--:-- Sean Rameswaram: Support for Today Explained comes from Saks Fifth Avenue. Fall is here. Might be time to find some nice new pieces you can wear again and again.
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--:-- Sean Rameswaram: This is very Sean. This is very Sean-coated. Gucci loafers.
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--:-- Sean Rameswaram: Not all journalism is the same. Take The Guardian.
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--:-- Sean Rameswaram: Read, watch and listen to The Guardian for free at theguardian.com.
--:-- Sean Rameswaram: Please raise your right hand and repeat after me.
--:-- Sean Rameswaram: I, Donald John Trump, do solemnly swear.
--:-- Sean Rameswaram: I, Donald John Trump, do solemnly swear.
--:-- Sean Rameswaram: That I will faithfully execute.
--:-- Sean Rameswaram: That I will faithfully execute.
--:-- Sean Rameswaram: The office of President of the United States.
--:-- Sean Rameswaram: The office of President of the United States.
--:-- Sean Rameswaram: And will, to the best of my ability,
--:-- Sean Rameswaram: Preserve, protect, and defend,
--:-- Sean Rameswaram: The Constitution of the United States.
--:-- Sean Rameswaram: The Constitution of the United States.
--:-- Sean Rameswaram: So help me God.
--:-- Sean Rameswaram: So help me God.
--:-- Sean Rameswaram: Congratulations, Mr. President.
--:-- Sean Rameswaram: It's Today Explained. I'm Sean Ramas-Furham.
--:-- Sean Rameswaram: Four years ago, Donald Trump from reality TV won the presidency, and our shared reality hasn't been the same since.
--:-- Sean Rameswaram: The relentless pace of headlines, controversies, and tweets has rendered the country divided at present and unable to fully recollect the past.
--:-- Sean Rameswaram: I've seen the tweet about tapes. Lordy, I hope there are tapes.
--:-- Sean Rameswaram: We've struggled to remember what this president said or did last month, let alone in 2017.
--:-- Sean Rameswaram: For the past few weeks, we've been helping you remember with our series on the Trump years.
--:-- Sean Rameswaram: We've been looking back on Donald Trump's policies, accomplishments, and scandals during his four years as president to figure out what they mean for the future of the American political experiment.
--:-- Sean Rameswaram: On today's show, the health of our nation.
--:-- Sean Rameswaram: Before he was president to this very minute, Donald Trump has been talking about health care.
--:-- Sean Rameswaram: Not necessarily a vision, but undoing the vision of his predecessor.
--:-- Sean Rameswaram: And then, of course, in his fourth year, he was hit with the biggest challenge of his presidency, a global pandemic that continues to set the worst kinds of records in the United States.
--:-- Sean Rameswaram: Today, we're going to look at these two essential health stories with Dylan Scott, who has covered both for Vox.
--:-- Sean Rameswaram: Dylan, let's start with President Trump's obsession with undoing Obamacare, which he seemingly remembered is one of his obsessions lately.
--:-- Dylan Scott: What I would like to do is a much better health care, much better.
--:-- Dylan Scott: It's like TBT with President T. So I'd like to terminate Obamacare, come up with a brand new beautiful health care.
--:-- Sean Rameswaram: He's been saying he has a plan again. Does he have a plan, Dylan?
--:-- Dylan Scott: No, he doesn't have a plan.
--:-- Sean Rameswaram: We're four years into the Trump presidency, and there is still no comprehensive Trump health care plan.
--:-- Dylan Scott: But he still really hates that other one by his predecessor.
--:-- Sean Rameswaram: One of the worst things anybody's ever had to live through.
--:-- Dylan Scott: We got rid of the individual mandate. Yes, he is still promising that he can repeal Obamacare and deliver better, cheaper health care to Americans.
--:-- Sean Rameswaram: But I think Trump's problem on health care is that he's never actually been able to come up with a plan to meet those promises, and neither have congressional Republicans.
--:-- Sean Rameswaram: Let's go all the way back to candidate Trump for a second. What were his health care promises when he was running against Hillary Clinton?
--:-- Dylan Scott: So I think Trump was making three big promises on health care.
--:-- Sean Rameswaram: One of my first acts as president will be to repeal and replace disastrous Obamacare.
--:-- Dylan Scott: He was promising to repeal and replace the Affordable Care Act, as Republicans had been doing for years.
