Thursday, October 13, 2016

Understanding Trumpers

We are often the cause of our own resentments.

I know I am. Perhaps there are things I want to do but something holds me back. My own personality; my own misperceptions; my own reluctances; messages from my parents, parts of them that live on in me whether I like it or not. My own laziness. My own comfort in the familiar. My own confusion over what I can change and what I can't. My fears.

That's actually what I see when I see a red stain over the middle of the country, broader in the middle and the lower right of the picture, tapering in the less populous mid-continent. Or when I hear about Arlie Hochshield's five years in Louisiana with the left-out whites who think others are being taken care of, but not them. Or about others who lurk about the South and talk to Trump sign-displayers who still talk about the Communist New York Times. I see Reagan voters, I see Bush voters, I see McCain and Romney and now Trumpers who inexplicably vote for lower taxes on others than themselves. I see What's The Matter With Kansas voters. They resent what they have supported and still support and cause to be perpetuated and I guess can't help themselves from doing it to themselves.

Years ago I took a year and lived in Sweden, doing research on medical care, and learning Swedish so I could travel comfortably throughout the entire Swedish Empire, as I joked at the time. If you don't learn the language of the country you are in, it's hard to really be in the country you are in, and it's good to use your brain even if it's hard going. But I was surprised to see how easy Swedish is for English speakers, despite the weird sing-song that I like so much. Unlike Asian and African and Bushmen languages, there are so many cognates and the grammar is straightforward for us. We hear that English is half Romance and half Germanic, with other words thrown in from somewhere else, like typhoon, and assassin. But the Germanic side of English isn't actually German, it's Scandinavian, from the Vikings in the ninth and tenth century – by the way, for a great read, read The Long Ships by Frans Bengtssen (New York Review Books Classic, recommended by my local bookseller Diesel Books, who said Michael Chabon loved it, and I see why, after reading it). So Swedish has an eerie familiarity for an English speaker.

I also read about 10 books on Sweden, the first being a basic history of Sweden. What I didn't know was that in the early days of the 20th century Sweden was known as “fattig Sverige,” or “poor Sweden.” (“Sverige” is Swedish for Sweden, and is pronounced “Sveria.”) That's why we have so may Scandinavians in the upper Midwest; just as the Irish fled the famine (and English oppression), the Swedes and Norwegians fled poverty that had no obvious end in sight. The ostensible reason I had gone to Sweden was to see how the Third Way (Marquis Childs' term) worked. At the time that the imagination of most of the world turned to Communism, the Swedish Social Democratic party, the political arm of the Landsorganisation (the LO, pronounced “landsorganisa-shoon”), had taken the country by the bootstraps and booted up. They enforced equality, and education. As time went by, they saw that they were a small country, a cold country, a homogeneous country, a country with iron and lumber up north, and fish, and about 6 million people when I was there, and an out of the way country that no one had to cross to get to somewhere else. So if they were going to make something of themselves, they would have to do it by themselves, and they would have to think it through and figure out what to inject to the world and how to do it.

So they did. They saw they had to marshal their resources as they found them, and use their brains and their self-discipline and their capacity for unity as enforced by a dominant party. They had to target their shots and specialize in what the world needed. To tell you the truth, I forget now exactly what they found. Electrolux, that I remember. Forest products. Steel. From Wikipedia: “motor vehicles, telecommunications, pharmaceuticals, industrial machines, precision equipment, chemical goods, home goods and appliances, forestry, iron, and steel.”

But here's the point I'm trying to make. They saw the need for self-discipline, education, pulling together, and thinking things out. When they found what they thought was their best shot, they went for it. And that effort had to be extensive and people-centered. So they invested in training – they paid for people to go to school. And they invested in moving people around – they paid people to move, paid for new housing, and let them spend supported time getting situated and learning their new skills in these industries. Paid them not to work for a while.

So, guess what? It worked. Fattig Sverige became fattig no more. It became a country that worked because they tried to make it work, they dared, and they did it through a state that people complained about, but that they supported and paid lots of taxes to, and that was worthy of trust. Today (well, in 2013), from The Local, a Stockholm publication: Sweden has come in second place in a ranking of citizen well-being on the OECD's Better Life Index, beating its Scandinavian neighbours but still outgunned on the happiness scale by the Australians.”

The United States has a long and glorious history. We were poor, too. The colonists didn't have much. Look at what they wore in the Civil War – God, they had nothing! They had a couple of shirts and pairs of pants, maybe. And yet the country came to prosper, led along a different path than Sweden, rich in natural resources and a constantly enriched population of ambitious immigrants who understood the need to learn a new language, get educated, and work hard. World affairs helped as Europe despoiled its own lands and industries and we had lots of fields to ourselves. But when they regrew, we didn't see exactly how we could target our shots forward. Almost inadvertently, it seems, we enlarged our capacity by putting our women to work, and we are now, certainly belatedly, starting to find strength in our formerly excluded populations, our “minorities.” So progress is being made.

