Current news reports suggest that Kellyanne Conway, counselor to the president, has been assigned the task of “opioid czar,” coordinating a response to America’s most serious public health challenge in decades. It’s not clear exactly what’s going on, whether Conway has any new powers, what she plans to do that CMS administrator Seema Verma, Surgeon General Jerome Adams, FDA Commissioner Scott Gottlieb, or others aren’t already doing.
But this matters more than the usual White House organizational musical chairs, because the opioid epidemic may be the one national challenge that has not been disfigured by the deepening polarization of American public life, at least yet. Bipartisan progress is still genuinely possible. Donald Trump spoke humanely about the epidemic’s lacerating effects in Appalachia and the Rust Belt while on the campaign trail. By some reckonings, this helped him politically.
Republican governors such as Charlie Baker, Chris Christie, and John Kasich have been working hard on the problem, often using tools provided by Affordable Care Act’s Medicaid expansion to expand and improve addiction treatment. We had a major surgeon general’s report in the closing days of the Obama administration. We had the bipartisan 21st Century Cures Act. We’ve had a highly touted presidential task force promising to declare a public health state of emergency.
Yet as far as I can tell, the Trump administration has done little on the ground to address this epidemic. It fired Surgeon General Vivek Murthy, who had made addiction a major focus. The Office of National Drug Control Policy is basically dormant, particularly after Tom Marino, President Trump’s nominee to head that office, was forced to withdraw. To my knowledge, congressional Republicans and the Trump administration are doing little to deploy interventions that could help with prevention.
Candidate Trump also promised not to cut Medicare and Medicaid, the two largest payers for addiction treatment. Then, of course, the Trump administration tried to overturn the ACA, threatening Medicare and Medicaid. Across the country, Republican proposals to block-grant and cut the ACA created huge policy uncertainties that slowed state and local responses to the opioid epidemic. State legislators didn’t know whether to reauthorize their Medicaid expansions. Treatment providers remained uncertain whether to make key investments predicated on their patients’ continued insurance coverage. Insurers didn’t know the fate of mental health and addiction parity requirements extended with bipartisan support within the Senate Finance Committee in the passage of the Affordable Care Act. The administration has done nothing to expand insurance access in southeastern states, where hundreds of thousands of Americans with addiction disorders lack Medicaid coverage. Prominent “just say no” bromides offered by President Trump and his key advisers were also unimpressive, particularly when unaccompanied by more substantial steps.
And yet, Trump and his colleagues know they are accountable to do better. Many Republican or Democratic public managers and addiction experts could certainly help in that, coordinating efforts across government agencies, reaching across the partisan aisle, working with state governments. His own FDA commissioner and his new surgeon general are two obvious candidates. There are many others, including widely respected officials from both the George W. Bush and Obama administrations.
But instead, the president’s apparent selection of Kellyanne Conway suggests that he’s going another way. Conway is a political figure with no specific addiction expertise. That fact in itself is not particularly disqualifying—the Obama administration appointed Ronald Klain to lead our government’s ultimately-successful Ebola response (Klain was not an Ebola expert).
But there is a key difference. Although Klain was no household name, he had deep experience organizing government agencies at the highest levels. He had been chief of staff to Vice Presidents Joe Biden and Al Gore, and to Attorney General Janet Reno. He helped to oversee the Obama administration’s admirably efficient implementation of the $787 billion stimulus package. He’s the epitome of the solid, behind-the-scenes figure most presidents turn to when they need to get something difficult done.
I can’t peer into Conway’s mind or heart. She may be deeply committed to helping resolve this public health crisis. Whatever her motivation or dedication, she brings none of Klain’s policy or management prowess. I fear that the president chose her because of the skills she definitely has: that of the partisan show horse. She is the sort of flashy insubstantial figure this president turns to when he needs someone to argue on cable TV that he’s doing something—when in reality he is doing very little.
With this appointment, President Trump expresses his disdain of the craft of governance. That’s no way to address the most brutal epidemic America has faced since the emergence of HIV and AIDS.