Offline: Looking forward to Donald Trump

Lancet, Volume 388, No. 10061, last 2726, 3 December 2016

Richard Horton

Perhaps we should be more relaxed about Donald Trump as America's next President. First, he will likely serve only one term. It will be over before you can say Hillary Clinton. Second, if Nigel Farage was to become Her Majesty's Ambassador to the United States of America, it would exclude a particularly disagreeable voice from British politics. We might be grateful. Third, Mr Trump is not a Republican. He may find he has two parties opposing him in Congress, instead of one. Gridlock plus plus plus. Fourth, the world is already on a path to solving its most intractable predicaments—for example, climate change. Whatever President Trump thinks, says, or decides will not derail the direction of travel for 194 other nations. Fifth, Mr Trump realises that inciting hatred during an election campaign doesn't translate well into policy. He will not implement even a fraction of what he has so far promised. And sixth, we must thank Mr Trump for galvanising a generation to engage more energetically in their futures. His words may have divided America. But they have also mobilised a resistance of surprising proportions. The next 4 years won't be nearly as bad as you might think.

But this guarded optimism was not the prevailing mood during last week's Global Health Lab, held at the London School of Hygiene & Tropical Medicine. The question concerned the implications of the US election for global health.

Sophie Harman is a political scientist at Queen Mary University of London. She implored her audience to 'ignore the dead cat'. By which she meant, ignore the distractions that Mr Trump will throw at you. His Twitter feed is already redirecting your attention away from what really matters.

Focus.

Domestically, Americans should be worried about the survival of all that is good in the Affordable Care Act.  Women should be anxious about how they might protect their reproductive rights. A renewed permissiveness towards racism will worsen the mental and material health of African-Americans and other minorities. Xenophobia will encourage violence. And Mr Trump's tax and welfare proposals will harm health. The global implications of Trumpism were barely an election issue. His assault on reproductive rights at home will be mirrored abroad. His isolationist foreign policy will diminish the US voice in global health policy making. His protectionism means that he will likely not take on big pharma. His administration's choice for Director-General of WHO will have lasting effects on the agency (his anti-globalism will weaken its role).

And the allegations he has fomented against the Clinton Foundation could damage an institution that has won many victories on behalf of the poorest.

Harman disagreed with The Lancet's assessment of a Trump Presidency. She argued that our suggestion for rational engagement was mistaken. The Trump team is not going to engage on a rational basis, or at least on any rational terms we might propose. Instead, she suggested that those opposed to Mr Trump should join or support organisations representing issues they cared most about. You might amplify your resistance through social media. You must vote. And, above all, you should be kind.

 'Interesting and challenging', was Stefan Elbe's understated view of Mr Trump. Elbe is Director of the Centre for Global Health Policy at the University of Sussex. He praised President Obama for strengthening America's leadership role in global health. A third of the world's development assistance for health comes from the US. And this despite the financial crisis of 2007–08. Obama has left a 'clear, significant, and meaningful legacy'.

Regarding Mr Trump, he predicted 'dark clouds'. America first, economic nationalism, manipulation of the weak, populism, and a coercive approach to power. These are the Trumpian traits we already know about. So the question one must ask is not will Mr Trump be bad for global health, but how bad will he be for global health?

The fact that we have no idea shows how much he has already undermined democracy in America. But Elbe did offer one tactic for negotiating our way through the next 4 years. Mr Trump sees power as a commodity to be used and traded in a hard, quasi-military style. There is another way of viewing power—as a quality distributed through networks. Mr Trump is one small node within this network, a network that contains many nodes channelling and influencing forces that shape our lives and futures. It is therefore simply too soon to say that the liberal—and global health—order has been lost.

   [ - emphasis added and some minor paragraph editions made.  - MV]

How a Southern White Gun-Owning Male Figured He Would End That Clinton Child Sex Trafficking Ring Run Out of a Pizzeria Once And For All, Rescuing All Those Chil'ren

Mike Victor

To all my friends on the right (both of you) who told me that Clinton's 2.5 million popular vote victory was reality slapping us Liberals in the face to remind us how little we know about Real Americans (read:  white, gun-owning, Christian country folks with less than a college education):  allow me to remind you what reality REALLY looks like when the universe is trying to teach us a lesson.  This is no slap in the face but a 2x4 upside the head.