But we are not biting the bullet the way the Swedes did. Globalization and automation are here to stay, and they should be. Imagine the backbreaking work of farming, or mining, or working on the line. As Galbraith observed in his autobiography, when he worked in the agricultural fields of Ontario, he quickly found the attraction of “inside work,” on his road to economics stardom. Who would want to go back to the past of drudgery? Imagine if the fields could plow themselves, wouldn't that be great? Yes, of course it would be, and it is, but the problem is, who owns the means of production, who reaps the reward? Therein lies the rub. How does one distribute the benefit?

You have to find a way that people who are displaced get the benefit of the advancing technology. That was the genius of Sweden. They did it in a social democratic way. They took those displaced workers and made of them something else, not usually economists, but technicians in other fields that needed skilled workers. They paid for them, and the people put in the work. That is precisely what the United States has not done.

We have instead followed a Conservative line. We have kept our money from the state instead of investing in our people through the state. We have neglected not only transportation infrastructure, but people infrastructure. We have said the government is the enemy. We – and I mean not me, not my part of the country, but rather that red swatch of states from South and Southwest up through the Midwest and Upper Midwest, and don't forget coal country in West Virginia and Kentucky – have been distrustful of government and instead voted for conservatives for 40 years at least. The Christian Coalition has been successful. The governing group is not really a majority of the country, actually, it's the residue of the constitutional compromise that ensconced the Senate in the hands of the small states, that didn't foresee the importance of cities and coastal states. My America would vote for more training, for more support for the displaced, for rifling our economic shots, at least I think we would. But the less than 1 million Wyomingites have two senators and disproportional power, and so do the other red states. The South is still afraid that the money would go to those more darkly hued than themselves. The Democratic Party has been unable to muster the dominance the LO forged in Sweden, the country has been unable to think of itself as homogeneous in spirit, and those traditional populations in the South and the Southwest and the Midwest and the Upper Midwest and coal country have voted for lower taxes on others that they could have used to retrain and relocate themselves. Even Democratic Presidents have had to minimize their objectives. The Republicans have won, and whoopdedoo, where are you now, my fellow Americans?

My wife says, yes, it's a shame where they are economically, but what are they doing for themselves behind their Trump front yard signs? Well, I answer, what can they do? They don't have the schools and the training programs and the relocation funds and help available to them. Not everyone can do it for themselves, get themselves together and move to California or wherever and pull themselves up all by themselves. Most people are just average, and a fair percentage, I guess 49%, are below average. I remember them from high school, giggling or hacking off over on the side of the classroom. What were they ever going to make of themselves, they who couldn't learn French very well or chemistry or very much at all? They needed help then, and they need help now, and they could get it if they were smart enough to know they weren't smart and that they needed help.

Independence is great, I like it myself, but sometimes it gets in the way. Sometimes you have to work with others and trust, and sometimes you have to be smart enough to see that the business school people, graduates of Wharton, are just going to look after themselves. So you have to elect people to go out and make sure you get taken care of, and then be willing to do your part. You have to hang together and work together.

And sometimes you find that you can't. You get deluded and you get seduced, your memories of your parents and how they voted get in the way, and for 40 years or more you vote for those who lie and cheat and steal and do business the way the business schools taught them. But in the end, with all your resentments at your lot in life, you have to look at yourself straight and understand that, in the end, you did it to yourself. And then you have to take yourself by the bootstraps, boot up, and do for your children what your forefathers did for you, and start your journey with a single step, and just change how you vote, and do what you can do differently, if what you have been doing hasn't been working for you. You have to turn the red stain blue, and do it by the roots. The grass will always grow if you let it.

Budd Shenkin

Friday, October 7, 2016

Maybe I'm Not A Liberal II

I get my politics from my parents.  They we Democrats, Jewish Democrats, liberal Democrats.  I’ve always thought I was basically a liberal Democrat also.  I still think I am.

But maybe I’m not.  Not that labels are important, but they do describe something.  A general world view, maybe.  How you vote, yes, that’s probably right, at least for party.  But they say that nowadays labels are kind of out of date.  And since I’m one of the highly educated, maybe my nuances make labels even harder.  But being on the left is sort of a birthright to me.  Concern for others, that’s part of what it connotes for me, it’s a basic morality that was handed down.

So, given that, I am totally outraged at the Left, the way someone who has been betrayed feels.  All the lefties who want to restrict free speech, especially on campus.  Can you believe it?  These people are total jerks — or, better to say that their position they hold on this issue is mistaken.  Or, they’re jerks.  Dunno.

And the anti-Semitism!  God, how can you stand that?  It used to the the Right, now it’s the Left.  Maybe I feel the way liberal Republicans, or even moderates talk about that party — I didn’t leave it, they left me.  And the Republican party has indeed been highjacked - not that I could ever be a Republican.  I don’t like smug country club members.  They remind me of my middle school nemesis, Dicky Richards, with red faced and red haired daddy picking him up in a woody station wagon.  We’re talking identity.

