Nation Topics - Healthcare Policy
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If there were a firing squad for political rhetoric, the phrase "single payer" would have to be placed against the wall and blown away.
Just-released inmates with infectious diseases need continuous treatment.
Speech to The Democratic National Committee--Western Caucus
Saturday, May 25, 2002
o, my momma called, "Why are they letting them gouge us like this?" she wanted to know. "They" are our so-called political leaders in Washington, and "them" are the drugmakers now costing her $500 a month. Nearing 87, Lillie Mabel Hightower has to take two medicines regularly, including a heart pill to keep the old ticker ticking. She tells me her pill bill goes up just about every time she refills her two prescriptions, having soared 40 percent in only two years. For someone on Social Security, the difference between $3,600 a year and $6,000 a year is a serious piece of change. "Of course I know why," she quickly added in answer to her own question: "It's the big money they give the politicians. But can't we do something? Who do I write?"
Like my mom's, the blood pressure of millions of seniors and others has reached the political boiling point because of price-gouging by big drug companies. Americans pay the highest prices in the world for prescriptions--an average of 30 percent more, for example, than Canadians pay for the exact same drugs. The companies jacked up our prices by another 17.1 percent last year while they went laughing to the bank with the highest profit margins of any industry, more than triple the average of all Fortune 500 corporations.
Political consultants in Washington recognize the explosiveness of this issue, so there has been a flurry of bills, press conferences and photo-ops by both parties, with each claiming that it cares more than the other about the problem. But, as Hemingway once advised, never mistake motion for action. No lobbying group is as well financed and well connected as the drug industry is in our capital city. It has 625 registered lobbyists on its payroll--ninety more lobbyists than there are members of Congress! The industry also liberally greases the skids of the legislative process with huge campaign donations, topping $26 million in the last election cycle. The result is that Washington postures, drug prices keep going up and seniors continue to seethe.
Still, my mother asks, "Can't we do something?" Yes.
As Maine Goes...
Look to the states where citizens' groups have teamed up with legislative leaders who not only are in motion but have taken action. While Washington fiddles and faddles, twenty-six states now have some sort of program to cut drug costs, at least for the low-income elderly, and several are leading the way toward programs to take the gouge out of prescription prices for everyone.
Chellie Pingree led the charge in Maine. A small businesswoman, she was elected to the State Senate, where she took up the cause of seniors being pounded by drug prices so high that some were forced to choose between paying for essential medications or the heating bill. With the leadership of grassroots groups like the Maine People's Alliance, Consumers for Affordable Health Care and the Maine State Council of Senior Citizens, she led busloads of seniors on well-publicized trips across the Canadian border to buy their medicines; on just one trip, twenty-five seniors got prescriptions filled for $16,000 less than in the United States. Why should people have to take a six-hour bus ride to get fair prices, she asked? She answered by sponsoring the Fairer Prescription Drug Prices Act, which empowered a state pricing board to set retail prices in Maine.
Pingree's bill allowed seniors to go into any pharmacy in Maine and get the prescriptions they need at the same discounted price that Canada's government negotiates with drugmakers for its citizens. Her bill was simple, comprehensive, nonbureaucratic, effective...and it drove the big drugmakers bonkers. They dispatched their own buses to Augusta, loaded with lobbyists and money, in a frantic effort to kill the bill. In a blitz of TV and newspaper ads, the industry labeled the bill "a crazy idea" that would force the drug industry to abandon Maine. But the grassroots groups went to work, and Pingree, by now the Senate majority leader, took her bill directly to the people, holding public meetings from Madawaska to Biddeford. On April 12, 2000, her bill passed in both houses of the legislature by veto-proof margins, and the governor signed it.
Of course, the industry immediately hitched up a twenty-mule team of lawyers and rushed to federal court, but Maine's price-control law has been upheld all the way through the appeals court level and now awaits judgment at the US Supreme Court. Meanwhile, twenty-three other states, from Arizona to Wisconsin, are considering Maine's fair-pricing law, and public pressure from people like my momma is turning up the heat for national legislation.
Pingree, who is now running for the US Senate, has put the issue at the center of her campaign, vowing to bring the populist coalition behind the Maine Solution into play nationally. "There's such a disconnect between Washington and people's reality," she says. "This is more than an issue to people, it's personal outrage. Walk into any room, and it doesn't matter if the people are in overalls or suits; they've all got a story."