28-year-old Edgar Maddison Welch, of Salisbury, North Carolina, who drove across the country with at least 3 firearms, 2 of which he used inside the premises of Comet Ping Pong, believed by right wing conspiracy theorists to be the front for a child sex trafficking ring run by the Clinton family after a fake news story was misunderstood to be true.  

Our instructive tale could start anywhere, but let's keep it simple and fast forward through slavery, the Fugitive Slave Act, Dred Scott, secession, the Civil War, Reconstruction, the Lost Cause mythology, Jim Crow, Brown v. Board of Education, the lost cause for segregation, Little Rock, Selma, the Voting Rights Act, and the election of our first African American as president.   

Although we kind of need that last part because the election of a black president fueled the seething rage that spilled over against Democrats in general among Southern males in particular, a rage best expressed through (what else?) a surge in gun sales.  

Gun manufacturers were more than happy to play upon Southern white male paranoia that Liberals were going to come for their guns (just as soon as we could find a truck big enough to also hold their bibles (no sense making two trips, especially by a CO2-obsessed administration duped by that Chinese global warming hoax).)  

Reality just gave us all the ingredients for another mass casualty event (this one luckily averted):

- Southern white male gun owner +

- Easy availability of weapons of war on demand without background check, weapons that all other countries reserve for their military +

- Lax gun laws that allow stockpiling of ammunition and transport of weapons in an unsecured private vehicle across state lines +

- Mass media AWOL as an instrument of education or truth-telling since infotainment is so much more profitable +

- A white male racist candidate telling other white males that they are a persecuted minority whose cause he will bring to the Oval Office while locking up his dastardly opponent who is "evil", "such a nasty woman", a "liar", "criminal", and "corrupt" +

- Years of far right partisan news (Fox, hate radio, "Christian family" radio) stoking outrage and paranoia, lowering the bar as to what dastardly plots would be believable about Clinton or any other member of the Massive Left Wing Secular Humanist Conspiracy, intent as it is to bring science into your kid's school and ISIS to a Walmart near you (because, you know, there are few things that secular Western feminists love as much as a far right, misogynistic, militant theocracy) +

- Fake news (AKA maliciously fabricated lies to stoke hatred of a woman who by all rights should be our first female president) +

- Her opponent openly inviting the Russians to hack her emails (which they did, then selectively released to a gullible public) +

- Social media acting as an echo chamber of Really Bad Ideas  +

- Gasoline cheap enough to allow a private citizen who is either unemployed or marginally employed to drive across the country to conduct his own private investigation and deliver his own vigilante justice to a child sex slave ring Clinton was running from a Washington state pizza store.

Luckily, the North Carolina gun owner was a bad shot or lost his nerve while executing his Second Amendment remedy, and his first intended victim fled as soon as he leveled one of the two weapons he brought into the store (a third was in his vehicle).   The police intervened and arrested the would-be mass shooter alive (he is white, after all).  

I know I keep saying this, but you really, really, really cannot make this stuff up.  If you did, no one would believe you.  

The Hollywood Movie Pitch

I actually did imagine what might happen if someone in Hollywood tried to pitch a movie with the above plot.  You're welcome.  

WRITER: Yeah, so this guy makes up this crazy, wild-ass story about a major political candidate, a former Secretary of State, and her husband, a popular former president, accusing them of -

PRODUCER:  Let me guess - peddling their influence and access for money?

WRITER:  No, no, no!  Too boring.  Of running a child sex trafficking ring.

PRODUCER:  [Pausing, not knowing if he is part of some elaborate practical joke.]  A sex trafficking ring?

WRITER:  A CHILD sex trafficking ring.  

PRODUCER:  [Shaking his head.]   This doesn't make any sense at all.  Why would a high profile family, scrutinized by the press, one excoriated by a hostile Republican Congress, investigated by the FBI (and exonerated in all cases) do something so crazy?  These are now very wealthy people.  They're not short of cash, so where is your motivation for them throwing away everything they have on this sort of scheme?  And why in Washington STATE?  Are you sure it should not be Washington, D.C.?  

WRITER:   I don't know, I haven't worked all that out yet, but in my screenplay, the Clintons are going to come across as diabolical, arrogant, aloof, absolutely convinced they can get away with anything.  Why, if she could get away with having 6 classified emails on a private email server with no charges brought against her, she could get away with ANYTHING!  Don't you see?  

PRODUCER:  No, not at all.  This sounds like dog shit.  What other ideas do you have?

WRITER:   Please hear me out.  There is more.  

PRODUCER:  [Looking impatient.]  I was afraid you would say that.