In the NYT Dave Leonardt yearns for a Republican Party that actually represents some conservative views, instead of its simplistic partisan stance, often a cover for racism and stupidity.

Here is what he lists as some views they could responsibly reflect:

“…in favor of reducing the role of government in many areas of life and expanding the role of the market.

There are similarly serious arguments in favor of immigration restrictions, abortion restrictions, a more hawkish Syria policy, more competition in education and any number of other conservative positions.”

I looked at these and said, “Wait a minute!”

I am dismayed at the ignorance and ham-handedness of government a lot, and I see a lot to like in a market, if the market is governed properly, and I see a lot wrong with the way regulation works, and the way government works.  I see a lot to dislike in the modern corporation and the corporate-dominated state.

I’ve posted about immigration — I can see virtue in helping people in need, but there is a difference between that and welcoming people who want to keep their own culture and live their life that way when they are here.  If they want to learn English and live as Americans, then they should be able to come.  Otherwise, just take a timeout here until they can go back.  So I say there needs to be a middle ground, where we can be humanitarian but still safeguard American culture, at least to some extent.

Abortion - nah!  I’m for abortion, as necessary, on demand, only restricted when the fetus is viable.

Syria hawkish policy — hell yeah!  I think we should have bombed the Damascus airfield when the Red Line was crossed, and I don’t see “working with Russia.”  Russia is a hellhole.  Politically, how did they ever help the world except for WWII, which was in their own national interest?  Political ideas from Russia?  Anyone?  Culture OK, politics not OK.  And now, true to form, it’s Russian nationalism pure and simple.  Yes, it’s hard to get into Syria and distinguish opposition to an awful regime, war criminals (along with the Russians), from those who would have an Islamist state.  But it would have been good to hobble the regime, and now to establish some safety zones.

More competition in education — absolutely!  Public schools will never change from within, ever, and they are shortchanging everyone.

So, color me shocked by recognition.  I still can’t picture myself as a conservative.  Notice he doesn’t say anything about income distribution, or strengthening equal access to success.  Those are important.

My friend Colleen Kraft, with whom I share a Myers-Briggs classification (ENTP), and with whom I generally agree, says I’m socially liberal and fiscally conservative.  My old friend Jonathan Gross, who I think is conservative, says I’m a centrist.  Oh, God.  Maybe that’s just what I am.  That sounds so dorky!  I want to be vibrant, alive, incisive!  I guess a centrist could be that.  I dunno.  I think Snowden did us a big favor and should get a year, maybe, suspended if possible.  Is that Centrist?  I dunno.

I guess you have to wear what fits you.  Sigh!

Budd Shenkin

Monday, September 26, 2016

Out-Of-Network Sneaky Pricing

Seventeen years ago Peter Shenkin had a 4,500 pound live oak tree fall on him while his high school class was camping by the American River near Sacramento. Without the air mattress he was sleeping on and being teased about by his classmates, he would probably have been killed. 

Thank God he wasn't. Instead, he was transported to the nearest officially-designated trauma center, Sutter Roseville Hospital. I'll skip the bad parts of his care – the surgeons kept him waiting for hours before operating and let regularly scheduled operations proceed, they failed to preserve a kidney – and skip straight to the billing. 

Pete was fully insured by Blue Shield, the hospital was a participating provider, but amazingly (if you didn't know how these things work) the trauma surgeons, appointed as such by the hospital, were not Blue Shield preferred providers! That is, they were not “in-network.” Doctors sign up to be “in-network” so that they get more patients and accept a lower fee for doing that, and the insurance demands much less out of pocket payments from the patients. The trauma doctors saw no advantage to themselves by signing up, so they didn't. How a hospital could be in-network, and be a state-designated trauma center and yet allow the doctors to be out-of-network – well, let's just say that state law is sometimes deficient in their protection of the public.

So our insurance paid for the hospital, but we were expected to pay the full (very full) fees of the surgeons above what Blue Shield covered. That's what is now called a “surprise out-of-network billing.” Of course we didn't accept it, and Blue Shield eventually paid it. But law and insurance being what it is, can you believe when Peter got his settlement for the law suit we brought for various malfeasances that led to the accident, Blue Shield claimed tens of thousands of dollars of the settlement for their own payment for medical services rendered? It's just hard to believe. Despicable, really.

That was 17 years ago. You would think that even the slow-moving governmental system would have fixed the problem by now. Nope. It's just gotten worse, since insurance companies have adopted “narrow networks” as their preferred method of keeping costs down, which means offering very low payments to providers and seeing who will sign up at those low levels, and since only a few will sign up, the chance of being out-of network has been magnified. So imaginative of the insurance companies.

Here is what Peter wrote to me about a friend last week:

(My friend) had apparently reached his annual out-of-pocket maximum according to his health insurance, and Sutter continued providing him care for his ulcerative colitis. Sutter, though, did not inform Mike that the infusion treatments being provided to him were 'Out of Network' and he would be assessed a $399 charge each time. In fact, I am fairly certain that Sutter even went as far as to promise that there would be no charges for the infusions.”

