with Paulina Firozi

As some critics question President Trump's mental fitness, many psychiatrists are being reminded of the Goldwater Rule. Here's what you need to know about it. (Elyse Samuels/The Washington Post)

The physical exam President Trump will undergo today doesn’t include a mental evaluation – but if you heed the mental health community, you’ll stop trying to diagnose the president from a distance.

Rampant speculation about Trump’s mental stability – heightened recently by the president’s scheduled checkup and his own tweet that he’s a “stable genius” – is raising the eyebrows of mental-health professionals and advocates, who are reiterating their warnings against armchair diagnoses.

Anyone who hasn’t personally examined the president shouldn’t speculate about his health status, the American Psychiatric Association said in a statement this week. Doing so undermines the work of psychiatrists, who operate just like physical doctors by reviewing patients’ medical history and performing a thorough examination before offering any diagnosis, the APA said.

“A proper psychiatric evaluation requires more than a review of television appearances, tweets, and public comments,” the APA said. “Psychiatrists are medical doctors; evaluating mental illness is no less thorough than diagnosing diabetes or heart disease.”

The caution stems from what's known as the "Goldwater rule," which surfaced after a petition signed by over a thousand psychiatrists was published in 1964 by Fact magazine claiming then-GOP presidential nominee Barry Goldwater was "psychologically unfit to be President.” Goldwater, who lost the election, later won a libel suit against Fact. The APA issued a ruling prohibiting mental-health professionals from commenting on the well-being of a public figure who they have not personally examined.

As the debate over Trump has burgeoned, mental-health advocates are also becoming frustrated by some of the words used on social media to speculate about Trump’s state of mind – words like “unhinged,” “crazy” or “unstable.” They fear the use of such language will perpetuate the stigma around those with mental-health conditions, feeding into assumptions that such patients can’t be trusted or successful in life.

Having a mental health disability doesn’t mean they’re “bad,” “dangerous” or “unhinged,” the Bazelon Center for Mental Health Law said yesterday.

“Calling the president ‘mentally ill’ in order to insult or undermine him causes actual harm to people with mental health disabilities,” the group said in a statement.

See Bazelon's own tweets below:

Speculation about Trump's state of mind ramped up considerably after the publication of Michael Wolff's book, "Fire and Fury," reporting on the chaos in the White House:

Toronto Star's Daniel Dale: 

Yesterday, a group of more than 70 psychologists, psychiatrists and mental health professionals sent a letter to Trump’s physician imploring him to include an evaluation of the president’s neurological health in the checkup today. Per Dem donor Tom Steyer: 

Neither group mentioned by name Bandy X. Lee of Yale University, an assistant clinical professor of psychiatry who briefed a dozen members of Congress last month on Trump’s mental state and helped edit “The Dangerous Case of Donald Trump."

Lee and Harvard Medical School associate professor of psychiatry Leonard L. Glass penned an article for Politico Magazine this week arguing it is their "duty" to question Trump's mental fitness as psychiatrists: "Without diagnosing Trump in a specific way, as the Goldwater rule prohibits, it is not only acceptable but vitally necessary to have a public conversation about mental state of our nation’s leader ... Any president’s mental health is inextricably tied to our health as a society, and, in this case, Trump’s mental state poses a serious danger that we must be willing to discuss and address."

Yale -- Bandy's employer -- issued a statement that was critical of her yesterday. The school affirmed the “academic freedom” of faculty but said doctors should conduct an examination and obtain proper authorization before publicly stating a professional opinion about a patient.

“Dr. Bandy Lee’s opinions are her own and do not represent the views of the department, the medical school or the university,” Yale School of Medicine said in a statement.