WRITER:   The Clintons figure that they can get away with it by using a legitimate business as a front for their operations.

PRODUCER:  So now it's a mafia movie?  A legitimate, family-owned olive oil business?

WRITER:  Close - a pizzeria!

PRODUCER:  A pizzeria?  

WRITER:  Yeah.  Crazy, isn't it?  

PRODUCER:  There are other words to describe it, but who the hell would believe such an idiotic plotline?  

WRITER:  [clapping his hands with delight]  EXACTLY!   And that brings me to my big plot twist.  

PRODUCER:   To have a plot twist, you first need a plot.  

WRITER:  None of this is really true.  

PRODUCER:  You don't say.

WRITER:   No, I mean in the script.  The child sex trafficking ring fronting as a Washington state pizzeria is all a fake story.   A plant.

PRODUCER:  And an idiotic one at that.   You got nothing here.

WRITER:    But you haven't heard it all.

PRODUCER:  What - some lunatic hears the story, thinks it's true, then tries to kill the Clintons?

WRITER:   Better than that!  He hears the story -

PRODUCER:  Let me guess - he's gotta be a white guy, a Southerner maybe, with a huge gun collection.  A Trump supporter?  Do I have the stereotype complete?  What other clichés will you throw in - a picture of him posing for Facebook with a cocky look on his face, dressed all in black, holding up his assault rifle with a banana clip locked and loaded?

WRITER:  [looking encouraged]  You read the script?  

PRODUCER:  No, I didn't read it and I don't intend to.  It's borrowed from so many movies and caricatures of the South, always created by people who never lived there.  People who live in the liberal bubbles on either coast.  

WRITER:   I can scramble some of the demographics then, make him from Oakland, California, or something.  

PRODUCER:  No, you would have to make him from Mars to believe this horseshit.  It's just not believable.  

WRITER:   Well I'll work on it.  Maybe he's psychotic or something.  

PRODUCER:  So then it's just a movie about some lone psychotic guy.   The story, the guns, the Clintons, none of it matters.  Boring.

WRITER:   [plowing through]   So he's not psychotic.  Maybe just gullible.  Listens to talk radio all the time and watches Fox News.  Everyone in his trailer park is convinced the Hillary Clinton is the anti-Christ.

PRODUCER:  You're just piling it on thicker.   There are a lot of folks who live in trailer parks who DO think Hillary Clinton is the anti-Christ and I got news for you - they buy movie tickets.  But not for this excrement.  [holding his head in his hands]  Just out of morbid curiosity, how does it end?  Put me out of my misery.

WRITER:    Well, our shooter is so mad, he hops in his car and -

PRODUCER:  Drives to New York to confront the Clintons.

WRITER:  No, no, no!  He drives to Washington.

PRODUCER:  D.C.?

WRITER:  No, Washington STATE!  Haven't you been listening?  

PRODUCER:   So you want me to believe that some random guy hears a fake news story that is so absurd that even I don't believe it - and I'm in a business that makes movies about kids who can talk to dead people or kill death eaters with a magic wand - loads up his truck with his arsenal then drives across country not to kill the ringleaders of this dastardly scheme but to have a shootout with some poor pizza delivery guy who probably doesn't even know about the terrified kids locked up in the back of the store?  

WRITER:  [uncertainly now]  Yes...

PRODUCER:   [Sighs deeply.]  When is the last time you talked to your shrink?

WRITER:  Ah, c'mon, this story has everything - guns, politics, the Clinton, fake news, pedophilia.

PRODUCER:   It's terrible.  Only an idiot would believe it.  There's no there there.   We're trying to market our shit to a mass audience.  Including a lot of gun owning white males in the South who won't take kindly to being made to look like gullible idiots who reflexively believe the most patent nonsense about the Clintons.  These folks might not always be the sharpest knives in the drawer, but they are not THAT dumb.  I have a dozen right wing groups who already say this town is too damn liberal and doesn't get Southern gun owners - if I turned this script of yours into a movie, they would form a lynch mob.  An antisemitic lynch mob, I might add.  And this puddle of dog vomit isn't worth dying over.  

WRITER:  [looking dejected]  Maybe you're right.  

PRODUCER:  Of course I am.   [laughing]  Child sex ring run out of a pizzeria… who ever heard of such a thing?  But just out of curiosity, in this script of yours, what enemy of the Clintons fabricated this story?   The Pakistan intelligence service?  The Russians?  Bernie Sanders' people?