--:-- Sean Rameswaram: He was promising that he would be pro-life, anti-abortion, you know, pursue regulations and appoint judges who would advance that agenda.
--:-- Dylan Scott: I've become pro-life. I was, in a meek fashion, pro-choice, but I've become pro-life.
--:-- Sean Rameswaram: And he was promising that he would bring down drug prices.
--:-- Dylan Scott: So we buy drugs, biggest in the world, and we pay about $300 billion more than we're supposed to if we negotiated the price.
--:-- Sean Rameswaram: So there's $300 billion on day one we saw.
--:-- Dylan Scott: That was one of his big populist talking points, trying to talk to pocketbook issues that voters really care about.
--:-- Sean Rameswaram: Well, let's go through those in reverse order, starting with at least what sounds like maybe the easiest of the three, just reducing drug costs.
--:-- Dylan Scott: How did he do on that?
--:-- Sean Rameswaram: The president's agenda has taken a couple of different tacks.
--:-- Dylan Scott: For one, he certainly has sent out a fair number of threatening tweets.
--:-- Sean Rameswaram: Trump, the president, tweeting again. Now, drug prices will soon be lowered massively.
--:-- Dylan Scott: Big Pharma, drug companies, are advertising against me like crazy because lower prices mean less profit.
--:-- Sean Rameswaram: When you watch a fake ad, just think lower drug prices.
--:-- Dylan Scott: You know, the looming specter of more aggressive federal regulation might encourage pharma to keep drug prices down on their own, but that's not much of a policy agenda, obviously.
--:-- Sean Rameswaram: The most interesting thing that the administration has proposed would be using international drug prices to set the prices that Medicare would pay for medications.
--:-- Dylan Scott: Basically, you would take like Germany and maybe the UK and Canada, other rich developed countries, check the price that they pay for a given medication, and then the Medicare would refuse to pay anything higher than that.
--:-- Sean Rameswaram: And so that's an idea that even like Bernie Sanders has sounded receptive to over the years.
--:-- Dylan Scott: It's certainly an example of Trump promoting and supporting policies that are sort of unorthodox for a Republican.
--:-- Sean Rameswaram: This is much more of a democratic, progressive idea.
--:-- Sean Rameswaram: But they haven't actually finalized the regulation.
--:-- Dylan Scott: The administration first floated this idea very early on in the administration, and they released a draft proposal.
--:-- Sean Rameswaram: But the federal rulemaking process is very complicated.
--:-- Dylan Scott: There's a few different steps that you have to take for regulation to actually be finalized and in effect.
--:-- Sean Rameswaram: And the Trump administration hasn't taken those steps yet.
--:-- Sean Rameswaram: And they actually, I think, being cognizant of that shortcoming, President Trump signed an executive order just a few weeks ago saying that this was a policy that he supported.
--:-- Dylan Scott: Therefore, today I'm signing four sweeping executive orders that will lead to massive reduction in drug costs. Massive.
--:-- Sean Rameswaram: But all the policy experts and health law scholars were saying at the time that this executive order doesn't have any effect.
--:-- Dylan Scott: You still have to go through the process of writing and finalizing federal regulations, and they haven't done it.
--:-- Sean Rameswaram: The Trump administration has been talking about putting together these $200 discount cards that they would send out to Medicare beneficiaries, you know, maybe with the president's signature written across them.
--:-- Dylan Scott: These cards are incredible.
--:-- Sean Rameswaram: The cards will be mailed out in coming weeks.
--:-- Sean Rameswaram: I will always take care of our wonderful senior citizens.
--:-- Dylan Scott: Joe Biden will be doing this.
--:-- Sean Rameswaram: They've been trying to finagle some way to make this legally permissible, pretend it's some kind of demonstration project to test whether drug costs will be lower for people if they get effectively a gift card from the government.
--:-- Sean Rameswaram: But I think the subtext of all of that is a recognition on the Trump administration's part that they have not really delivered on this promise.
--:-- Sean Rameswaram: And we see that in a few different ways.
--:-- Sean Rameswaram: The fact that they haven't finalized regulations.
--:-- Sean Rameswaram: The fact that prices are still going up,
--:-- Sean Rameswaram: And the fact that they're making these kind of last desperate attempts to try to get something done on the issue just before the election.