Then just a few days later, Lola and I were up at John Muir School with her old friend Yuval, as much as a 6 ½ year old can have an old friend – they met at the “Nanny Park” in Berkeley as 2 or 3 year olds. Yuval came up with an unusual case of liver cancer, and has been well and successfully treated, thank God. He's now fine, although hearing-impaired from the treatment. Indeed, his father, Justin, said that they had just had their valedictory visit to Lucile Packard Hospital; after this, no more annual visits, just cured. It was a visit that lasted two hours, during which he received an ultrasound exam and a blood drawing for alphafetoprotein, nothing terribly special. Great, all negative.

Then came the bill. The bill. The bill was $12,000 for the visit. $12,000. $6,000 an hour? But, being the forgiving institution it is, Packard cut it down to $8,000. I wonder if they said “Just for you!” And – you've been waiting for this – when the bill came, that was when Justin discovered that Packard was now “out-of-network.” So the family is expected to pay the balance of the bill. Surprise!

He will protest, he's a sophisticated guy, and I'll bet he won't pay. But can you believe it? It's bad enough to raise the price to the patient right in the middle of the process, but adding stealth?

So, what is the basic issue here? To my mind, a big part of the problem here is the confluence of health care and business. Clearly, health care has to think about business economics. The past is horrendous. As my old attending pediatrician Henry Shinefield said, medicine was given an unlimited budget and they exceeded it. Medicine needs to be more mindful.

But mindful how? There is not just one way of being “business-like.” There is the stolid, thoughtful, rigorous costing and pricing and economizing and making efficient activities of any business. The Main Street Ethic. Good! That's what we need.

On the other hand, there is also the Wall Street Ethic. What is the ethic of Wall Street? Lying, cheating, stealing, and charity balls. They have elevated this into “the American way of business,” as though this has always been true, which it hasn't. They have even exported it. Talk about obnoxious. Talk about rationalization. Talk about Trump as the apotheosis, even though he doesn't have their “class.” Or pretensions, better said. Or maybe he does.

The WSE says do whatever you can or whatever you want, greed is good – yup, it's still with us. I won't go on, the reader will have his or her own examples up the wazoo, certainly from the newspapers, possibly directly from one's own life. WSE is exemplified by the generic pricing scandal. If it's not illegal, why not do it, if you will make more money? And maybe it doesn't even have to be legal. Wells Fargo customers are no doubt checking their statements.

The question, then, is which form of business will medicine be adopting? Will trauma surgeons at a trauma hospital be forced to accept preferred provider status, or something similar? Will out-of-network charges be capped and applied to the insurance companies rather than the patients? These are governmental decisions at some level. In California AB-72 is on Governor Jerry Brown's desk. It would limit out-of-network payments to 125% of Medicare, with some other provisions, I guess. It is patient-generated legislation.

It's too bad that this legislation had to be patient-generated. At another level, isn't this something the medical profession itself should be taking on?

Do we want to be stealth pricers? Do we want to countenance prices like $12,000 for two hours of work? Or do we want to voluntarily construct a system that eschews the WSE and adopts the MSE instead, where pricing is both fair and transparent, where efficiency is a goal, where patient service is a goal, where the patient is treated with respect?

If medicine is silent and accepting of how others structure our profession, if medicine does not stand up for righteousness, the business of medicine will contaminate the profession of medicine, and trust and respect will be further eroded. There is no Chinese Wall between business and practicing medicine. The medical profession should be standing up. The medical organizations should be standing up.

They haven't so far. But will they? That's really the basic question.

Budd Shenkin

Friday, September 16, 2016

The Plague of Generic Medicine Pricing, Two

My wife has pernicious anemia. That is a condition where the gut does not absorb vitamin B-12 into the bloodstream, so it needs to be injected into a muscle periodically. This malady was first described in the early 19th century and was known as Addison's anemia. Mary Todd Lincoln was a famous sufferer of pernicious anemia and eventually died of it. Medical science learned to treat it with liver extract in the 1920's, and the vitamin was specifically identified in 1948. In the 1950's purified vitamin B-12 was available for injection.

For years I have injected 1 cc of vitamin B-12 into my wife's shoulder every 6-12 weeks. Each vial costs about two dollars. What a wonderful gift it has been! What a triumph of medical science! Don't tell me modern medicine isn't great – today, my wife will get a life saving treatment that was unavailable to the wife of the President of the United States about 160 years ago. Today it was time for another injection and we found that it was time to reorder the vials. I called Sharon in the pharmacy and they had it in stock. I will pick it up this afternoon.

But all is not rosy in the world of modern medicine's generic pharmacy section. Sharon called me back. She said that while each vial of this life-saving medicine had formerly cost two dollars, the price had now gone up 600%, to twelve dollars per vial. 600%, ladies and gentlemen, 600%. Sharon asked me if I still wanted it. Well, yeah, it's kind of important to our family, saving lives and all, I'd say. (Gotta admit also, compared to the other generic problems, this is little league. But it's the principle!)