And some mental-health professionals have stated they don't agree with Lee and others who worry about Trump's mental fitness. Dr. Allan Frances, a former chair of the Psychiatry and Behavioral Sciences Department at Duke University who helped revise the manual identifying mental illnesses, disagrees that Trump is ill. "Confusing Trump’s behavior with mental illness unfairly stigmatizes those who are truly mentally ill, underestimates his considerable cunning, and misdirects our efforts at future harm reduction. And the three most frequent armchair diagnoses made for Trump — narcissistic personality disorder, delusional disorder, and dementia — are all badly misinformed," Frances wrote for STAT in September.

More will soon be known about Trump’s physical health, although exactly how much more isn’t clear. The exam will take place today at Walter Reed National Military Medical Center under the supervision of Navy Rear Adm. Ronny L. Jackson, who has been the lead White House doctor since 2013 and oversaw two of former president Barack Obama’s exams, The Post’s Jenna Johnson and Lenny Bernstein report.

External signs of Trump’s daily behaviors – his affinity for fast food, lack of exercise and short nights – cast doubt on a past claim by his personal physician that Trump is “the healthiest individual ever elected to the presidency.”

“Trump is older than all previous presidents when they first took office,” Jenna writes. “He is also the heaviest president in at least a generation and consumes a diet heavy with Big Macs, Filet-O-Fish sandwiches, fried chicken, pizza, well-done steak and two rounds of dessert. He seems to get little exercise beyond swinging a golf club, as he spends most of his time on the course traveling in an electric cart. And he likes to brag about how little sleep he gets.

The risks of such a health profile are well known: heart disease, strokes, diabetes and high blood pressure, to name a few.

“He doesn’t look healthy,” said Daryl Isaacs, a New York internist who monitored the impact of Morgan Spurlock’s month-long McDonald’s-only diet for the 2004 documentary “Super Size Me” and one of the few medical experts willing to venture an opinion about the president. “His complexion doesn’t look healthy.”

The White House has said Jackson (the doctor examining Trump) will appear at Tuesday’s press briefing to take questions about the president’s health after compiling detailed results over the long weekend.

But there’s no guarantee Jackson will provide a comprehensive report, because undergoing a physical is voluntary for a president and Trump can pick and choose what the public hears.

President Trump on Jan. 11 said he expects an upcoming physical examination to “go very well.” He added that he will “be very surprised if it doesn’t.” (The Washington Post)

One is thing is apparent: Trump’s doesn't seem to be a hypochondriac, at least not publicly.

“I think it’s going to go very well,” he said yesterday afternoon. “I’ll be very surprised if it doesn’t.”

PROGRAMMING NOTE: The Health 202 will not publish on Monday, Jan. 15, for Martin Luther King Jr. Day. We'll be back in your inbox on Tuesday.


AHH: Allowing states to set up work requirements for Medicaid recipients is actually one of the least controversial things Trump has done as president, our colleague Aaron Blake argues. After all, Americans have supported mandating work requirements for government assistance for years.

Seventy percent of Americans were in favor of allowing states to impose Medicaid work requirements on non-disabled adults, a Kaiser Family Foundation poll found in June. The idea was backed by 82 percent of Republicans, 77 percent of independents and 56 percent of Democrats.

“Opponents of the move quickly decried the Trump administration's action, arguing that it represented a gutting of Medicaid and the administration's disregard for the poor (which was a big part of the pushback against the failed effort to replace Obamacare),” Aaron writes. “But assuming such exemptions are included in how states implement their changes — and the Department of Health and Human Services is recommending they are, urging states to mirror the work requirements for food stamps — this seems to be something the vast majority of Americans support.” 

"Similar requirements have already been imposed on recipients of welfare and food stamps, though the Obama administration in 2012 gave states more flexibility on welfare's work requirement," Aaron writes. "That requirement was initially part of the Clinton administration's welfare reform efforts in the mid-1990s, and it was overwhelmingly popular at the time."

It's also unlikely the change will affect that many Medicaid beneficiaries because such requirements usually have key exemptions for family care, the disabled and those of retirement age. "Only about 1 in 10, per Kaiser's numbers, didn't work and didn't qualify for one of these exemptions," Aaron writes. "And most of those said they were searching for work, which is another exemption that recipients can generally use — provided it's documented."