--:-- Dylan Scott: Okay so promise one prescription drug prices would go down. Lots of talk lots of tweets an executive order but he really didn't deliver.
--:-- Sean Rameswaram: Let's move to promise two that the Trump administration will be anti-abortion.
--:-- Dylan Scott: I've just come from the Rose Garden of the White House, where I proudly nominated Judge Amy Coney Barrett to the United States Supreme Court.
--:-- Sean Rameswaram: Evangelical Christians are a very important part of his base.
--:-- Sean Rameswaram: This is an issue that they really care about.
--:-- Sean Rameswaram: Life is a core tenant of who we are as Americans.
--:-- Sean Rameswaram: And this election is a choice between two radical anti-life activists and the most pro-life president we have ever had.
--:-- Dylan Scott: And so I do think there has been a concerted effort by the administration to fulfill some of those promises.
--:-- Sean Rameswaram: So, you know, the federal judges and the Supreme Court justices that Trump has appointed are generally more pro-life, anti-abortion, certainly more so than any judges and justices who would have been appointed by a Democratic candidate.
--:-- Sean Rameswaram: And this is another area where they actually have followed through on regulations.
--:-- Dylan Scott: Early on in the administration, Trump's health department proposed allowing employers from, you know, Fortune 500 companies to nonprofit Catholic organizations.
--:-- Sean Rameswaram: They would be allowed to refuse to cover contraception if they so chose for any religious or moral reason.
--:-- Dylan Scott: And that regulation, as all are on contentious issues, was the subject of a lawsuit.
--:-- Sean Rameswaram: That lawsuit actually worked its way to the Supreme Court over the summer.
--:-- Dylan Scott: The justices on the Supreme Court have sided with the Trump administration, allowing employers to opt out of Obamacare's birth control mandate.
--:-- Sean Rameswaram: The impact is immediate.
--:-- Sean Rameswaram: The government estimates between 70,000 and 126,000 women will lose their contraception coverage under this ruling.
--:-- Sean Rameswaram: Which, you know, was a win both for Trump's anti-abortion agenda and for his efforts to focus on the judiciary and put more conservative justices on the bench.
--:-- Sean Rameswaram: Yeah, this is definitely one where I think Trump has had a real focus and has actually been able to deliver for his supporters.
--:-- Sean Rameswaram: And that contraception mandate Trump rolled back was one small part of Obamacare, which brings us to his third promise we talked about at the top, get rid of Obamacare.
--:-- Dylan Scott: He's been obsessed with that from the jump.
--:-- Sean Rameswaram: Absolutely.
--:-- Sean Rameswaram: I mean, President Trump came into office and the first item on Congress's agenda was repealing and replacing Obamacare.
--:-- Dylan Scott: One of the Senate's very first acts this Congress was to pass the legislative tools necessary to repeal Obamacare.
--:-- Sean Rameswaram: We did so because the American people who had suffered for years under the failures of Obamacare were calling out for relief.
--:-- Sean Rameswaram: Remind us how that went.
--:-- Dylan Scott: It didn't go well.
--:-- Sean Rameswaram: It was a failure.
--:-- Sean Rameswaram: It ended up sucking up almost all of the Republicans' time and attention during their first year with full control of Washington, which is such like a pivotal period.
--:-- Sean Rameswaram: That's when you have a chance to really get things done before concerns about re-election and just sort of the inertia of Washington, D.C. takes over.
--:-- Sean Rameswaram: And they really did try.
--:-- Sean Rameswaram: You might remember House Republicans initially failed to come together on a plan back in March of 2017.
--:-- Sean Rameswaram: Yeah, I don't know what else to say other than Obamacare is the law of the land.
--:-- Sean Rameswaram: It's going to remain the law of the land until it's replaced.
--:-- Sean Rameswaram: We did not have quite the votes to replace this law.
--:-- Sean Rameswaram: And so, yeah, we're going to be living with Obamacare for the foreseeable future.
--:-- Sean Rameswaram: I don't know how long it's going to take us to replace this law.
--:-- Dylan Scott: I think that reflects a couple of things.
--:-- Sean Rameswaram: One is, you know, Trump made a lot of big promises on what his health care plan would do.
--:-- Sean Rameswaram: He would say things like, Everybody's got to be covered.