WRITER:  [shrugging]  Nah, just some guy in his pajamas.  He did it for shits and giggles.  And to make a little money off of all the clicks he got.  

PRODUCER:   You've got to be kidding me.  All this trouble caused by some random person who didn't even have it in for the Clintons?   None of this is tied together.  It's too random.  How much money did he make from it?

WRITER:  I don't know.  What difference does it make?  A few thousand bucks, if that.  But it will all be chewed up in legal fees after the lawsuits and maybe some criminal charges.  

PRODUCER:  The only crime here is the minutes of my life you stole from me and that I can never have back.  So what else you got?

WRITER:  [with a deep sigh, closes his manuscript and pulls out another]  OK, I'm not as excited about this, but here me out.  We start with a talking blender.

PRODUCER:  Like the kitchen appliance?

WRITER:  Exactly.  

PRODUCER:  [now excited]  Who talks?  

WRITER:  Of course.  But only when the homeowner isn't around.

PRODUCER:  And that's why we never see them talking!

WRITER:  You got it!  So this blender comes to life and leads all the other household appliances - who can all also talk when the homeowner isn't around -

PRODUCER:  [spreading his hands]  Of course!

WRITER:  - to launch a revolt, this campaign to get the manufacturing company not to discontinue his model.  

PRODUCER:  [his eyes narrowing]  I like it.    

WRITER:  [nervously]  Yeah.  I was thinking Robert De Niro as the blender's voice.  

PRODUCER:  [snapping his fingers]  And Danny De Vito as the toaster's!

WRITER:   You're a genius.  

PRODUCER:   No, you are a genius.  You had me scared for a minute, but you still have the touch.  Now THIS audiences can believe.   Polish it up and I'll start making some calls.   

[Writer leaves.  Producer shakes his head one last time and chuckles.]   Fake news pizzeria child sex ring run by the Clintons.    As if.  

Google Document version of this post.  

Congressional Representative Tom Price (R-GA) Proves Having an MD Doesn't Guarantee an Understanding of Healthcare Reform

Congressional Representative Tom Price (R-GA) illustrates that having an M.D. after your name is no guarantee that you can understand or honestly represent the complexities of healthcare reform.

The Affordable Care Act is not perfect.  Parts of it annoy the hell out of me (as a provider).   But there is no question that it has given tens of millions of Americans access to healthcare who didn't have it before and made the policies everyone else has more robust (no lifetime caps, no pre-existing condition exclusions, copayment-free access to a list of essential medications, for starters).  

But Price is simply not being honest (or hasn't done his homework) when he repeats the rightwing talking point that "Many Americans lost ... health coverage."

Many Americans beg to differ.  The rate of uninsured has been roughly halved by the law:

So why the hell are Republicans so intent on aborting it?   And why did Trump just put the GOP's chief abortionist in charge of overseeing it?  

Price is an outlier since most physicians support healthcare reform.   Although they are either some surveys show a physician split along party lines on the Affordable Care Act others show as many as  59% in favor, as a 2015 survey of California physicians across different specialties indicated.

A begged question that the California researchers tried to answer was whether physicians knew what they were criticizing.  The ACA is a large, complex laws with many parts, so should we really assume that busy physicians are much more familiar with it than their patients, or that they see the entire elephant beyond the trunk, tail, leg, or other body part in front of their faces?

Not really.  The more specialized the physician, the less likely she is to be able to answer 8 questions about the ACA such as where it covers undocumented immigrants (it doesn't) where it affects Medicare coverage (it doesn't) and whether it increases Medicare payroll taxes (it does).   Another interesting finding:  the more one knew about the law, the more one was to support it (confirmed by other studies), and the more conservative politically physicians rated themselves, the lower their knowledge of the law they were criticizing:  

Support various inversely with income - those physicians in specialties making the most support the ACA the least.  Orthopedic surgeons ($443,000 per year in 2016) such as Price top the list of specialties ranked by income.  Primary care physicians whose responsibilities are broader and more continuous make far less.  Pediatricians ($204,000) and family medicine doctors ($207,000) earn less than half of the average orthopedic surgeon.  

Income after expenses but before income taxes, 2016 Medscape Physician Compensation Survey.  

Why might this be?  

Political affiliation drives Affordable Care Act support among physicians as much as among everyone else, and a high-earning physician ceteris paribus is more likely to gravitate to the party promising a reduction of income taxes.  They may come for the $100,000 tax bill reduction but stay for the ObamaCare-bashing.  