I railed against the American Academy of Pediatrics for not taking a stand on this in a post a few weeks ago: Now I say, forget the AAP. Let me say, diplomatically, they are what they are.

Instead, the culprits are (1) the evil pharma industry and the evil Wall Street culture of “if it's not illegal, it's OK,” and (2) the toothless bought-off government. What a world.

If I were a Hillary advisor – what a plague that would be, but if I were – I'd take this up as a cause. She proposed a commission for the Epipen problem and moved on. But I would take it as a case where she could stand up for people against industry and Wall Street. Call for laws for regulation that protected people against the evils of untrammeled capitalism. If I were a Trump advisor – heaven forfend – I would do the same. It's hitting everybody, and the case is so black and white it makes itself. What an opportunity – away from emails, or away from is Obama a citizen.

But, once again, what can one say about this depressing era? O tempora, o mores? As I recall, that speech was given not long before the demise of the Roman Republic. Hoping that's not the case, I remain your faithful correspondent,

Budd Shenkin

Friday, September 9, 2016

New Trump Appointment

President Donald J. Trump today named Harland Dorringer, DC, a chiropractor from Harlingen, Texas, as the Surgeon General of the United States.

Dr. Dorringer stated in his acceptance statement that he welcomed the opportunity to serve his country by redressing the ills brought on by the “current craze for allopathic medicine.”
“This country has been anesthetized by the self-interested magical spell cast by rich doctors,” he stated.

“Look at the millions of dollars we are wasting by all these vaccinations,” he added. “Not only are they expensive, they cause untold numbers of diseases and side-effects. It would be much safer and cost-effective to substitute spinal manipulations for these injections, not to mention less painful.”

Dr. Dorringer also said that the trend toward using electronic medical records was a result of doctors' bad handwriting, which could be better corrected by massage. He also questioned medicine’s poor opinion of tobacco use, stating that the nature of sedentary work required that the lungs needed some stimulation, “so it might as well be tobacco smoke.”

Mr. Trump was asked if he supported these opinions, and responded: “We're certainly going to look into it closely, with the best people. I know that I have benefited greatly from chiropractors in my life, and it was a chiropractor in fact who introduced me to my wife in a special office he ran for VIPs, of which I certainly was one.”

Budd Shenkin

Friday, September 2, 2016

Hillary and the Ron Burgundy Strategy

I certainly hope that Hillary is not playing the prevent defense when she is ahead, which has been known to prevent victory.  It’s important for her to appear restrained, adult, capable, knowledgeable, and safe for the electorate.  She’s not really very maternal, and it’s hard for a woman to be paternal, which usually gets a male candidate pretty far.  So I’m not sure what the image should be.  Capable and sure-handed for sure.  Looking for an image here and not coming up with much.  Maybe it’s because I’m so ambivalent about the whole mother thing.  And maybe football also isn’t the right image.  Maybe tennis.

She’s come a long way.  She doesn’t shout much anymore, although I still hear her as strident in a large forum.  She still can’t bat away problems like the emails very well; I don’t get the impression she would be a very good net player.  So I guess she needs others at the net while she strokes the ball back and back and back, sometimes with a decent angle.

Her problem is control, which she feels she needs.  That’s OK for tennis.  Her problem is warmth, which she doesn’t have much of – too much in control, at least in large groups.  Her problem is that the press can’t wait to get at her when she’s at net, so she stays back because she hates them, and truthfully, I wouldn’t like to face them if I didn’t have a good net game, which she doesn’t.  JFK did, for sure, but he banked on charm and did that all of his life.  He could get away with it.  Her, not so much.  

So what should she do now?  Don’t play defense, don’t overplay offense, stay away from crowds and shouting, appear competent and safe.  I would use some underspin, be a little subtle.  Try the back courts sometimes; no need to be center court all the time.

Play to your strength, which for her probably is the long, low shot from her forehand the other corner’s forehand.  Not showy, just consistent, issues rather than personalities; issues are her forte. She should take a new issue every two weeks.  Choose them carefully, but don’t make them look too easy.  Infrastructure has already appeared; that’s good.  Tie education to infrastructure – the future is our people.  Go into the details, personalize it with people.  Fernando F. is good with his hands, OK at math, isn’t that much of a student.  A match for him is skilled work.  What we need is technical academies where he can learn technical arts – building things, using computers to do so, etc.  We can do this!  Mary G. doesn’t have much money in her background, but she is an excellent student with strength in science.  She needs college to have a few different choices – here’s what the country needs to offer her.  Etc.

