking office. The US maintained WHO membership throughout Biden’s term.

Trump’s new executive order would end US membership on January 22, 2026.

Many public health leaders—here and abroad—view Trump’s WHexit move as reckless. It leaves US-based agencies like the CDC and the National Institutes of Health out of the loop on day-by-day global disease surveillance data, it will hinder the nation’s participation in coordinated international responses to future epidemics, and it diminishes the American presence on the international public health stage.

In an interview with CNN, Lawrence Gostin, a public health law professor at Georgetown University, stated that US non-participation in the WHO “could be sowing the seeds for the next pandemic.”

Laura Yasaitis, an analyst for the Eurasia Group recently noted on GZero Media, that a US exit from WHO might prompt other leaders—especially rightwing leaders in European countries—to follow suit, a domino effect that could potentially capsize an organization that many credit with landmark public health victories like elimination of polio and smallpox.

Toppling Covid Policy

Among his “Initial Rescissions of Harmful Executive Orders and Actions,” Trump also issued orders to reverse these six Biden-era executive orders:

  • Executive Order 13987 of January 20, 2021 (Organizing and Mobilizing the United States Government To Provide a Unified and Effective Response To Combat COVID-19 and To Provide United States Leadership on Global Health and Security).
  • Executive Order 13995 of January 21, 2021 (Ensuring an Equitable Pandemic Response and Recovery).
  • Executive Order 13996 of January 21, 2021 (Establishing the COVID-19 Pandemic Testing Board and Ensuring a Sustainable Public Health Workforce for COVID-19 and Other Biological Threats).
  • Executive Order 13997 of January 21, 2021 (Improving and Expanding Access to Care and Treatments for COVID-19).
  • Executive Order 14099 of May 9, 2023 (Moving Beyond COVID-19 Vaccination Requirements for Federal Workers).
  • Executive Order 13999 of January 21, 2021 (Protecting Worker Health and Safety).

Taken together, these orders would unmake most if not all of the Biden administration’s Covid response policies.

Trump has never overtly identified as “anti-vax,” and development of the Covid-19 vaccines occurred under his Operation Warp Speed. But his order to rescind Covid vaccine requirements, coupled with his choice of Robert F. Kennedy, Jr—a very vocal vaccine critic—to head the Department of Health and Human Services, indicates a high degree of skepticism about vaccines and the public health policies that promote them.

Climate change is another subject about which Trump and his close associates have expressed skepticism. Three of his new executive orders will rescind the following Biden-era climate initiatives:

  • Executive Order 14027 of May 7, 2021 (Establishment of the Climate Change Support Office).
  • Executive Order 13990 of January 20, 2021 (Protecting Public Health and the Environment and Restoring Science to Tackle the Climate Crisis).
  • Executive Order 14008 of January 27, 2021 (Tackling the Climate Crisis at Home and Abroad).

Those moves are not at all surprising. Throughout his first term, Trump expressed doubt about the scientific consensus that human activity—especially fossil fuel combustion—is adversely affecting the climate. In 2017, he pulled the US out of the Paris Climate Agreement, and he has signaled that he intends to end US involvement in any and all international climate commitments during his second term. “Drill, baby, drill,” was a rallying cry during his inauguration speech.

Drug Pricing Drama

More baffling is Trump’s order to rescind Executive Order 14087 of October 14, 2022 (Lowering Prescription Drug Costs for Americans), which directed HHS to develop payment and delivery models that would lower prescription costs and improve access to vital drugs. In the context of Biden’s Inflation Reduction Act, this order gave Medicare greater leverage for negotiating drug prices.

It also capped some generic drug prices at $2 for Medicare beneficiaries, set a $35 monthly cap on insulin, limited annual out-of-pocket costs to a max of $2000, and laid out accelerated pathways for bringing gene therapies to market.

The order to reverse course will halt all HHS programs to test, assess, and improve upon the cost reduction models. Though the very popular $2 insulin and out-of-pocket limits will remain in effect, the move has thrown into question almost everything about how Medicare and Medicaid under Trump 2.0 will handle prescription drug pricing. And that, in turn, has raised questions for the pharmaceutical industry.

On face value, the decision to nix EO 14087 seems out of step with Trump’s promises to tame Big Pharma.

On the campaign trail, he vowed to implement policies ensuring that Americans would never pay more for prescriptions than the lowest prices available in other countries. But he never detailed how that would happen. He also supported permitting Medicare to negotiate prices with pharma companies.

Based on that, one would think he’d leave EO 14087 alone—or at least use it as a basis for further reform around drug pricing. But the president’s priority right now seems to be about eliminating all-things-Biden.

“The previous administration has embedded deeply unpopular, inflationary, illegal and radical practices within every agency and office of the federal government,” Trump states in the order rescinding EO 14087. He contends that this, along with his other orders will “repair our institutions and our economy.”

Radio Silence

During his first week in office Trump also ordered a 60-day freeze on all rule-making (exempting any emergency rulings deemed necessary by the director of the Office of Management and Budget), and a suspension of the implementation of any rules or regulations published in the Federal register and scheduled for implementation but not yet actualized. Regulatory freezes like this are typical of incoming administrations, so there’s nothing inherently unusual about that.

Practically speaking, the regulation freeze will put two pieces of Biden healthcare legislation into suspended animation: an uptate to HIPAA security rules, and new Drug Enforcement Agency regulations concerning tele-prescriptions of controlled substances.

The Department of Health & Human Services also issued a moratorium on all public communications issuing from the 18 agencies under its jurisdiction, “until at least February 1.” This includes health advisories, website updates, research reports, and CDC bulletins. Trump did the same thing at the beginning of his first term in 2017. Though Biden did implement a regulatory freeze at the beginning of his term, he did not halt federal healthcare communication.

Though the current ‘radio silence’ will likely be temporary and short lived, former CDC Director and former New York City Health Commissioner Tom Frieden, posted on social media on January 23rd that: “CDC’s Morbidity and Mortality Weekly Report (MMWR) has provided real-time data and analysis about disease outbreaks and emerging health threats without a break every week since 1960. Until today.”

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