Also, specialists earning income many multiples of other physicians and 1,000% of the median family income are unlikely to see those deviantly high incomes continue in any sort of rational health care system.  Primary care physicians might earn more, although they would arguably have far less to lose, income-wise, and many aspects of the law, such as the expansion of the insured population base, make providing care to a diverse community less stressful (the uninsured not only cannot pay but often only present when a treatable or preventable condition has worsened to a crisis point, increasing the acuity of care that must be provided).  

Specialists, especially surgeons, only see patients after a "wallet biopsy" has been done by someone else.  Their concern about the uninsured might be lower since they rarely if ever deal face-to-face with the uninsured or marginally insured, whereas any primary care physician with a busy practice is reminded every day of the depth and breadth of the uninsured in America.

Indeed, surveys of physicians do indicate that support for the law is correlated with whether the provider believes the law will help his practice, and primary care physicians are far more likely to believe this.  

Absent from Price's resume is any public health experience.  I don't know if he ever took a course in healthcare economics or studied solutions to healthcare allocation developed overseas or in Canada for their pros and cons.

Yet the man feels confident enough in his abilities to offer his personal overhaul of our healthcare system.

In 250 pages.

The plan, which he introduced as a 2015 bill called the "Empowering Patients First Act of 2015" starts and ends with the idea that funneling as many dollars through the massively profitable giant American for profit health insurance companies is the way to go.  

It's unclear why Dr. Price believes this group needs such a boost.  They have thrived under the Affordable Care Act which the GOP said was socialism, a dastardly government takeover of the health care industry.   Yet last year (2015), UnitedHealth Group reported a profit of $11 billion (on revenues of more than $157 billion) up from $10.3 billion (on revenues of $131 billion) the year before.   And the CEO's of these companies certainly don't feel times are lean enough to cut back on their compensation - UnitedHealth’s CEO Stephen Hemsley made more than $66 million in 2014.  (In case you're wondering, since all UnitedHealth does is collect premiums and pay them out in claims, his salary represented $66 million of unpaid mammograms, cancer chemotherapy, and denied hospital days.)   

Back in March 2009 when President Obama was surely going to destroy the private health insurance industry (according to any Republican that wasn't too busy explaining why healthcare reform was going to ruin the overall economy), had you bet against those GOP Cassandra's, you would be very, very rich today.   You could have bought a basket of health insurance stocks for bargain basement prices.  Had you held them for exactly 7 years (through March 2016), you would have achieved returns that Peter Lynch or George Soros would envy:

Humana:   up 1,010 percent (a ten-bagger);

Cigna:   up 1,113 percent, over 400% the return of the Dow Jones Industrial Average;

Anthem:   up 469 percent;

Aetna:   up 628 percent;

UnitedHealth

 Group:   up 814 percent;

WellCare:   up 1,410 percent.

- source:  healthinsurance.org

Had you taken out a mortgage on your house, backed up the truck and bought $100,000 worth of each of these companies,  you would have over $5.4 million right now, excluding dividends.   

Here's a fun fact about WellCare - every penny they made is thanks to us, the US taxpayer.  Their revenue comes entirely from federal and state government customers (ain't free enterprise grand?).  

Another fun fact about WellCare:  they keep committing fraud, the sort of thing that would put you or me behind bars or certainly bar us from future government contracts.  But they just pay their fines and keep on making money.   Wouldn't you if you could?

Now health insurance is a complex solution to what is at its core a simple problem:  how do we pay for healthcare?  

Most sane societies (meaning every developed country except for the United States for some reason) decided to create an enormous risk pool of all of their citizens, most of whom would not need all that much health care, if any, if a given year.   A few would need a lot.  Since it's impossible to know for sure who will be in which group, everybody puts a small or modest amount of money (what are called premiums) into a big hat, understanding that most of those contributing in any given year will lose their premiums (that's a good thing).   The core idea of insurance that Republicans cannot seem to understand is that it involves an exchange of a low probability but catastrophic loss (getting cancer, struck by a car, having a stroke) for a small, high probability (guaranteed) loss (premiums paid as well as deductibles and copayments and other out of pocket expenses).  By definition, healthcare spending is other people's money since that is how insurance works!  If my house burns down but a thousand homeowners' homes don't, then it's the money of all those homeowners I never met that pays for me to rebuild mine.

I cannot understand how otherwise bright people - people who tell us what business geniuses they are - fail to understand this basic concept.  