I would also play in regional tournaments; every day doesn’t need to be the Open.  I’d take what I call the RON BuRGUNDY STRATEGY.  Every community in the country has its local news anchors, and local weather-people, and local sports people – the local club champions whom everyone knows.  Get out and meet them!  Drop in like Stephen Colbert did in Minnesota, or schedule a session with two or three of them together from the different local stations – but without long preparation, more like popping up.  Dropping in with the locals will humanize her, and won’t tempt her to look like a blowhard.  She could push the issue of the two weeks at these shows, and be prepared to volley well when emails and Libya come up.  These volleys will be easier to handle than at the Open.  They won’t have many follow ups, or if they do she can compliment the questioners and tell them that’s what we need, involvement with the issues at every level – thank you!  The local format would bring out her warmth, I think.  Just calling the local people by their first names without being patronizing would work.  The national shows would pick these up and voilá – free media! 

The Ron’s of the world will bring up the emails.  How should she volley that back?  Hey, Ron, I made a mistake!  I wouldn’t do it that way again – by the way, Ron, have you ever made a mistake?  If you did, I hope you apologized and learned from it, because we all make mistakes, and that’s all we can do, is to make sure we don’t make the same ones again.  So, it’s true, I made a mistake. 
But one thing I have learned in my public life is this: consult widely.  I have this policy I’ve been talking about recently, and there will be others.  One of the reasons I’m coming here to Charlotte, and I’ll be going other places, too, is so I can get input on these issues.  If we don’t talk about it, we won’t come up with the best approach.  One thing about the news industry in this country is, it’s independent.  So I’m hoping to get the fullest reach of opinions I can so we can make good public policy.  Ron, I hope that if there’s more discussion about this, you’ll get in touch with me and let me know what everyone’s thinking.  Now, do you want my personal or my campaign email address?  (Joke Ron!)   Or do you want me to come back and we’ll talk again?  Maybe if I’m elected, we’ll have a whole bunch of local newscasters come to an event in DC – waddya think?

Ron might also ask: What do you think about all that negative opinion about you out there?  Doesn’t that make you feel bad, or nervous?  Volley back: Ron, I think everyone likes to be liked, and I’m sorry about those numbers, it kind of hurts my feelings, you know?  But here’s what I’ve learned about that.  In every public job I’ve had – senator and Secretary of State – as I’ve worked at it, the public has always come around to appreciating that I’ve done a good job.  I might not always have pizzazz, but one thing I do have is persistence.  I’ll work at something until we have it right!  I really will.  And in a way, those negative ratings motivate me, kind of like some athletes feed off of being underrated.  I think it gives me extra incentive to work hard and do a good job – and that’s exactly what I intend to do, if I’m lucky enough to get this job I’m applying for.

Those are good answers, I’d think, and tearing up Trump to Ron Burgundy and friends won’t work.  But getting the surrogates out there tearing up Trump – that will work just fine.  Then she can just refer to the others’ anti-Trump speeches and say, I agree with him or her – did you see that speech she made on Thursday?  I thought it was pretty good.

Even a baseline player has to come to net sometime, and the debates will force her to do that, to think on her feet.  But she is steeped in knowledge of the issues, and she’s very smart and a good debater, so I think she’ll do well, especially if she can flash some humor.  If Donald goes after her as “crooked Hillary” or something else very demeaning, I’d just call him on it.  I’d say, look Mr. Trump, when you make that kind of schoolyard personal attack, it just demeans us both.  So I’m not going to respond in turn.  I’ve stood up to bullies in my life since I was 4 years old, and I’m not going to stop now.  So just stop it and grow up and talk about things you believe or you know.  How about that?

Anyway, that’s what I’d do.  That and go back to central Pennsylvania as she did in 2008 and do shots with the guys.  That's always fun in the middle of a tournament.  The great Bill Tilden said, don’t change a winning game.  He also said, it’s fine to go after an opponent’s weakness, but if you really want to destroy him, go after his strength.  When that collapses, he’s totally done.  If she succeeds in getting the moderate Republicans over to her side, maybe she can make the Democrats into that party people have been aching for, one that occupies the great center while the opposition splinters and fights among themselves.  It could happen.  I wonder what she’ll do.

And on the other hand, this might all just be a load of crap.  Maybe she's just as happy hanging out with rich friends, and there's not much else she can do but wait for time to run out and become President with all the honor and glory and power, because that's all there is there.  Who knows?

Budd Shenkin

Saturday, August 27, 2016

Epipen, Generics, and the Challenge to the AAP

Now everyone knows Epipen, the auto-injectable allergic anaphylaxis antidote whose manufacturer is now price-gouging patients who need it. Little Pharma (generic manufacturers, as opposed to Big Pharma, with the blockbuster brand names) has finally, perhaps, gone too far, just as Jose Canseco, Mark McGuire, and Sammy Sosa finally broke the steroid back way back when. A generic company has an old drug that was cheap for years, and instead of simply continuing to charge what it charges and make a normal profit, since it holds a monopoly on manufacturing the drug, it blithely raises the price to the rafters. Those needing the drug have no choice but to pay a lot more than they used to. The biggest difference with McGuire et al., I guess, is that Major League Baseball had the tools to enforce reform. With the federal government prostrated before pharma, the arrow in the quiver is not so apparent. A new arrow will have to be manufactured, because the government can't now price fix in a (fictional) free marketplace for medicines.