But NBC's Benjy Sarlin breaks down why critics say the policy shift is a bad idea: "Opponents of the decision have argued that work requirements go beyond Medicaid's stated goal to provide aid to low-income households and that only Congress can expand its objectives to also include pushing people toward employment. This is likely to be a primary contention in lawsuits challenging the administration."

OOF: The insurer Centene is being sued by customers who claim the company misled them about the scope of benefits in Obamacare plans sold on the marketplaces. The plaintiffs allege contrary to the tone of Centene's advertising, they had difficulty or were unable to find medical providers who would accept their plans, Bloomberg reports.

“Centene misrepresents the number, location, and existence of purported providers by listing physicians, medical groups, and other providers -- some of whom have specifically asked to be removed -- as participants in their network and by listing nurses and other non-physicians as primary care providers,” claims the suit, which was filed on behalf of two Centene customers seeking class-action status to represent all customers of the insurer’s Obamacare plans. 

A spokeswoman for Centene -- one of the largest ACA insurers with more than 1.4 million customers across 15 states -- told Bloomberg it had not yet seen the lawsuit but insisted its physician networks are "adequate." “We work in partnership with our states to ensure our networks are adequate and our members have access to high-quality health care,” spokeswoman Marcela Hawn said.

"Chief Executive Officer Michael Neidorff built up Centene by covering poor, disabled and pregnant individuals in state Medicaid programs," Zachary Tracer reports. "The company has used many of the skills and strategies developed in that program in its ACA plans, including limiting where its members can get care to hospitals and doctors willing to accept lower reimbursement rates...The scrutiny of the company’s provider networks could limit its expansion plans or reduce profits."

OUCH: According to the Trump administration, there's been a massive drop in the number of health plans available in the individual and small-group insurance markets: There are now just 700 plans, down from 2,400 previously, the Centers for Medicare and Medicaid Services said in a notice this week. The new data would reflect a 70 percent decrease, Modern Healthcare reports.

So what's going on? The drop could reflect the repeal of the law's individual mandate to buy coverage, reporter Virgil Dickson writes. “The new figure comes weeks after President Donald Trump signed a Republican-backed tax bill that repealed the individual mandate. Insurance companies stated repeatedly last year that not enforcing or eliminating the mandate would cause insurance companies to exit the federal and state exchanges,” Virgil writes.

But one expert told Virgil they don’t believe mandate repeal would have affected the latest numbers, in part because the individual mandate won’t actually be eliminated until 2019. Larry Levitt, senior vice president at the Kaiser Family Foundation, said it was more likely a result of marketplace defections.

"In some cases, these insurers just couldn't earn a profit when competing against plans with narrower networks and lower costs,” Levitt said. “More recently, uncertainty over how the Trump administration would run the ACA marketplace has caused some insurers to exit."

Cheryl Fish-Parcham, of the advocacy organization Families USA, said the data reflects the need to shore up the marketplaces. "We need to make sure there is policy that is conducive to keeping carriers in the marketplace and making sure consumers have great choices," she said. 


--The general feeling among Democrats and liberals is that Alex Azar is a much better choice than Tom Price to lead the Department of Health and Human Services (even if they don't agree with all of Azar's positions). The former drug executive and HHS official under George W. Bush now has two Democratic backers in the Senate. North Dakota Sen. Heidi Heitkamp called Azar "incredibly competent," in a statement shared with The Health 202.

“I don’t share a lot of his philosophy, but he understands, as someone who has been in the administration, the importance of the rule of law and compliance,” Heitkamp said. “I believe I can work with him in the future, especially on Indian health.”

Another red-state Democrat, Sen. Joe Manchin of West Virginia, has also said he'll help confirm Azar. The Senate Finance Committee intends to vote on his nomination later this month before consideration in the full Senate. 