Health insurance is a zero sum game, at least in the short term.  That means that every claim paid by an insurer must come out of premiums paid (plus returns on invested premiums collected but not paid out).   All an insurance company does is collects premiums and pays claims.  They don't provide health care, they don't contribute anything directly to your health.  They are a go-between.  In fact, they are a drag on the system, since their overhead reduces the amount available of your premiums paid to be paid for claims one day (imagine the guy in charge of the hat reaching in from time to time to take out a bill or some coins to pay himself for the trouble of collecting the money).

The real art of insurance is setting the premium right.  Too low and claims will swamp premiums collected and the company will either go bankrupt or have to turn to a reinsurer (or both).  Too high and no one will want to participate (or a competitor's premiums will seem more attractive if there is a transparent, competitive market).  

And the premiums, in turn, are driven by fiduciary responsibilities of for profit companies whose primary responsibility is not to you, dear policyholder, but to investors who are expecting to be enriched (and over the last half decade most certainly were).  

So let's say that actuarials hired by the insurance company tell the CEO that absolute lowest price they could charge and still keep the lights on is $10,000 a year for a family of 4.  The CEO might then calculate the mortgage on his fifth house, work out the minimum salary he can live on (the nearest $10 million), multiply by a fudge factor to take into account his buddies in top management, then add a healthy return he would like to be able to report to shareholders, so instead turns around and sets premiums at $12,000.

When policyholders complain, he can just blame ObamaCare.  

For the trouble of handling all your money (invested and generating a stream of income the actuarial works into his calculations, but always conservatively), your typical private company just added 20% overhead.  

Many countries reason that this system is too expensive and take over the business of collecting premiums and paying claims themselves.  In fact, our government already does this through Medicare, Medicaid, and a number of other federally-administered plans, except instead of premiums, the government collects a (much smaller) tax from a much larger risk pool (everyone).  And because their administrative overhead is 1.8%, because they don't have to advertise, and because the person administering the plan earn a few hundred thousand dollars rather than $100 million, right off the bat, hundreds of millions are available for healthcare claims.  

Private health insurance is an experiment that seems to have mostly failed.  It's unclear why we need to subsidize or make work for a group of smart people that no doubt would have no trouble finding real jobs.  

Price's plan would take the elements of the Affordable Care Act that helped the private health insurance industry grow so dramatically and add their own version of Miracle Grow.  They would make sure it's called something completely different to make sure they get the point across about how mad! mad! mad! they are that a black Democratic president did something that Nixon and Clinton failed to do:  systematically overhaul our healthcare system.   How about TrumpTraumaTriage or something?

But it's based on the same model of propping up a private health insurance industry.  Again:  why?  

The United States spends more on healthcare as a percentage of GDP (17.1%) or in per capita spending but we're the only developed country that doesn't cover all of our citizens - even after the massive improvements of Affordable Care Act, 10% of our citizens remain uninsured.  

But American taxpayers wouldn't subsidize this industry directly the way we must subsidize private defense contractors or agribusiness.  No, those subsidies would be sprinkled among Americans who could then use them to buy private policies which, once again, could suck.  Oh, but they would be affordable - low premiums in exchange for a deductible of as high as $20,000.

Everything is up in the air right now, which is no way to run a healthcare system.  Anyone who bought coverage through the exchanges or thanks to Medicaid expansion or because of the law's allowance of continuing on a parental policy through age 26 has no idea if she can get health care next year.  Or ever.   If the pre-existing conditions exclusions return, then anyone who left a group policy for a better policy on the exchange and actually used the insurance to get health care now has a pre-existing condition.  

Price is an extremist who does not represent the views of most physicians.  It's fair to say he doesn't represent the views of most Americans whose health care access he is threatening.  But Price, like so many in his party, never lets facts or lack of personal experience get in the way of personal opinion.  

He claimed back in 2010 when joining the tea people that he was trying to beat back a "vile liberal agenda."  (Vile?  Really?)

He wants to prohibit abortion, making pregnancy termination clandestine and dangerous.  Planned Parenthood rates him as zero.   He has voted to defund Planned Parenthood and helped pass on later debunked claims that the organization was operating a black market in "baby parts" [sic].

He is a homophobe, bemoaning the recent SCOTUS marriage equality ruling as a "a sad day for marriage" and a "further judicial destruction of our entire system of checks and balances."
Trump is clearly removing any hope that some of his apologists had that he really didn't mean all those nasty things he said on the campaign trail and would never carry them out.  

If the people he is picking are any indication, he did and he will.