Archive for November, 2022

A Few Items To Ponder, Two Of Them Important

Wednesday, November 30th, 2022

Type 1 Diabetics get good news

As I have written before, Type 1 diabetes (T1D) is a horrific disease. It is a leading cause of stroke, heart disease, blindness, kidney disease and non-traumatic amputations. It also costs a lot to manage. The media has been full of stories of unfortunate people who have had to choose between taking insulin or food. The Inflation Reduction Act, passed in August, caps the cost of a vial of insulin at $35 for Medicare beneficiaries, but does nothing for diabetics not on Medicare. About 70% of the nation’s 1.9 million Type 1 diabetics are on Medicare.

Research has proven Type 1 diabetics contract the disease in three stages over time. According to a 2015 study on the presymptomatic stages of Type 1 diabetes:

Insights from prospective, longitudinal studies of individuals at risk for developing type 1 diabetes have demonstrated that the disease is a continuum that progresses sequentially at variable but predictable rates through distinct identifiable stages prior to the onset of symptoms. Stage 1 is defined as the presence of β-cell autoimmunity as evidenced by the presence of two or more islet autoantibodies with normoglycemia and is presymptomatic, stage 2 as the presence of β-cell autoimmunity with dysglycemia and is presymptomatic, and stage 3 as onset of symptomatic disease.

Type 1 diabetics go through two stages of disease development before full-blown diabetes appears in Stage 3. Imagine a platform diver. Stage 1 is climbing to the platform and standing at the edge. Stage 2 is lifting off and moving through the air. Stage 3 is hitting the water and getting very wet. Diabetics don’t know they have the disease until they hit the water. But what if they did, and what if the time in the air between the platform to the water could be extended, say by 25 months?

On 17 November, the FDA approved a biologic therapy that delays the onset of Stage 3 by about that much.

The monoclonal antibody teplizumab, which will be marketed under the brand name Tzield, from ProventionBio and Sanofi is given daily through intravenous infusion over two weeks. And it works. Patients who take it extend Stage 2 by a little more than two years.

But there’s a catch, two, in fact. First, PreventionBio announced last week it is pricing Tzield at $193,900, which is considerably higher than insurers anticipated. Second, how does a person know they’re in Stage 2 and, therefore, should be taking the drug? The answer is screening for autoantibodes that are markers for diabetes. This will also incur a cost. More about that below.

The question to be answered is will insurers cover the considerable cost for screening and drug infusion?

In 2014, the FDA approved Harvoni as treatment for Hepatitis C, which is the leading cause of liver failure. Hep C is a life-threatening disease. Harvoni cured it. Completely. Its maker, Gilead, priced the pill at $95,000 for a twelve-week course of treatment. At the time, I was a Director at a Boston HMO. We wrestled with the cost issue. In the end, because Harvoni cured what was a horrific and terrifically costly disease, we gladly decided to provide it for our members.

Tzieild is different. It does not cure diabetes. Rather, it delays its onset. The American Diabetes Association and the Juvenile Diabetes Research Foundation (JDRF) are ecstatic about the arrival of Tzield. They point out this is the first time a successful treatment for diabetes has appeared on the scene, although it’s not really a treatment. However, they’re concerned about the screening issue.

Aaron Kowalski, CEO of JDRF, says the main challenge in prescribing Tzield will be finding people who need it. The drug is approved for people who don’t have any symptoms of the disease and may not know they’re on the road to getting it.

“Screening becomes a really big issue, because what we know is, about 85% of type 1 diagnoses today are in families that don’t have a known family history,” Kowalski said. “Our goal is to do general population screening” with blood tests to look for markers of the disease.

It will be interesting to learn how insurers and health plans react to Tzield. According to the JDRF, 64,000 people a year are diagnosed with Type 1 diabetes. If every one of them received the drug the total cost would be about $12.5 billion. But if you were one of the 64,000, my guess is you’d happily stand in line for it. So would I.