--:-- Sean Rameswaram: This is an un-Republican thing for me to say, because a lot of times they say, no, no, the lower 25%, they can't afford private.
--:-- Sean Rameswaram: And he promised that it would bring costs down for everybody.
--:-- Sean Rameswaram: Those are two really hard promises to make, because in order to cover everybody, you have to be willing to cover people who have really expensive medical conditions.
--:-- Sean Rameswaram: And that makes it really hard to bring down costs for everybody.
--:-- Sean Rameswaram: So those two goals are kind of in tension.
--:-- Sean Rameswaram: And Republicans, the reason they found themselves in a pickle, I think, is because in the end, the Affordable Care Act is a pretty conservative health policy.
--:-- Sean Rameswaram: Is that why it's so hard for the president to come up with an alternative plan?
--:-- Dylan Scott: Because Obamacare wasn't a public option and wasn't private insurance, but instead something in between?
--:-- Sean Rameswaram: And that's kind of the only other thing you can do?
--:-- Sean Rameswaram: There are certainly some tweaks you can make to Obamacare to try to make it more conservative, a little less heavily regulated.
--:-- Sean Rameswaram: And there are some conservatives who have proposed ideas to do that.
--:-- Sean Rameswaram: But yes, fundamentally, Obamacare is a pretty conservative health care plan on its own.
--:-- Sean Rameswaram: And if you are promising to repeal it from a more conservative viewpoint, it's really hard to continue guaranteeing coverage for everybody and making sure pre-existing conditions are covered and making sure health insurance is affordable.
--:-- Sean Rameswaram: Without, you know, doing more of Obamacare rather than less.
--:-- Sean Rameswaram: And so I think that's why you've seen, you know, President Trump has been reduced to signing completely symbolic, legally toothless executive orders that say things like it is the policy of the United States for pre-existing conditions to be covered.
--:-- Sean Rameswaram: The irony of that is that it is already the policy of the United States for pre-existing conditions to be covered because Obamacare is federal policy.
--:-- Sean Rameswaram: All told, I mean, four years of attacks on Obamacare coming after what was already some pretty heavy Republican opposition.
--:-- Sean Rameswaram: What effect has it had on this health plan?
--:-- Dylan Scott: The uninsured rate has started to tick up under Trump.
--:-- Sean Rameswaram: They've taken some small regulatory actions to try to undermine the Obamacare markets, cutting advertising, trying to allow for non-ACA coverage to be more available to people, and other things like Medicaid work requirements, though those have been caught up at the courts.
--:-- Sean Rameswaram: So like we have seen several million more people become uninsured under Donald Trump, even before coronavirus and the unemployment crisis that has led to more people losing coverage.
--:-- Sean Rameswaram: So I don't want to I certainly don't want to lose sight of those material effects that have already happened under Trump's watch.
--:-- Sean Rameswaram: But I think the most significant thing that Trump has done was he and congressional Republicans repealed the individual mandate penalty as part of their tax legislation that passed at the end of 2017.
--:-- Dylan Scott: That was kind of the one thing that everybody could agree on.
--:-- Sean Rameswaram: The mandate had always been unpopular, and Republicans had always kind of cited that more than anything else as the reason that Obamacare is such an affront to what they think of as American values.
--:-- Sean Rameswaram: But the scary thing, and almost the irony of their repealing the mandate, is that that has now become the basis for a Supreme Court case that could end up invalidating Obamacare in its entirety and leading to 20 million people losing health coverage if Congress and the White House aren't able to come up with a plan to replace it and prevent that from happening.
--:-- Sean Rameswaram: So we're talking about potentially 20 million people losing health coverage.
--:-- Sean Rameswaram: And this is where Trump's failure to come up with a health care plan is so worrisome because he and the Justice Department are asking the Supreme Court to overturn Obamacare next spring, and they still haven't come up with a plan to replace it if that were to happen.
--:-- Sean Rameswaram: And as I know I don't need to tell you, but I will, this would be happening in the middle of a global infectious disease pandemic that has already killed more than 200,000 Americans and more than a million people worldwide.
--:-- Sean Rameswaram: And we are facing the very real possibility that millions of people who are going to potentially need treatment, who are potentially going to need a vaccine, you know, people who had long symptoms who are going to be dealing with health problems for a long time.
