Category Archives: Politics

Governing By Scuttle

On the day Virginia seceeded from the Union, there was a scramble for control of Navy ships. The USS Merrimack was a steam powered frigate which had been in federal service for five years. She was moored at the Norfolk Navy Shipyard, along with many other Union vessels. In preparation to move the Merrimack to Philiadelphia, her engines were lit and plans were made to take her out to sea, away from advancing Confederate forces. However, during the night, small ships were cleverly sunk by the enemy, thereby blocking the Merrimack in dock. Her commanding officer ordered the crew to set fire to the ill-fated vessel and burned her down to the water line to prevent her from falling into Confederate hands. The USS Merrimack sank right where she had been moored.

USS Merrimack

Desperate to develop a navy, the Confederates raised the USS Merrimack and remade her into an ironclad ram. Nearly two years after being burned and sunk, she was renamed the CSS Virginia and put to use to disrupt the Union blockade. The Virgina saw action on several occasions, but was eventually trapped in a bay and faced the threat of being taken by the Union. The Confederate commader ordered her to be stripped of all value and destroyed (yet again). After plundering guns and munitions, the CSS Virginia was filled with a good amount of gunpowder. The resulting blast ripped her in two and sent her once again to the depths.

CSS Virginia

Scuttling, the deliberate sinking of a ship by it’s commander, commonly involves opening valves and hatches, lighting fires, or blowing a hole in the vessel. Donald Trump is the commander of the USS America. Surrounding himself with former military leaders, there is a wartime-like obsession with disabling our great vessel. To his devoted crew who romanticize authoritarian rule, scuttling makes perfect sense. It is adrenaline charged action against all that has stood in the way of right wing rule. The crew cheers with each destructive event, even as water rushes into the hull and our government rides low in the waves.

Never in the history of political transitions have there been so many unfilled leadership positions. Many agencies are running on autopilot. And in those cases where leaders have been appointed, many of those chosen have openly professed the intention to cause damage to the agencies they lead. Before being appointed as the 14th Secretary of the Department of Energy, Rick Perry ran a campaign to shut that department down. Before being appointed as the 11th Secretary of Education, Betsy DeVos made it clear her intention was to divert public education funds to private schools. And before becoming the 17th Secretary of Housing and Urban Development, Ben Carson said poverty is a state of mind and stated his intention to cut services to the poor.

Domestically, Trump has knocked great holes in the side of our boat by defunding insurance subsidies for the Affordable Care Act (ACA), threatening the program’s solvency and ultimately threatening the health insurance of 20 million citizens. With another blast, he has defunded the Chidren’s Healthcare Insurance Program (CHIP) blowing 9 million poor children out of Medicaid coverage. White Supremacists have and been made to feel confortable on deck with their guns and axes and torches. They are chopping away at civil rights and setting fires. Smoke is billowing into the sky.

Internationally, the historical good will and trust of our allies has been badly damaged. Explosive charges have been detonated, blowing holes in the base of our great ship by questioning the US commitment to NATO, backing out of the Paris Accord thereby hampering an international response to global warming, decertifying the Iran nuclear deal and opening the door to future military engagement, and brushing aside diplomacy in favor of threatening North Korea with nuclear strikes.

Finally, plans are underway to remove plunder from our sinking ship. Beautiful yachts, the best money can buy, have pulled alongside the USS America. They wait greedily to load their hulls heavily with tax cuts for the richest citizens while Commander Trump falsely assures passengers there is no cause for concern as this massive removal of wealth will benefit everyone.

Like the USS Merrimack, the USS America is moored in her home port. The engines are lit, but she will not be going out to sea. No course has been charted. On the distant horizon, a potential rescue can be seen coming toward us, but it won’t arrive until November 2018. Will we be prepared to lend a hand?

[Special thanks to American Research Writer Micah Crittenden for critical input]

Las Vegas: The Cost of Our Wild West Gun Culture

It took 15 minutes for one man to fire thousands of rounds down on 22,000 concert goers in Las Vegas on October 1, 2017. There were 59 killed and hundreds injured in the deadliest shooting rampage in modern American history. 

Save your breath with friends/families and forget about any Facebook campaigns to draw attention to this tragedy. Prayers, condolences, and flags at half staff are the best we can hope for. 

Gun enthusiasts are a loud group and well financed. What they want is worth more than your freedom. Open carry is worth more than your freedom to feel safe in a grocery store. Being able to sell guns with hardly a background check is worth much more than your freedom to attend large public gatherings with peace of mind. Purchasing guns that can be easily converted to human murder machines is worth more than the freedom of you child to safely attend school.