Donald Trump and the Mar-A-Lago fiasco

By now, every sentient person in America knows ex-president Donald Trump dined last week with Nick Fuentes, the poster child for anti-Semitic white nationalism, and Kanye West, who now calls himself Ye and has also spouted anti-Semitic whinge. Afterwards, when social media lit up like the Rockefeller Center Christmas tree, Trump claimed he didn’t know Fuentes was going to be there; West just brought him along.

Putting aside the fact that Trump’s Secret Service detail would never in a month of Sundays allow just anyone to drop in to break bread with the big cheese without getting clearance from the big cheese himself, I’m more concerned with the response of the Republican Party’s leadership to this. Republicans who are likely to run for President, notably Mike Pence and Chris Christie, criticized their former leader, although it took them two or three days to do it. It took more than a week for anyone in Republican leadership to put their wet finger in the air and decide to say he shouldn’t have done it.

The stench wafting from the halls of Congress is remarkable, indeed.

A personal note

Starting tomorrow I shall be away from this, and any other, keyboard for a little bit.

Since I was eight years old, I have been an avid, competitive, pretty good, tennis player. I’ve calculated that in the intervening years I have hit somewhere around just under a million overhead smashes. That’s a lot of serves and put-aways. And they have taken their toll. So, at 7:00 AM tomorrow morning, a very good doctor (I hope) will be concentrating deeply (I hope) on the job of giving me a new shoulder. I’m told it will be a little painful for a while, but on the other side lies bliss, and more overheads.

I look forward to being back at the keyboard.

Today, We Thank Our Veterans ― Ninety Years Ago, We Did Something Else

Friday, November 11th, 2022

Well, that was interesting. The midterm election, not yet over, showed once again experts and their predictions are worth about as much as a sneaker full of puppy poo. All the supposedly smart pundits who predicted the end of democracy as we know it are now doing their best to explain what happened, and why. They forgot, or ignored the fact, that, on the whole, Americans are decent, loyal citizens. Right now, regardless of how the election turns out, we can feel proud of most our neighbors around the nation thoughtfully exercised their right and duty to vote, regardless of how they voted and for whom.

It would be nice to think the Congress we are now still electing will be as thoughtful, decent and loyal to the oath it will collectively take in January. However, I can’t help fearing that in Ronald Reagan’s “shining city upon a hill,” internecine, malodorous warfare will remain on full display. Looking for all the world like a gussied-up version of the Hatfields and McCoys, Republicans and Democrats will once again assemble in a highly organized circular firing squad, seeming far more intent on annihilating each other than on devoting themselves to the moral imperative of governing.

But enough of that. This is Veterans Day, a day to give thanks to all the men and women who gave themselves to the defense of our country.

We’ve come a long way in that regard. It wasn’t always so. One hot summer, fourteen years after Johnny came marching home, he was persecuted, dehumanized and then cast into the darkness of the Great Depression. Here’s what happened.

1932 – Washington, D.C.

At the close of World War I, Congress decided to thank the war’s veterans for their service with some cash — $500, which, in today’s dollars, would be about $7,500. Quite a bonus. But there was a catch: The “bonus” authorized by the Adjusted Compensation Act of 1924 would not be paid until 1945. The veterans did not complain at the time. It was The Roaring Twenties. Everyone was flush.

But then along came the Great Depression. The economy descended from full employment in 1929, where the unemployment rate was 3.2 percent, into massive unemployment in 1933 when the unemployment rate reached 25 percent. From sitting on top of the world, plutocrats were suddenly seen jumping out of windows on Wall Street. Breadlines became the meal du jour. The word, “Hobo,” which had been around, but hardly used, since 1888, became a symbol for the forgotten man.