USAction, a network of state and local citizens' coalitions, has been a leader in developing the state proposals, and it's now working with other groups to move this public grievance from the low, slow backburner of Congress to the forefront of the progressive agenda (202-624-1730 or www.usaction.org). "This is a case where the people are miles ahead of the politicians," points out USAction's executive director, Jeff Blum, urging that progressives in Congress put forth a "fair pricing" plan that would give every senior the lowest price available on every drug. The key is not merely to provide universal coverage but to connect this to effective controls over the industry's ripoff prices. US citizens should pay no more than the average price that the drugmakers charge foreign customers in Canada, Japan, Italy and elsewhere.
If Congressional Democrats have a strategic bone left in their bodies, they'll grab this proposal and run with it, for the Lillie Mabel Hightowers are desperately looking for someone who'll stand with them against the drug profiteers. As pollster Celinda Lake reports, "This is the most powerful and intense issue of the 2002 elections, and Democrats should take the lead." If the party won't even stand up for our mommas, who'll stand up for the party?
John Elias, my patient, has a dilemma. He can't afford to buy his medicines and also pay his rent. I'm sure he won't give up his apartment just to keep his veins filled with my chemical suggestions. But he is willing to take whatever free drug samples I provide. Luckily, drug company representatives visit my office regularly and drop off oversize, brightly colored boxes of pills, one or two pills per box. Sometimes I can fill a plastic bag with enough medicine to supply a patient's needs. Still, my sample closet is not as well stocked as the local pharmacy.
The explosion of samples occurs most often when two drug companies are competing over a similar product. When I have one set of pills, it's Elias's diabetes that's treated; when I have another set, it's the hypertension. He does not die, but his blood pressure goes up and down, and his blood sweetens with rising sugar, which lowers whenever I happen to have the right pills. Elias leaves my office smiling, more comfortable with his predicament than I am.
"See you in a month, Doc. And don't worry. I got enough pills here to last me a good ten days."
I do worry--about the remaining twenty days, about his risk of a heart attack or a stroke--but samples arrive at the drug company's rate, not in response to my urgent requests.
Elias is disabled, the result of a spine operation that didn't go his way. He has Medicare, but like millions of other disabled and elderly Americans, he's unable to afford the secondary insurance that would include a drug plan. He earns too much in his part-time clerical job to qualify for Medicaid, which also covers prescriptions, or to be accepted into a drug company's "Share the Care" program. He does qualify for New York State's EPIC plan, which allows some Medicare patients to fill all their prescriptions for under $100 per month, but he says he can't afford even that. He says he won't consider leaving his job to get Medicaid as others have done; he's proud of the fact that he can still work.
Elias lives in his wheelchair; the levers and locks are extensions of his arms, the wheels his legs. He navigates the street outside my office, leaning back on two wheels to jump the curb. His arching wheelies are another man's sidestep. But he has not managed to navigate his other diseases the way he has his paralysis. When I tell him the dangers of not controlling his diabetes and his high blood pressure, his smile fades. "When you're out, then I'm out," he says simply.
Meanwhile, the same company that makes his diabetes pill offers to fly me, all expenses paid and with a $1,000 stipend, to a frolicking weekend in Naples, Florida, where I would hear lectures for three hours a day on a drug I already prescribe, before adjourning to the surf and a sightseeing sunset booze cruise. The competitor invites me to the corporate box at the ballgame, with a lobster buffet and a live calypso band to entertain us between innings.
The drug salesman infiltrates the somber atmosphere of my medical office, trailed by a huge sample case on tiny wheels. It's uncanny: He knows how much of his drug I prescribe, and he wrongly assumes that I will respond to his enticements. He provides catered lunches to my office staff where the only apparent cost is listening to him harp on about a product that he freely admits I know more about than he does.
Despite the money spent on massive advertising, the manufacturers insist that exorbitant drug prices are the result of research and development. Several of the industry's best researchers are former professors who have been wooed away from the universities for higher salaries and better laboratories, and for every participant in the drug pipeline, from discovery to production, the excitement is almost palpable. New medicines for arthritis, hypertension, high cholesterol and diabetes improve the quality of life with fewer side effects. However, the new drugs are sold in Canada and Europe for a much lower price--a $15 pill in Detroit may cost $5 across the river in Windsor, Ontario--and there are foreign chemists producing these drugs in the laboratory and companies selling them for a fraction of their cost in the United States.
The more expensive the drug, the more difficult it is to determine how it is going to be paid for. Recently, a new wonder drug for arthritis became available in two formulations, one oral, the other intravenous. The choice of which form to use illustrates a basic problem in reimbursement. Since Medicare pays only for the more expensive intravenous, patients are being hospitalized unnecessarily to receive it.