This is the era of the Wild West Gun Culture. Our children and grandchildren will study our political paralysis. Historians will write about how we undervalued our own freedom so gun enthusiasts could walk the streets packing heat.

The Parasitic One Percent

The one percent (1%) who fund the political campaigns of Congress, are pushing for tax reform. This is code speak for chaneling more wealth to them while working Americans pay their expenses. 

The One Percent:

  • Use our roads to drive their goods to market
  • Use our legal system to form agreements and protect their wealth
  • Use the Internet created by our tax dollars
  • Land at our public airports
  • Trade using U.S. currency
  • Sell their goods in protected and regulated markets 
  • Utilize banks, which we insure and protect
  • Invest in the stock market we regulate
  • Eat foods and take medications we pay to insure for safety

They reap profits and live comfortably while doing all they can to avoid contributing to the system where they flourish. And then they brag about paying nothing! They say it’s their obligation to avoid paying a #FairShareTax. 

They say we owe them for creating jobs. But what’s really true? They hire profit creators (workers) which we paid to educate in our public schools and colleges. Those profit creators make goods for the one percent, deliver those goods to market for the one percent, and sell those goods to consumers for the one percent. And then, to add insult to injury, the profit creators pay a #FairShareTax for the bed of roses which the one percent sleeps upon!

I’ve had enough. This is immoral.

#FairShareTax

Corporate Culture, Ashley Madison, and Trump

Many of us have heard of the salacious AshleyMadison.com, an internet resource platform for people seeking extramarital affairs. In 2015, the Ashley Madison website was hacked and gigabytes of scandalous information was released to the public. Interestingly, many of the exposed accounts were registered with corporate email addresses. This provided an opportunity to make comparisons between Ashley Madison activity and corporate behavior within the companies where account holders worked. 

In an article cleverly entitled 50 Shades of Corporate Culture, researchers found corporations which fostered a culture of innovation and risk-taking had the most Ashley Madison accounts. These were companies with business models built around rapid financial cycles and cut throat competition. The research also showed that high rates of Ashley Madison account ownership strongly predicted corporate tax disputes, lawsuits, product quality concerns, and financial misstates due to bribery, fraud, and inflated earnings. These findings built upon research conducted four years earlier, where Harvard business scientists described “the dark side of creativity.” Turns out inventive individuals show a propensity toward dishonest behavior. 

President Trump was elected by an impatient group of citizens to change government using his wealth building ingenuity. There are certainly many historical examples where Trump skirted the rules to avoid an obstruction or to cash in on profits. One example of this involved a financial crisis at Trump’s Taj Mahal. The casino was on the verge of missing a critical bond payment when father Fred walked into the casino and bought 3.5 million dollars worth of chips and walked out without gambling. This action immediately put money on the books to pay the bond debt (Trump was later assessed a $30,000 fine by the New Jersey Division of Gaming Enforcement for this illegal loan). Trump came up with a creative solution to get around an obstacle. 

As we would expect in the life of a very creative person, there are also many articles about Mr. Trump’s pre-POTUS years as a man who has lived his personal life outside the box. The dark side of creativity is evident. Professionally, Trump has evidenced cycles of dizzying success followed by bankruptcy and reorganization. We have also seen tax disputes, lawsuits, product quality concerns, and financial misstates. Personally, Trump has had high profile affairs and failed marriages.

And who does Trump surround himself with? Other ingenious individuals who see opportunities to cash in on their seats at the White House. Jared Kushner aiding his family’s real estate business, Stephen Bannon hanging on at Breitbart News, Ivanka Trump hawking jewelry, and General Michael Flynn working deals for his consulting firm during the Trump transition. Trump fills his executive stable with business people who live their lives outside the box.

From the Ashley Madison study, there were corporations which had very few accounts. They came from industries which favor slower paced business models where steady, smooth operations yield the best profits. These included fabricated products, mining, shipbuilding, railroad equipment, textiles, rubber/plastic products, and coal. The federal government might best be compared to these corporations. There’s a place for some ingenuity, but steady and smooth operations yield the best results.

Trump is the lead engine of a federal freight train pulling 110 cars. He wants to use his ingenuity to suddenly change course, and he’s getting frustrated that flashy moments of deal making aren’t impacting the speed and direction of the load. 

For those worried about a train wreck, we have two things going our way: inertia and the inevitability of serial scandals due to the dark side of Trump’s creativity. 