In the summer of 1932, 25,000 penniless, desperate veterans and their wives and children descended on Washington, D.C. They camped in District parks, dumps, abandoned warehouses and empty stores.  These aging warriors had come to the nation’s capital to ask Congress, admittedly 13 years early, for their $500. Newspapers christened them “the bonus Army,” or “the bonus marchers.” They called themselves the “Bonus Expeditionary Force,” the BEF.

The men drilled, sang war songs, and, once, led by a Medal of Honor winner and watched by a hundred thousand silent Washingtonians, marched up Pennsylvania Avenue bearing flags of faded cotton.

The BEF had pleaded in vain with Congress for the money. They were ignored and left to wither. As a last resort they appealed to President Hoover to meet with them. He sent word he was too busy. Then, confronted with 25,000 squatters he would later label “communists,” while asserting less than 10% of them were veterans*, he isolated himself from the city, canceled plans to visit the Senate, had police patrol the White House grounds day and night, chained the gates of the Executive Mansion, erected barricades around the White House and closed traffic for a distance of one block on all sides of the Mansion. A one-armed veteran, attempting to picket, was beaten and jailed.

Conditions for the veterans were pathetic. The summer heat was severe. Lacking shade or screens, the BEF was beaten down by the climate’s fury. Since the founding of the city, Washington was viewed as a place to be avoided in the summertime. In the words of an official guidebook, Washington was “a peculiarly interesting place for the study of insects.” The veteran men and their families had arrived at the height of Cherry Blossom season, but by July they were debilitated, ghostly, dehydrated and hot. Very hot. The columnist Drew Pearson called them “ragged, weary and apathetic with no hope on their faces.” Downtown businessmen complained through the Chamber of Commerce that “the sight of so many down-at-the-heel men has a depressing effect on business.”

And that was the extent of their crime, their threat to the country. They weren’t good for business.

General Douglas MacArthur, the Army’s only four star general who, even then, referred to himself in the third person, had met with some of the men and assured them if he had to evict them he would allow them to leave “with dignity.” But when the end came for the BEF at 10:00 A.M. on 28 July 1932 there was no dignity to be found. Hoover had had enough, and he ordered “Mac” to get rid of them. Trouble was, he didn’t tell the General “how” to get rid of them. MacArthur, who never did anything small in his life, was unleashed.

First, Police Commissioner Glassford, who had been sympathetic to the men, was sent to tell them they had to leave, orders of the President. They refused, which was when MacArthur sent the Army in, led by then Major George Patton and his 3rd Mounted Cavalry — with him prancing at the front atop his privately-owned horse (he had a stable-full; he was rich) — followed by infantry and a World War I vintage Tank Brigade. Bullets began to fly. BEF men were killed. Two babies were gassed to death. And Joseph Angelino suffered a deep wound from Patton’s sabre-wielding cavalry, the same Joseph Angelino, who, on 26 September 1918, had won the Distinguished Service Cross, the Army’s second highest medal, for saving the life of a young officer named George Patton.

By midnight that day, the Army had driven the BEF veterans, their wives and children across the Potomac and out of the city. But that wasn’t good enough for MacArthur and Hoover. The BEF was chased and harassed west and south, out past Ohio and all the way down to Georgia. Then, the veterans just folded into the vast transient population that roamed the land in 1932.

In 1936, overriding a veto by President Roosevelt, Congress voted to immediately pay World War I veterans their full $500 bonus specified in the Adjusted Compensation Act of 1924.

____________________________________________

*The Veterans Administration, which had the actual service records, would subsequently refute Hoover’s claim with an exhaustive study concluding that 94% of the  bonus marchers were veterans of World War I.

A Midterm Reminder That Bears Repeating

Monday, November 7th, 2022

The Midterms are tomorrow, and, if you’re like me, you can’t wait for the campaigning to be over. The constant emails, texts and television ads will stop―for about a week, after which we’ll begin getting bludgeoned by the 2024 campaign. God help us all.

According to Bloomberg, the two political parties and their candidates will have spent nearly $17 billion to get elected, by far the most for any Midterm election in history. That’s more than the budgets of 14 US states.