I first heard about the generic issue a few years ago when my med school roommate, now an ophthalmologist in Anchorage, told me the price of an ophthalmic generic he uses in the office had gone through the roof. Then there were articles in the media, and pediatricians on our American Academy of Pediatrics SOAPM listserve started complaining that mebendazole, a great and formerly cheap medicine for pinworms, now cost $600. Sneering Martin Shkreli then entered public consciousness by raising the price of daraprim by 6,000% or something, and even Congress had to become aware of the gap in the law. And now Mylan Pharmaceuticals, headed by Heather Bresch, the daughter of conservative West Virginia Democratic Senator Joe Manchen, says she is “just running a business,” but in the process has stepped on the snake of allergic families, who are too numerous to be ignored, by boosting an Epipen two-pack to $600, a supply that has to be renewed every year and a half, and which quite often needs to be paid directly by the patient because of their high-deductible policies. Congress is once again “Shocked! Shocked I tell you, Ricky!”

What a charade. What a charade. You are a professional organization dedicated to the health and well-being of children and their families, but you evade an issue as long as you can, do nothing, have no plan, don't give a crap, really, crocodile tears up to the knees. When the issue finally comes to a head, led by an on line petition from patients, not professionals, patients – they publish a “me, too” statement from our president that commiserates with the financial burden of patients and says not one stinking word about the general subject. No outrage, just hand-wringing.

At the AAP, they tell us don't say “they,” say “we,” “we are the AAP!” OK, I'll say “we.” We are full of crap. We knew it was going on – the listserve had it on there time after time. I suggested to our Committee on Child Health Financing that we compile a list of affected generic drugs and press this on our government. I suggested it publicly on the Listserve. At least confront Congress with the scorecard. Good luck with that.

So the Listserve erupts along with the public over Epipen. One participant points out that the issue was number four in priority in last year's ALF – the Annual Leadership Forum – where the top ten are supposed to be acted upon. Acted upon. That means, taken up as a priority. Something done about it. I said, great, an ALF resolution. Duck and cover, crouch and shelter, because here comes the earthquake of AAP intervention! Right, the Listserve commentator wrote to me privately, it's really a shame what happens to ALF resolutions.

My friend Christoph, Chairman of SOAPM, a courtly and energetic young man from North Carolina whom I like, whom I indeed urged to run for the position, forwarded the issue to another competent and amiable young man (they're all getting young to me, sigh) who heads the AAP Washington office, whom I also like. He responded:

  • we have been thoroughly engaged in working with public policy makers, the company and others to address the burdens the high cost places on families and the barriers it creates to accessing this crucial medicine.

  • we are working with Congressional staff to help them understand the issues. Since ALF, we have been pursuing an advocacy agenda, led by the AAP Committee on Drugs, and have participated in Congressional hearings as well as HHS meetings on Epi Pen and other drug pricing issues. We have also formally joined an AMA task force on pharmaceutical costs. 

  • With AAP support, one of our members ... took our concerns right to the COO and CEO of Milan (sic) earlier this summer.
  • To keep up the pressure, Dr. Dreyer is issuing a media statement today.
So I responded:
­Mark, why haven't we heard anything about this?  Why is the President's column in the AAP News always about helping the poor (not that there's anything wrong with that)?  What has the AAP been doing?  Is testimony effective?  What has it been, anyway?  Have I just been inattentive?
There is a whole list of drugs that have gone up and up and up, Schkreli-ized.   What is the AAP perception of the problem?  As someone has said, it's not what's illegal that should be stopped, but what's legal that should be stopped.  What is the AAP preferred solution?  Or at least, where is the AAP explanation of the difficulties of having a solution?
Is the AAP modus operandi to be a soft voice inside the tent, or to make common cause with parents and patients outside the tent?
Is it better for the AAP membership to be left out of the action?  It may be, that's a viable position, but it probably conflicts with the concern for membership numbers.
I have a lot of respect for our Washington people ....  I'm less secure in the AAP's traditional avoidance of public controversy in political matters, and this is a political matter, with lots of money and power on the other side (pharma), some of which spills into AAP coffers, I imagine.  That can lead to an organizational dilemma.

There are lots of questions here.  But at this stage, I think it should be embarrassing for the Academy to be upstaged by an on-line parents' group in a matter that relates directly to the health and well-being of children.

budd shenkin

More discussion followed. Christoph observed that lots went on that we won't know about but that this is appropriate, because the Listserve is available to many people who work for pharma. Some truth in that, but only some. Christoph expressed his confidence in the AAP, which I don't share. But he is congenitally trusting and I'm suspicious, a learned habit.

What kind of an organization are we (“we are the AAP”)? I think we are not a shit-kicking, obstreperous organization, which can be OK. As long as we press forward and stick to achievement. But all organizations need to guard against being a blame organization, where the chief objective of members of the organization is to avoid blame and thereby to keep one's job. There is a difference between patience and complaisance.