 

ALERT! YOUR CO-PAY HAS BEEN CLAWED BACK

How Does Prescription Drug Insurance Work?

Every insurance plan has preferred drugs, brand name drugs and drugs that are either not covered or have a high co-insurance cost.  These are often arranged into Tiers.

  • Tier 1 – Generic Drugs

    • Once a drug has been on the market for 20 years (25 in some circumstances), the patent held by the company which created the drug expires.  This allows other companies to create the exact same drug (chemically and in delivery) for a tiny fraction of the price.
    • Lowest copay amount
  • Tier 2 – Non-Preferred Generic Drugs

    • Same as above just more complex or expensive ingredients.  Could also be generics purchased by new companies trying to drive profits.
    • Slightly higher copay amount
  • Tier 3 – Preferred Brand Name Drugs

    • These drugs are less expensive than the Non-Preferred list, but are still under patents and therefore significantly more expensive than a generic.
    • Often have a higher copay than a generic drug
  • Tier 4 – Non-Preferred Brand Name Drugs

    • These are expensive drugs which are still under patent.  They are often the brand name drugs for the generics in Tier 1.  Considered an unnecessary insurance expense.
    • These drugs are often susceptible to a copay and having to pay the cost difference between the Brand Name and the Generic version.
  • Tier 5 – Specialty Drugs

    • These drugs are expensive, new and used to combat complex diseases.
    • They are often not covered at all or require heavy co-insurance payments and restrictions on access.

So…how do tiers become tiers?  Why is a drug covered under one insurance plan and not another?  Who controls this system?

Pharmacy Benefit Managers

Insurance Companies and Employers contract PBMs (Pharmacy Benefit Managers) to organize and negotiate plans with pharmacies and drug companies.  These folks are super important to understanding the cost of pharmacological medicine.

BCBS uses Prime Therapeutics from Irving, TX, as their PBM for many of their plans.  According to Prime Therapeutics’ website:

“Prime Therapeutics’ NetResults is one of the most aggressive formularies in the industry. And it works. Our clients are seeing an estimated savings of more than $10 per member per month.

So being aggressive pays off — we get people the medicine they need without the use of high-cost drugs.

Go bold or go home.”

So wait.  You do this formulary thing and we avoid high-cost drugs and everyone wins?  Cool.  

What’s a formulary?

A formulary is a tiered list of drugs covered by a prescription plan.  The “NetResults” formulary can be accessed here.  It uses a “p” for Tier 1, “np” for Tier 2, “P” for Tier 3 and “NP” for Tier 4.  The copay assigned to each of those tiers depends on how much your insurance company/business wants to pay for prescription coverage.

The average copay for a three-tier system (usually combines tiers 1 and 2 from above and excludes all drugs from tier 5) are $11 for Tier 1, $31 for Tier 2 and $53 for Tier 3.

So how do Wal-Mart and Target offer $4 generics WITHOUT INSURANCE? (They totally do.  Check out their lists here and here)

Average Wholesale Price

The Average Wholesale Price is the price a pharmacy buys the drug for in bulk.

It is considered the industry’s average price paid by a pharmacy to a drug manufacturer per 30/day or traditional supply.  You can find the federal government’s ACA payment AWP list here.

Let’s use Meloxicam 15mg as an example.  Target offers it for $4 without insurance.  The FDA says its AWP is about 1 cent a pill.  That’s a wholesale cost of 33 cents per 30 day supply.  With my insurance it is $4.18/30 day supply at Walgreens (as mine is a percent, not a copay).  The average cash price for the same amount is $13.78.  Priority Health will charge you $7 after you meet their $75 deductible.

NOTE:  The pricing isn’t even this simple as it is what the manufacturer reports to the government.  It doesn’t include all of the standard rebates and coupons given as incentives to PBMs and Pharmacies in the form of checks after our collective purchases.

Has it ever occurred to you that pharmaceuticals are like a grocery store without price tags?  Everyone pays a different amount and no one knows exactly why.  But more importantly, does Walgreens keep all of the 1,250% markup on my Meloxicam?

The Clawback

A PBM clawback occurs when an insurance company assigns expensive copays to a drug, a price that may be significantly higher than the actual value and acquisition cost of the drug.

Clawbacks occur when your pharmacy submits a claim for a prescription drug, and you’re directed to collect a specific dollar amount for the copay. The amount will likely be excessive and unrelated to the acquisition cost of the drug. – pbahealth.com

So for example, if you paid that $7 co-pay for 30 days of Meloxicam and Walgreens paid 33 cents, the PBM would clawback over $6 of that copay YOU PAID after paying your deductible and monthly premiums.  The amount of clawback to these PBMs has skyrocketed the cost of medication.

  • The PBM negotiates with drug companies to decide which drugs will be part of their formulary and on which tier.
  • The PBM establishes a rebate program for themselves based on purchases made by member of their formulary.
  • The PBM then sets the copay amount (often far above the actual price of the drug).
  • When the copay is more than the pharmacy charges, the PBM claws back all of the copay paid beyond the cost of the drug.

On top of this, you could have gotten the prescription cheaper by paying cash and not using your insurance.  But, if you’re a pharmacy, telling a customer not to use their insurance is asking for big-time PBMs to make your pharmacy a persona non grata under all plans they administer.  That would be a huge loss.

What Did We Learn?

There is a lot about pharmaceuticals that needs overhaul and transparency.  When the pharmaceutical rep shows up in a short skirt to your doctor’s office talking about the next big drug, she’s bringing with her a list of PBMs who have tiered that very medication.  The whole system revolves around a few key players who negotiate the prices, set the premiums, set the copays, choose the drugs, tell the doctors what scripts to write, tell the pharmacies what to charge and then collect back huge sums of cash from your family’s bank account.  We need transparency so that we can reform this broken system.  The only thing that can fight darkness is the light of day.

Further reading on other relevent pharma shenanigans

Micah Crittenden is a Senior Writer for American Research and is on Twitter at @thatgingerish

 

 

One Day in the Life of a Private Payer

The Backstory

We were in between insurance plans.  My husband had changed jobs and his new insurance would kick in on May 1st.  By the time we realized all of this, we had about 14 days to go.  We were faced with a decision – pay $1,800 for COBRA or take the risk and hope our family’s care for two weeks would cost less.  We took the risk.

With seven days to go, I developed a really ugly cough and fever.  I’ve had pneumonia a couple of times and the intensity seemed similar.  I had to go in.  We decided on Care Now, a “doc in a box” clinic which does Urgent Care.  I knew their fees would be standard and up front while my doctor’s office’s would be based upone many variables.

I have visited Care Now in the past for treatment on a weekend or during the evening when I didn’t want to miss work.  With insurance, they normally cost about $75 ( co-pay flat rate) and are able to do x-rays, blood work, urinalysis on site.  This is an affordable way to get rapid care for more intense illnesses – Pneumonia, Kidney Infections, Bronchitis, Pertussis – without having to do a stop at the doctor, then a lab, then an x-ray technician and wait for results.  Additionally, in the latter scenario, I often get a co-insurance bill from the x-ray tech and the lab for the cost of the testing.  This isn’t the case with Care Now.  One price to the patient — if you have insurance.


One Day as a Private Payer

Returning back to my day as a private payer, I used the mobile app to call ahead.  They usually call you back and let you know your wait will be 1 1/2 to 2 hours and they’ll call you when they are almost ready.  When they called me and I explained that I was going to be a private payer, they told me it would be about an hour or so.  Within 5 minutes they called me back and told me they were ready to see me.

Normally, even though they call you when they’re “ready” they’re not really ready.  I expect to spend a half hour sitting in their lobby with sick kids watching Moana on repeat anytime I want to see a doctor at Care Now.  I even brought my phone charger.  Within 5 minutes I had checked in, filled out their questionnaire and was called back to a room to be seen.  I was blown away.

My nurse was unexpectedly prompt as well, popping into the room to assess my condition.  She took basic vitals and then told me the doctor would see me soon.  She wasn’t kidding.  Within 3 minutes, the doctor was in my room to listen to my lungs and talk about my symptoms.

After she finished with the stethoscope, I asked what she thought.  She said, “well, I would recommed blood work and an x-ray to check for any possible infection – just to be safe.”  Then she looked down at the chart.  “But I see you’re a private payer, so I’ll leave that decision up to you.”

I think my jaw fell on the floor.  I have never had a healthcare professional let me make my own testing decisions.  I said, “well, you listened to my lungs…how did they sound?”

She thought for a moment.  “They sounded a little strained.  But that could be because you weren’t breathing all the way in – probably because it hurts.  Because of that, I wasn’t able to tell how well they were functioning.”

Jaw-on-floor-again.  “I could try harder, if you want to listen again?”

She agreed and we repeated the breathe-in breathe-out routine.

“Your lungs actually sound pretty clear.  It seems to me that you have sinusitis and it isn’t infecting your lungs yet.”

Excited by the new medical conversation I’m able to have I ask, “so then why am I coughing so hard?”

“Because the drainage from your sinuses is irritating your throat.  Its hard to tell.  Your lungs could be a problem.  I can never know for sure without testing.”

“But as it stands right now, you would be willing to treat me for sinusitis and then, if it didn’t improve in a couple days, we could explore doing the blood work and x-ray?”

“Absolutely.  If that’s the course you decide to go, I think I would also prescribe you a cough syrup to help as we fight off the sinus infection.”

“Sold.”

I sailed out of Care Now within 5 minutes of that moment paying only $150 for the visit.  I left with an antibiotic and a cough syrup.

Next up was Walgreens.  Certainly this would hurt, right?  Prescriptions with ZERO coverage have gotta be EXPENSIVE.  I dropped the scripts off and explained again that I would be a private payer.  She took the time to give me an estimate of my prescriptions before I left the window so I would know what they were going to cost.  $116.41 for my antibiotic and syrup combined.  Not too bad.

When they were ready for pick up, I walked up to the window.  The clerk said “I noticed you’re a private payer, so I hope you don’t mind, but I looked up some coupons for you.  Instead of $116.41, your total is $68.42.”  I thanked her and collected my medicine in awe.  Since when has Walgreens tried to save me money?

The doctor was right.  I was better within 48 hours of treatment and had spent a total of $218.42.


The Takeaway

 

If I had used insurance on that day in April the total bill paid by my insurance company would have been higher than what I paid as a private payer.  They would have charged for the visit, the blood work and the xray.  In addition, my copay would have been subject to The Clawback.  All of these costs would have resulted in a net cost increase for the coverage across the board.

This is the long term result of allowing doctors and pharmacies to bill our insurance companies whatever they think could be necessary.  While the cost to patient appears less with insurance, the cost to the system is greater due to the freedom afforded to perform tests and prescribe at will.  If we begin to work with our doctors as collaborators on our health instead of as flat-rate consumers, we can decrease costs to the system and lower the burden on the flawed American insurance system.

Think of it like managing data on a cellular plan.  If we all agree to only stream netflix when we are on wifi, there’s more to go around for everyone.  Hell, with collective cost savings in mind, we could make single payer dreams affordable for our nation without sacrificing quality or skyrocketing cost.  We just need doctors to join us in our fight.

The Diminishing Voice of the People

The Founding Fathers believed the Legislative branch (Congress) would be more powerful than the Presidency or the Courts. They were so concerned about the potential for Congress to become tyrannical, they split the Legislative branch into two groups: the House of Representatives and the Senate. It was the House of Representatives that would be the voice of the people, elected by popular vote every 2 years. 

When the first 65 U.S. Representatives were elected, the ratio of citizens to Representative was 60,000 to 1. The voice of the people was strong, as interested citizens could get a chance to communicate with their Representative. If only 1 in 100 citizens wrote a letter in 1790, the elected official would need to read and respond to 600 letters that year. Requests for face-to-face meetings were easily accommodated.

As the population of the U.S. continued to grow, Congress increased the number of U.S. Representatives to try and keep pace. By 1911 there were 435 U.S. Representatives. The Apportionment Act of 1911 put a cap of 435 on the number of U.S. Representatives, a cap which remains to this day.

The story of the United States has been one of perpetual population growth. Since 1790, the population of the United States has gone from nearly 4 million to 308 million (2010 Census). The ratio of citizens to U.S. Representative in 2010 was a staggering 709,000 to 1. Since 1790, the voice of the people has become diluted to more than 1/10th of what the Founding Fathers saw in their time. If 1 in 100 citizens wrote a letter to their Representative in 2010, that Rep would need to read and respond to 7,090 letters a year. That would require a team of staff to do the actual reading. It would also require the use of form letter responses, like many of us have received, responses that barely address the topics of concern. Good luck getting a private meeting.

Sometimes a picture or a graph says it all.

Think of doing laundry. We start off putting in one scoop of detergent and it works well. We start washing larger loads, still using one scoop of soap, but becoming dissatisfied with the results. We change brands and the one scoop still doesn’t cut it. The loads get ten times larger, but no matter which brand we use, or how fresh the soap is, our clothes just don’t get cleaned. 

Today, there is high demand and limited access to U.S. Representatives. Who gets the most face-to-face time? Donors, lobbyists, big business, and other useful parties. Enter political careerism and corruption. Little wonder the people feel disconnected from government. 

There is an unmet need for engaging representation. It’s time to reconsider the arbitrary number of 435.