Predictions are Republicans will win in the House, and perhaps the Senate, too. If they do, what will happen then?

In early April of this year I wrote about that when I analyzed Florida Senator Rick Scott’s Plan to Rescue America. Scott was the only Republican lawmaker willing to put a stake in the ground and tell America what the GOP would do when, at least in his mind, it inevitably came to power. At that time I thought his plan so outlandish and, to use a technical term, flat out wacky, it would die a quick death. I was wrong. By my count, the majority of Republican candidates, especially for the House, have been trumpeting, Trump-like, many of Scott’s prescriptions for “rescuing” America. And that’s not all. One of the things not in Scott’s manifesto is the myriad investigations the Republican-controlled House will begin immediately upon taking power to show the rest of America all the evil things done by President Biden and his fellow Democrats in the last two years. Impeachment will likely follow. This is not hyperbole, but it sure is scary.

Therefore, today I’m republishing the April analysis to give us all an idea of what might be in store for us over the next couple of years, and maybe beyond. Fasten your seatbelts.

Rick Scott Is Going To Rescue America!

Rick Scott is the junior U.S. Senator from Florida. Elected in 2018, Scott has now served in Congress for 39 months. In November, 2020, his Senate GOP colleagues elected him Chairman of the National Republican Senatorial Committee (NRSC). His job is to get Republicans elected and reelected to the Senate.

Prior to the Senate, Scott was a two-term governor of Florida, succeeded by Republican Ron DeSantis. Before that, he was a businessman. We’ll get back to that later.

You would think the Chairman of the NRSC would be lock-step with Republican leadership in the strategy to take the Senate from the tenuous hold of the Democrats in the upcoming mid-terms. But this does not appear to be the case. Senator Scott is marching to his own drummer.

On Thursday, after no consultation with or cooperation from Senate GOP elites, Scott officially unveiled and launched the Rick Scott, 31 page, 11 Point Plan to Rescue AmericaThe Rescue Plan has 117 agenda items.

This is not a surprise to GOP Senate Leader Mitch McConnell. Scott’s Plan has been discussed for more than a month, and as far back as 1 March McConnell publicly rebuked Scott for it. McConnell is fixated on making the mid-terms a referendum on President Biden, not on laying out a Republican plan he and the GOP establishment would have to spend the entire mid-term campaign defending. He wants Biden playing defense. Scott, on the other hand, wants America to know what Republicans will do if given control of the Senate. Right at the beginning of his Rescue Plan he says, “Americans deserve to know what we will do if given the chance to govern.” If Scott gets his way, now they will. And you have to hand it to him; he certainly doesn’t tap dance around the many issues facing the country.

Before diving into his 11 point, 117 agenda item plan, Scott lays out what the future will look like if nothing changes:

The militant left now controls the entire federal government…Among the things they plan to change or destroy are: American history, patriotism, border security, the nuclear family, gender, traditional morality, capitalism, fiscal responsibility, opportunity, rugged individualism, Judeo-Christian values, dissent, free speech, color blindness, law enforcement, religious liberty, parental involvement in public schools, and private ownership of firearms.

Holy Militant Left, Batman! We need a plan to stop all that!

A few of Senator Scott’s 117 agenda items, guaranteed to be saliva-producing red meat for the trumpiest of trumpsters caught my eye.  For instance,

We will secure our border, finish building the wall, and name it after President Donald Trump.

Kids in public schools will say the Pledge of Allegiance, stand for the National Anthem, and honor the American Flag. We must foster national unity.

Teacher tenure at public schools must be eliminated

We will not allow political or social indoctrination in our schools. Teachers who refuse to comply will need to find new jobs.

We will close the federal Department of Education. Education is a state function.

Government will not ask American citizens to disclose their race, ethnicity, or skin color on any government form.

Our military will engage in ZERO diversity training, teachings on critical race theory, or any woke ideological indoctrination that divides our troops.

We will force prosecutors to prosecute. At present, many prosecutors in big cities are allowing criminals to go free with no justice, and they are doing it on purpose.

Immigrants will not be eligible to collect unemployment benefits or welfare for the first 7 years after arriving in the US.

No government assistance unless you are disabled or aggressively seeking work.

If Congress does not pass a budget, the members of Congress do not get paid. Full stop.

Other than disaster relief, the federal government must stop spending money on non-essential state and local projects until the budget is balanced.

All Americans should pay some income tax to have skin in the game, even if a small amount. Currently over half of Americans pay no income tax.

Enact term limits for the Washington ruling class – 12-year limits for Congress and government bureaucrats.

All federal legislation sunsets in 5 years. If a law is worth keeping, Congress can pass it again.

We will immediately cut the IRS funding and workforce by 50%.

Humans are born male and female, there are two genders, and to deny that is to deny science. No government forms will include questions about “gender identity” or “sexual preference.”

We will protect women’s sports by banning biological males from competing.

No tax dollars will be used to pay for any diversity training or other woke indoctrination that is hostile to faith.

We will not pay any dues to the United Nations or any international organization that undermines the national interests of the USA.

The weather is always changing. We take climate change seriously, but not hysterically. We will not adopt nutty policies that harm our economy or our jobs.

There are a few difficulties with a number of these policy tectonic changes. Ending Social Security, Medicare and Medicaid in five years being among the biggest. Also, Scott’s colleagues in Congress might have something to say about going without pay and getting sent home after 12 years. Increasing taxes on 50% of Americans may prove challenging for Republicans on the campaign trail. Pulling billions of dollars from the states until we have a balanced budget might irritate a few Republican governors. And reducing the IRS’s funding and currently understaffed workforce by 50% would have brought tears to the eyes of mobster Al Capone.*

Although Senator Scott’s plan is dead on arrival, the problem is it arrived in the first place. It’s not about getting Republican senators elected; it’s about Rick Scott.

And what about Rick Scott? As I mentioned above, before getting into government, Scott was a “businessman.” He co-founded Columbia Hospital Corporation in 1987. Columbia later merged with another corporation to form Columbia/HCA, which eventually became the nation’s largest private for-profit health care company with Scott as Chief Executive. According to The New York Times, “[in] less than a decade, Mr. Scott had built a company he founded with two small hospitals in El Paso into the world’s largest health care company – a $20 billion giant with about 350 hospitals, 550 home health care offices and scores of other medical businesses in 38 states.”

Sounds good, right? Quite the businessman.

But there were problems. In March of 1997, the FBI, the IRS, and the Department of Health and Human Services arrived with search warrants. Four months later, Scott was forced to resign by his Board. He didn’t leave willingly, but when he did, he left with a settlement of $9.88 million and 10 million shares of stock worth $350 million. Columbia/HCA pleaded guilty to 14 felonies and agreed to a $600+ million fine in what was at the time the largest health care fraud settlement in U.S. history.

The company admitted to systematically overcharging the government by claiming marketing costs as reimbursable, by striking illegal deals with home care agencies, and by filing false data about use of hospital space. It also admitted to fraudulently billing Medicare and other health programs by inflating the seriousness of diagnoses and to giving doctors partnerships in company hospitals as a kickback for the doctors referring patients to HCA. It filed false cost reports, fraudulently billing Medicare for home health care workers, and paid kickbacks in the sale of home health agencies and to doctors to refer patients. In addition, it gave doctors “loans” never intending to be repaid, free rent, free office furniture, and free drugs from hospital pharmacies.

And that’s not all. In 2002, HCA agreed to pay the federal government an additional $631 million, plus interest, and $17.5 million to state Medicaid agencies, in addition to $250 million paid up to that point to resolve outstanding Medicare expense claims. The entire fiasco cost the company $1.7 billion. Nobody went to jail.