--Sen. Bernie Sanders (I-Vt.) is striking out on his own to try to sell universal health coverage to the American public. On the evening of Jan. 23, Sanders will host a 90-minute "national town hall' online, with no major network behind it, The Post's Dave Weigel reports. Instead, the event will be streamed by the liberal video outlets NowThis, Attn:, and the Young Turks. Sanders said the idea came to him after appearing on CNN-hosted forums on health care and taxes — experiences he’d mostly enjoyed — and hit a wall.

“We expect that we’ll have a larger viewing audience for this live stream than we’d have if we’d run it on, say, CNN,” Sanders told Dave. “That’s revolutionary. You can have this discussion even if the owners of the big media companies don’t want to have it.”

“I talked to a very well-known TV journalist, and I said: ‘You know, I think it’d be really great to have a town hall on single payer. You can design it however you want,’ ” Sanders added. “He said, ‘Bernie, that’s a great idea. We’ll run it up the food chain.’ I never heard back.”

The Jan. 23 special -- to be streamed from an auditorium in the Capitol Visitor Center -- will use the networks’ streaming services to show Sanders taking audience and online questions about how single-payer health care could be implemented in the United States.

“I think there is an envy on the part of progressives, and most Democrats, of the Republican media world,” Sanders said. “They have Fox News, of course. They have the Rupert Murdoch papers. You’ve got Sinclair, which is acquiring more all the time. So we’re up against enormous opposition. And what many Democrats are beginning to sense is that you have to break through that. And what we’re trying to do here is ahead of the curve.”


--The marijuana boom could rake in billions. Our colleague Katie Zezima reports a new study from New Frontier Data found legalizing pot nationwide would generate $132 billion in tax revenue, and create more than a million new jobs.

Here’s how Katie breaks down the financial benefits, per the study, if pot were fully legal in all 50 states:

  • It would create at least $131.8 billion combined in federal tax revenue between 2017 and 2025.
  • The federal government would bring in $51.7 billion in sales tax in the same time frame.
  • There would be 782,000 additional jobs if pot were legalized today. That number would spike to 1.1 million new jobs by 2025, including workers at marijuana supply chains, farmers, transporters and sellers.

“When there are budget deficits and the like, everybody wants to know where is there an additional revenue stream, and one of the most logical places is to go after cannabis and cannabis taxes,” Beau Whitney, a senior economist at New Frontier Data, told Katie.

The new study comes as Attorney General Jeff Sessions announced last week he would reverse an Obama-era policy that discouraged enforcement of federal marijuana law in states where pot is legal. (The Health 202 took a look at how pot will survive Sessions’s announcement here.)

Katie writes some in the marijuana industry have speculated whether “Sessions’s actions could force Congress to step in and regulate the market, or move to legalize marijuana altogether.” And based on the study’s findings, there could be a financial incentive to do so. 

--A few more good reads from The Post and beyond:



Coming Up

  • The Bipartisan Policy Center holds a discussion on “Reinventing Rural Health Care: A Case Study of Seven Upper Midwest States” on Jan. 17.
  • The House Veterans’ Affairs Subcommittees on Health and on Economic Opportunity hold a joint hearing on addressing veteran homelessness on Jan. 18.
  • Kaiser Health News holds an event on what’s in store for health care in 2018 on Jan. 18. 

Baltimore hospital apologizes for putting a patient out in the cold:

A Baltimore hospital has opened an investigation into why an incapacitated patient was discharged on a cold night wearing nothing but a hospital gown. (Reuters)

Ikea wants pregnant women to pee on their ad: 

Ikea’s new advertisement, running in a Swedish magazine, asks women to pee on the page to learn about a discount. (Taylor Turner/The Washington Post)

Here's a running list of countries Trump has insulted: 

President Trump referred to African nations and Haiti as "shithole" countries on Jan. 11. Here are other nations he has insulted. (Melissa Macaya/The Washington Post)

Watch The Daily Show's Trevor Noah on Trump's "shithole" remark: