A hundred days: what is to show for it?

Abstract

The first 100 days of a presidency are often taken as a measure of initial success and an indicator of the future potential of an administration. By this standard, the first days of President Donald Trump present a bleak outlook. In many respects, the most important features of the Trump Administration so far are the things that have not happened. The repeal of the Affordable Care Act (ACA), a central campaign promise of the Republican Party, collapsed under the weight of logical inconsistencies in the Republican promise: that their plan could provide better health-care coverage, to more people, more cheaply, and cut taxes, all at the same time. Republicans remain divided between hardline conservatives who want repeal of the ACA, and more moderate factions who foresee electoral disaster from that path. The Republicans' ability to make sweeping changes to the US health-care system, which makes up a sixth of the economy, requires a stronger hand and clearer vision than Donald Trump can offer. But what the Trump Administration is not doing extends well beyond legislation. By the end of April, Trump has failed to nominate or even name hundreds of positions that have been left vacant since his inauguration. Dozens of people ordered to resign—ambassadors, federal prosecutors, and administrators—have not been replaced. In most cases, Trump has not named successors, and it is unclear when the vacancies will be filled. Even where Trump has named someone for a position, confusion reigns. Scott Gottlieb, Trump's controversial pick to head the Food and Drug Administration (FDA), and Francis Collins, Director of the National Institutes of Health (NIH) asked by Trump to stay on, remain in limbo, with Gottlieb awaiting confirmation, and Collins, acting as de facto NIH director, not knowing if someone else will be nominated. This kind of institutional confusion can be devastating for programmes and projects that unfold over years and require institutional stability. The Trump Administration's strongest statement about government is the so-called skinny budget, a budget blueprint put forth by the administration in March. A $54 billion increase in defense spending coupled with drastic and unprecedented cuts to discretionary domestic spending—from the Environmental Protection Agency, Health and Human Services, and the FDA to programmes essential to health in the USA and abroad, including USAID and the Centers for Disease Control and Prevention—undermines the USA's ability to respond to global health threats. Especially concerning are cuts to the NIH ($5·8 billion, 18% of its current budget), which specifically eliminate the Fogarty International Center, an initiative to build partnerships between governments and research institutions around the world, and train the next generation of global health scientists. With a budget of only $70 million, Fogarty provides invaluable experience for doctors and researchers from the USA and abroad. Although a strong campaign has been launched to protect Fogarty, close observers are anxious that Collins may sacrifice this critical part of NIH in order to protect other parts of the NIH budget. Trump's budget proposal is unlikely to become law. Congress sets budgets, and Republicans are less concerned with ideology-driven reductions in government than in functioning programmes that constituents depend on. However, his budget does indicate his administration's direction of travel. Based on current evidence, the Trump Presidency is no friend to science, medicine, or global health. By contrast, the elevation of Neil Gorsuch to the Supreme Court, is a solid accomplishment for Trump. Gorsuch is the kind of conservative jurist that any Republican would have nominated, and his writings and opinions have given conservatives ample reason to cheer. However, anyone concerned for women's reproductive health will only shudder at his nomination. Gorsuch's confirmation was full of seemingly reasonable pronouncements that still leave huge substantive gaps. Asked about Roe v Wade, the landmark case that ensured a woman's right to choose an abortion in the USA, he concurred that it had been upheld many times, and judges should “consider” precedent, but his writings leave unclear how far such “consideration” should extend. The first 100 days of Donald Trump's presidency have shown that he has few fixed opinions about government functions, whiplashing from advocating universal health coverage to promising to actively sabotage the operation of the ACA to hurt the Democratic Party, and the many Americans who depend on it for health care. But whether Trump believes it or is influenced by the people around him, so far the idea of an empty government, robbed of its ability to perform its most basic functions, is sowing confusion and uncertainty about the current US Administration's commitment to health, at home and around the world. Marching for science as budget cuts threaten US researchAcademics push back against President Trump's proposed budget cuts, which give a sobering insight into the future of US research. Susan Jaffe, The Lancet's Washington correspondent, reports. Full-Text PDF