All on Senator Scott’s watch.

There’s one last twist. In a civil suit deposition connected to the case (there were a lot of civil lawsuits), Senator Scott invoked his 5th Amendment rights 75 times.

Somehow, all of that has been forgotten, and Scott has managed to be a governor, a Senator, and, I’m guessing, a man, a businessman, who has his eyes on the biggest prize of all, the one up for grabs in 2024.

Rescue Plan, indeed.

*Capone was a nationally famous, Chicago-based killer and crime boss who went to prison in 1931 for tax evasion.

The Earth Is Moving Under Medicare And The Price Of Drugs ― But Slowly.

Friday, November 4th, 2022

Prologue

This is a story, 16 years in the making, of government-enabled corporate greed. It’s complicated and somewhat dense. It has to be to go on that long. It’s a story of how one industry, the Pharmaceutical industry, has done Olympian good while achieving Titanic profit, which has been surgically excised, Midas-like, from the hides of American taxpayers who never felt the touch. The story ends with a different way, a better way, but a way we common folk won’t likely see.

The story

Medicare Part D, a prescription drug benefit plan for Medicare beneficiaries, became law on 1 January 2006 under the George W. Bush administration and a Republican controlled Congress. The legislation was enacted with no funding provisions whatsoever. Since then, Washington politicians have been arguing over whether this government program should be allowed to negotiate with pharmaceutical companies the prices it pays for drugs its members need. Medicare beneficiaries, all 64 million of them, and the public at large, have overwhelmingly supported such a move. Over the years, pharmaceutical companies have spent a king’s ransom donating to politicians to secure―should we say “buy?”―their votes in opposition.

What’s been the result?

  • A study published recently in the Journal of the American Medical Association concluded more than a quarter (27.2%) of Medicare spending is now for prescription drugs;
  • That would be $180 billion, as reported by the Medicare Payment Advisory Commission for 2020;
  • According to the Kaiser Family Foundation, the total we in the US spent on prescription drugs in 2017 was $333 billion; and,
  • The Rand Corporation studied and compared US prices to 32 other OECD countries (The Organization for Economic Cooperation and Development – the most developed nations) and reported our prices are “nearly twice those of other countries after adjusting U.S. prices downward to account for rebates and other discounts paid by drug companies.”

And now, the gravy train may be slowing.

In August 2022, Congress finally passed―without a single Republican vote―and President Biden signed, the Inflation Reduction Act, which, among other things, allows Medicare to move forward with drug price negotiations―sort of. Right about now, you may be asking what prevented Medicare from doing that all along since 2006 as a normal part of its drug-purchasing process?

As the Kaiser Family Foundation explains:

Under the Medicare Part D program, which covers retail prescription drugs, Medicare contracts with private plan sponsors to provide a prescription drug benefit. The law that established the Part D benefit included a provision known as the “noninterference” clause, which stipulates that the HHS Secretary “may not interfere with the negotiations between drug manufacturers and pharmacies and PDP [prescription drug plan] sponsors, and may not require a particular formulary or institute a price structure for the reimbursement of covered part D drugs.”

In other words, although Medicare is buying drugs for its members, all 64 million of them, it has not been allowed to even hint that a lower price might be more fair and appropriate for the government to pay. That is the very definition of a “sweet deal” for drug manufacturers.

Giving the negotiation contrarians the benefit of a doubt they more than likely don’t deserve, their argument in opposition hangs on the slim thread that negotiations will lower the income of drug manufacturers, and that will, in turn, reduce the amount of money the companies invest in research and development to discover new life-saving drugs. My own opinion is that this argument is chock full of what makes the grass grow green and tall. And, by the way, the Congressional Budget Office agrees with me, although their analysists said it with a bit more eloquence.

And what does the aforementioned Inflation Reduction Act do, anyway?