--:-- Sean Rameswaram: Millions of people could wind up uninsured while they trying to confront those problems.
--:-- Sean Rameswaram: More with Dylan in a minute.
--:-- Sean Rameswaram: It's Today Explained.
--:-- Sean Rameswaram: Support for today's show comes from Adio.
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--:-- Sean Rameswaram: Dylan, we've been talking about the coronavirus since January of this year on the show, but I feel like we know a lot more now than we did back then about how exactly the president handled this.
--:-- Dylan Scott: So we know that even before anyone had heard of coronavirus, before it had ever found its way to humans, the Trump White House actually dismantled a pandemic response office that had been set up inside of the White House.
--:-- Sean Rameswaram: So that was sort of the first thing.
--:-- Sean Rameswaram: Public health has long been underfunded and under-supported in the United States, but the Trump White House took some very specific steps that made the U.S. less prepared when COVID-19 came to our shores.
--:-- Sean Rameswaram: But beyond that, we obviously know from the Bob Woodward interview, and really we've known it for the duration, that the Trump White House did not want to take a strong leadership role on COVID.
--:-- Dylan Scott: Which he said back in February that it's deadly, it's deadlier than the flu.
--:-- Sean Rameswaram: It's also more deadly than your, you know, even your strenuous flus.
--:-- Sean Rameswaram: Very much emphasized with numbers that it's more deadly than the flu.
--:-- Sean Rameswaram: This is 5% versus 1% and less than 1%.
--:-- Sean Rameswaram: And now today, he says, This is a flu.
--:-- Sean Rameswaram: And as I say, we're rounding the turn.
--:-- Sean Rameswaram: We're rounding the corner.
--:-- Sean Rameswaram: It's going away.
--:-- Dylan Scott: He continues to disparage Dr. Anthony Fauci and other government scientists, public health experts.
--:-- Sean Rameswaram: People are tired of hearing Fauci and all these idiots, these people, these people that have gotten it wrong.
--:-- Sean Rameswaram: Fauci's a nice guy.
--:-- Sean Rameswaram: He's been here for 500 years.
--:-- Sean Rameswaram: Every time he goes on television, there's always a bomb, but there's a bigger bomb if you fire him.
--:-- Dylan Scott: And so it's really not great altogether.
--:-- Sean Rameswaram: It doesn't seem like the president sees any problem with how he's handled COVID thus far.
--:-- Sean Rameswaram: And there doesn't seem to be any reason to expect a change from his administration in the coming months.
--:-- Sean Rameswaram: Not to mention if he wins re-election.
--:-- Sean Rameswaram: Not to mention if he wins re-election.
--:-- Sean Rameswaram: No, there's not been any sign of a pivot except a pivot away from paying any attention to COVID.
--:-- Sean Rameswaram: There was a moment there where it seemed like Donald Trump had the opportunity to really unite the country in the fight against this virus.
--:-- Sean Rameswaram: I mean, it just it didn't feel like in those early days that anyone was out there cheering for him to bungle this entire thing.
--:-- Sean Rameswaram: If anything, there was just a lot of confusion out there and people wanted reassurance.
--:-- Sean Rameswaram: And it just feels like such a shame that he didn't see this as a way to maybe even get re-elected.
--:-- Sean Rameswaram: Right.
--:-- Sean Rameswaram: Like Jacinda Ardern, just like one reelection with a whopping plurality.
--:-- Sean Rameswaram: Right.
--:-- Sean Rameswaram: It's very easy to imagine an alternate universe where, yeah, President Trump sees the coronavirus as perverse as it might sound as an opportunity.
--:-- Sean Rameswaram: He ran as a candidate saying that I alone can fix America's problems.
--:-- Sean Rameswaram: And here was the biggest problem that we faced during his four years in office.
--:-- Sean Rameswaram: And in my mind, anyway, I can at least imagine that somebody like Trump would be like, you know, now I get to do stuff.
--:-- Sean Rameswaram: I get to order people around.
--:-- Sean Rameswaram: I get to direct supplies to be distributed across the country.
--:-- Sean Rameswaram: I can mobilize the military.
--:-- Sean Rameswaram: Like, there's all kinds of stuff you get to do as the president when there's a pandemic and a national emergency that requires a national response.