Mark's reply is CYA – we have fulfilled our responsibilities to the membership, here are our activities. Our theory? Dunno about that. Our endpoint? A rollback of Epipen prices for a while? That's pretty limited.

In fact, the problem with generics is generic, not particular. What do you do about the phenomenon? It's a puzzle. In a past era of corporate responsibility, corporations did not identify their actions the way the Mylan CEO does, as simply increasing shareholder value. Instead, they saw their responsibilities as extending to the welfare of their clientele, their workers, their community, their country. They identified their actions not in reference to what was legal, but to what was right. Not all of them, and not all of the time. But the feeling was expressed by Charlie Wilson, president of General Motors, when he was asked in his confirmation hearing to be Secretary of Defense in 1953, if he could make decisions as Secretary of Defense that were adverse to the interests of GM, said yes he could, but that he could not conceive of that situation “because for years I thought what was good for the country was good for General Motors and vice versa.” Or think about the relationship of Eastman Kodak to Rochester, New York. So in those days, unlike today, shareholder interest was important, but not decisive.

Not that the 50's were definitive of greatness. The auto industry declined in serving the public well, their organizations became blame organizations, and it took the Japanese for the industry to start serving the public well again, and it's not clear that Detroit ever really caught up. Industries decline – nations decline, for that matter. The point is, for decades the generic industry functioned well. When the patents on brand-named medicines terminated, generics took their place with much lower prices, the public was well served, and the new manufactures made a reasonable profit. Now, like Detroit in the 70s, the generics industry is in moral decline, driven by the nefarious Wall Street perception that the only boundary for industry action should be legality that can't be evaded, and if it can't be evaded, legal change can be bought. Epipen is just a symptom.

Every change in profit-seeking is buttressed by an ex post facto ideology. The current ideology is that of the radical free market, to an extent that Adam Smith never dreamed of. Narrow self-interest has been deified as socially responsible. “Greed is good” prevails. But this is new. In fact, as current debate on the course of capitalism illustrates, there has always been conflict between capitalism and democracy. Democracy sets the playing rules for competition so that it serves the public interest, and democracy also erects such public protections as labor laws, financial regulations, and welfare systems. (see unfortunately behind a pay wall, )

And because economics is never stable for long, there need to be constant readjustments. The surprise over the depth of Trump and Sanders support reveals once again how unstable capitalism is, how there are always losers, and how limits always need to be set on the winners. One need not be a Marxist to understand how the triumphs of today lead to the contradictions of tomorrow – how will we pay our populace as robots edge toward the nirvana of less and less boring work? But I digress.

The point is, if custom and moral social responsibility will not regulate a company that finds itself in possession of a monopoly product, how can we restrain the rents obtained? (that is, profit based on monopoly rather than competition and costs.) One way would be to bust up the monopolies by easing entry into the field (reform the FDA), or even subsidizing the creation of competitive entities. This would be nice, but oligopoly is not a great solution to monopoly, much as we welcome the self-regulating mechanism of competition. Oligopolists also enjoy rents. Another would be to regulate profits of the generic industry – difficult, but it could be done by clever economists. I could imagine other solutions as well, but whatever, it is crystal clear that something needs to be done.

How does this relate to the AAP? For government to act, there needs to be public pressure. As FDR said when meeting with a convincing case presented in his office (paraphrase): “You've convinced me. Now you need to go out there and make me do it.”

If you want to keep your job, you can follow procedures. You can refer an issue to the Committee on Drugs (what did they do, I wonder?). You can “meet with Congressional staff,” which means bring the issue up when you are meeting with them anyway. Etc. You can “maintain your relationships” with your counterparts in government. You can defend yourself before your constituents by citing procedures followed.

Or you can make the case and build up pressure. The NRA has no problem doing that. They educate their members on the issues at hand, they meet forcefully with representatives in Congress, they threaten vengeance on non-adherents. They aren't lovable – Wayne La Pierre is probably psychotic – but they sure are effective.

The AAP (I forgot - “We”) could make the case to our membership. What pediatrician is not enraged by these price increases, but these suddenly unavailable medicines? Instead of sending out email missives “let your Representative know!” “we” could really organize and bring it to them. We could get our task force moving in important districts. We could have a position, for God's sake – currently all we have is hand-wringing. We could have a newsletter that mentions the issue now and then, and actually elucidates the general problem so that there really is a general consciousness and understanding within the organization members.

We” could generate a sense of outrage. Here are companies that act against the general welfare under the guise of “doing business,” as thought that were clearcut. “We” could push as though we meant it. “We” could actually stand for something against the weight of pharma. Think it's dangerous to do so? David probably did also, thousands of years ago, but he seems to have done pretty well.

Google says, “Don't be evil.” The AAP could say, “Don't be pusillanimous.” In both cases, it's naming the temptation to be avoided.

Or maybe I'm all wrong. Who knows? Maybe the spontaneous patient uprising was covertly ignited by an AAP agent. Wouldn't that be a great surprise?

Budd Shenkin