It does a number of things, one of which is to lay down new rules for price negotiations. These are its major health care provisions, leaving out, for the moment, the negotiation issue. It will:

  • Require drug companies to pay rebates to Medicare if prices rise faster than inflation for drugs used by Medicare beneficiaries, beginning in 2023;
  • Cap out-of-pocket spending for Medicare Part D enrollees and make other Part D benefit design changes, beginning in 2024;
  • Limit monthly cost sharing for insulin to $35 for people with Medicare, beginning in 2023. This might be the most far reaching and important item in the entire legislation.
  • Eliminate cost sharing for adult vaccines covered under Medicare Part D and improve access to adult vaccines in Medicaid and CHIP, beginning in 2023;
  • Expand eligibility for full benefits under the Medicare Part D Low-Income Subsidy Program, beginning in 2024; and,
  • Further delay implementation of the Trump Administration’s drug rebate rule, beginning in 2027.

Notice the years in which these provisions take effect. In most cases, it’s 2023.

The negotiation provision of the Inflation Reduction Act:

  • Requires the federal government to negotiate prices for some drugs covered under Medicare Part D and Part B* with the highest total spending, beginning in 2026. Note the year.

This provision targets the most expensive drugs. Here’s how.

Under the new Drug Price Negotiation Program, Medicare will negotiate the price of 10 Part D drugs for 2026, another 15 for 2027, another 15 for 2028, and another 20 for 2029 and later years. The drugs to be chosen for negotiation will be selected from among the 50 drugs with the highest total Medicare spending. The number of drugs with negotiable prices  will accumulate over time.

So, beginning four years from now, the law goes after the most expensive Medicare drugs.

There are debatable reasons for delaying implementation until 2026, all dealing with operational processes. The period of negotiation between the Secretary of Health and Human Services and manufacturers of the selected drugs will occur between 1 October 2023 and 1 August 2024, and the negotiated “maximum fair prices” will be published no later than 1 September 2024 and will go into effect 1 January 2026.

This seems to me a rather long and drawn out negotiation process, but it is, after all, a political compromise.

The better way

And now for the better way.

There is another government health care organization that has never had a prohibition with respect to negotiating drug prices. It is the Department of Veterans Affairs. The VA.

In January, 2021, the Government Accountability Office released a study that concluded:

“the Department of Veterans Affairs (VA) paid, on average, 54 percent less per unit for a sample of 399 brand-name and generic prescription drugs in 2017 as did Medicare Part D, even after accounting for applicable rebates and price concessions in the Part D program.”

This means what the VA pays is in line with those other 32 OECD countries.

Moreover, the GAO found that 233 of the 399 drugs in the sample were at least 50% cheaper in the VA than in Medicare, and 106 drugs were at least 75% cheaper. Only 43 drugs were cheaper in Medicare than in the VA.

What are the operational differences between the two organizations?

For one thing, the programs pay for drugs differently. Medicare reimburses the Part D plan sponsors to pay pharmacies through the middlemen―Pharmacy benefit Managers, but the VA buys drugs directly from manufacturers. It cuts out the middlemen. The VA can get lower prices because it can:

  • Negotiate as a single health system with a unified list of covered drugs; and,
  • Use discounts defined by law that Medicare doesn’t have.

As in everything political, it all comes down to economics. The VA, with only nine million health care beneficiaries, as opposed to Medicare’s 64 million, could fly under the political radar and avoid congressional restraint. It was able to keep the congressional camel’s nose and, more to the point, its sticky fingers out of its tent.

Medicare is so big, it could never do that.

And here we are.

______________________

*Medicare will also negotiate in a similar manner the prices of Part B drugs. These are drugs administered in physicians’ offices or hospital outpatient departments.

The Role Of Religion In Our Divided America

Wednesday, November 2nd, 2022

Everyone who follows the political winds in the US is laser-focused on the upcoming midterms, which are six days from now. Most prognosticators expect Republicans to end up controlling the House of Representatives, and maybe the Senate, too. While that is certainly possible, perhaps even likely, if we look out farther into the future, the picture is decidedly less rosy for the Grand Old Party.