--:-- Sean Rameswaram: And we have certainly seen a lot of other national leaders around the world enjoy a surge in popularity because of how they've handled COVID-19.
--:-- Sean Rameswaram: And now we've seen the opposite effect for him in that he is obviously struggling in his re-election campaign, and his handling of the COVID-19 response is very unpopular with the American public.
--:-- Sean Rameswaram: So I remain as perplexed as you are.
--:-- Sean Rameswaram: And the only real explanation that I can offer is, and it goes back to the same issue he encountered with Obamacare, which is that it requires a plan to respond to a pandemic.
--:-- Sean Rameswaram: It requires that kind of engagement and an active interest.
--:-- Sean Rameswaram: And, you know, the president has never really shown an affinity for those finer details of public policy.
--:-- Sean Rameswaram: And I think we've seen the consequences of that during the last year.
--:-- Sean Rameswaram: Dylan Scott, he reports on healthcare at Vox.
--:-- Sean Rameswaram: He's also been covering the heck out of this pandemic.
--:-- Sean Rameswaram: Find all his reporting at Vox.com.
--:-- Sean Rameswaram: And while you're there, you can find all the previous episodes in our series on the Trump years.
--:-- Sean Rameswaram: They're at Vox.com slash Trump years.
--:-- Sean Rameswaram: We'll wrap up our series tomorrow with Rebecca Traitster from New York Magazine and Ezra Klein from Vox, the website.
--:-- Sean Rameswaram: And now, the ones we lost along the way.
--:-- Sean Rameswaram: Steve Bannon.
--:-- Sean Rameswaram: Let them call you racist. Wear it as a badge of honor.
--:-- Sean Rameswaram: Fired.
--:-- Sean Rameswaram: Dina Powell.
--:-- Sean Rameswaram: Resigned.
--:-- Sean Rameswaram: Rick Dearborn.
--:-- Sean Rameswaram: Resigned.
--:-- Sean Rameswaram: Sebastian Gorka.
--:-- Sean Rameswaram: They want to take your pickup truck.
--:-- Sean Rameswaram: They want to rebuild your home.
--:-- Sean Rameswaram: They want to take away your hamburgers.
--:-- Sean Rameswaram: This is what Stalin dreamt about but never achieved.
--:-- Sean Rameswaram: Fired.
--:-- Sean Rameswaram: Jeremy Katz.
--:-- Sean Rameswaram: Resigned.
--:-- Sean Rameswaram: George Sifakis.
--:-- Sean Rameswaram: Resigned.
--:-- Sean Rameswaram: Anthony Scaramucci.
--:-- Sean Rameswaram: What happens to leakers on your watch?
--:-- Sean Rameswaram: They're going to get fired.
--:-- Sean Rameswaram: Fired.
--:-- Sean Rameswaram: Tom Price.
--:-- Sean Rameswaram: Resigned.
--:-- Sean Rameswaram: Keith Schiller.
--:-- Sean Rameswaram: Resigned.
--:-- Sean Rameswaram: Carl Icahn.
--:-- Sean Rameswaram: Resigned.
--:-- Sean Rameswaram: Ezra Cohen-Watnick.
--:-- Sean Rameswaram: Fired.
--:-- Sean Rameswaram: George Gigikos.
--:-- Sean Rameswaram: Resigned.
--:-- Sean Rameswaram: Renz Priebus.
--:-- Sean Rameswaram: You know, we heard from the pool reporter there, they were headed to the same car, they got in the same car in the motorcade, and then it became clear as the news broke that Reince's car was no longer going to be in the presidential motorcade.
--:-- Sean Rameswaram: And then, according to the Poole report, Scavino and another aide leave, go into a car that is returning to the White House with the president.
--:-- Sean Rameswaram: And Reince Priebus alone heads off in a different direction.
--:-- Sean Rameswaram: Maybe heading home.
--:-- Sean Rameswaram: That's pretty amazing, don't you think, Mark?
--:-- Sean Rameswaram: Fired.
--:-- Sean Rameswaram: Thank you.
--:-- Sean Rameswaram: of generative AI that's commercially safe.
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--:-- Sean Rameswaram: Meet Adobe Express, the quick and easy app to create on-brand content.
--:-- Sean Rameswaram: Learn more at adobe.com slash express slash business.