Stay with me as I try to explain why.

According to the Public Religion Research Institute’s American Values Survey, which provides insight into the beliefs of most of the nation’s faith groups, nearly three in four Americans (74%) say things in this country are going in the wrong direction, and 49% say things were better in the 1950s. That’s right, the 1950s when a third of the country, 51 million people, still had to use outhouses, a cancer diagnosis was a death sentence, rotary dial phones were how we communicated, and Jim Crow was alive and well and on the march. Sixty-six percent of Republicans believe our culture and American way of life have deteriorated since then. Thirty percent of Democrats feel the same way. PRRI sums up its September 2022 Values Survey this way:

Approximately three-quarters of Americans agree that the country is heading in the wrong direction, but there is considerable division over whether the country needs to move backward — toward an idealized, homogeneous past — or forward, toward a more diverse future. Though most Americans favor moving forward, a sizable minority yearn for a country reminiscent of the 1950s, embrace the idea that God created America to be a new promised land for European Christians, view newcomers as a threat to American culture, and believe that society has become too soft and feminine. This minority is composed primarily of self-identified Republicans, white evangelical Protestants, and white Americans without a college degree. The majority of Americans, however, especially younger Americans, the religiously unaffiliated, and Democrats, are more likely to embrace a competing vision for the future of America that is more inclusive.

When examined in concert with PRRI’s 2020 Census of American Religion, a pattern emerges that does not bode well for Republicans.

In 1996, 65% of Americans identified as white and Christian; that number is now 43%, down nearly a third. Sixty-eight percent of Republicans identify that way. Twenty-nine percent of Republicans are white evangelicals. The problem for Republicans is white evangelicals now make up just 14% of the total population. That is down significantly from 23% in 2006. The following chart depicts religious affiliation by age. It also shows vividly that white evangelicals, the rock solid foundation of the Republican party’s base, and to a lesser degree mainline protestants, are aging out of the population. They are being replaced by people unaffiliated with any religion.

Unfortunately for the Republicans, the unaffiliated are predominantly Democrats.

The PRRI data also shows younger generations, especially 18 to 29 year-olds, more often identify as Democrats than Republicans, which should be good news for the Democrats. The problem lies in getting them to vote. Seventy percent of Republicans say they are very or somewhat excited about voting next week. For the Democrats that number is only 64%.

One more startling point from the PRRI Values Survey. Among a host of other issues, the PRRI researchers asked about QAnon, and this is how they framed the subject:

To measure the scope of the QAnon movement, PRRI tracks agreement with three statements that form the core tenets of the conspiracy theory:

  1. The government, media, and financial worlds in the U.S. are controlled by a group of Satan-worshipping pedophiles who run a global child sex-trafficking operation.

  2. There is a storm coming soon that will sweep away the elites in power and restore the rightful leaders.

  3. Because things have gotten so far off track, true American patriots may have to resort to violence in order to save our country.

PRRI labels people who believe all three statements to be true as QAnon Believers. It may shock you to learn QAnon Believers now comprise 19% of the population. It may shock you even more to learn the number jumped five points in the last year. You might want to think about that.

What I take away from all of this is Democrats have a solid opportunity to take command looking out into a somewhat distant future, but they may first have to walk through the valley of death to get there. Republicans, on the other hand, will continue to yearn for “the good old days” of white isolated and insulated America. They may win next week, but that just might be the beginning of their collective swan song, a swan song the Chad Mitchell Trio suggested nicely way back in 1964 with Barry’s Boys, their white-hot roasting of Arizona Senator and that year’s Republican presidential candidate Barry Goldwater:

I wanna go back to the days when men were men
And start the First World War all over again
Back to Barry
Back to Cash and Carry
Back to Barry’s Boys.