As a doctor, I'm frustrated by the current system's inability to consistently provide for a patient's medicinal needs. Clearly, there is a need for government to intervene, but it's crucial that this intervention include an understanding of inflated costs and a plan for combating this inflation. As Medicare expands to cover pills, will the federal government drive a hard bargain and negotiate a lower price per pill the way HMOs, hospitals and other countries already do? I don't see how taxpayers can avoid being penalized if the government agrees to pay top dollar.
This year, after many insufficient attempts to maintain his health with samples, Elias wheels into my office with, if wheels were legs, an almost detectable swagger. All his years in service as a clerk have finally paid off. He is now the recipient of secondary insurance with a drug plan. He is one of the lucky ones. Now all his medications will be covered, at least for the moment.
"I'm ready to be healthy," he says with a grin that reveals his neglected teeth. "Lay those prescriptions on me."
Single-payer healthcare is favored by the public, yet the insurance industry has too much to lose if it is enacted.
Foundations formed when nonprofit hospitals became for-profit are often not living up to their obligations.
The number-one healthcare issue facing the country is not which prescription drug plan is best for seniors or whether a handful of patients will be able to sue their HMOs. It is the 44 million people, or nearly 20 percent of the population under age 65, who have no health insurance and, for many, no healthcare at all. The myth that emergency rooms provide all the care the uninsured require continues unchallenged. But the emergency room is not the place to get primary care, follow-up care or care for chronic conditions, which most people need. Federal law requires emergency rooms to stabilize patients. After that, they are sent on their way, especially if they have no money to pay for further treatment. When they are given prescriptions, 30 percent of the uninsured don't fill them because of the cost.
Rationing specialty care for the uninsured is common. In Washington, DC, the uninsured wait four months for an MRI and two months for a CT scan. In California, some counties have money to screen women for breast cancer but no money for treatment. During the four to seven years following an initial diagnosis of breast cancer, one national study shows, uninsured women are 49 percent more likely to die than women with insurance. Community clinics that treat the uninsured rarely have specialists on their staffs and resort to begging area physicians to help out--not always with success.
The Bush and Gore solutions do little to help the uninsured and a lot to keep the healthcare system safe for insurance companies, the AMA, employers and the pharmaceutical industry, all of which have shoveled money into their campaigns. Bush proposes an annual refundable tax credit (that is, one that's given even if a person owes no taxes) of up to $1,000 for individuals and $2,000 for families. His campaign literature makes tax credits sound ideal: "If a family earning $30,000 purchases a health insurance plan costing $2,222, the government will contribute $2,000 (90 percent)." Trouble is, most families can't buy insurance for $2,222. The average premium for a family policy is $6,740 and for an individual, $2,542. Gore calls for a credit equal to 25 percent of the premium. Using the average premium as a benchmark, that's about $1,700 for family coverage; a family wanting a policy would still have to cough up more than $5,000.
Tax credits, moreover, leave intact the ability of insurance companies to select good risks and exclude sick people who will cost them money. That, of course, is what the industry wants to protect--and is part of the payoff for its campaign largesse.
Both Bush and Gore would also fiddle with the Children's Health Insurance Program (CHIP) to boost coverage. CHIP has brought health insurance to some 2.5 million kids, but 10 million still have none. Bush's solution: Give the states more flexibility in administering the program. But many states have not even spent federal dollars already earmarked for them, and could be tempted into using the money for something other than insurance. Gore's solution: Stretch the eligibility rules to include children whose families have incomes up to 250 percent of the federal poverty level, or $41,000 for a family of four. But what if a family's income is above 250 percent, say $43,000? Gore's answer: tax credits.
Then there are medical savings accounts, which Bush likes and Gore doesn't. Congress now allows self-employed people and employees in small companies to buy MSAs, which are a combination high-deductible insurance policy and tax-deferred savings account. But at the end of 1999, only 45,000 policies of the 750,000 Congress authorized had been sold. Still, Bush wants to let more people buy them, a move that will spark interest mainly among the healthy, who won't need the savings account to pay for care, and the wealthy, who can assume the costs not covered by the large deductible and who will simply get another tax break.
The major battleground in healthcare, though, is over a prescription drug benefit for Medicare beneficiaries, with pharmaceutical companies replacing HMOs as this year's healthcare villains. Under Bush's scheme, the very poorest seniors would get help paying for the entire cost of a drug benefit. Individuals with incomes greater than $14,600 and couples with incomes up to $19,700 would get a partial subsidy. Bush would pump $48 million into the state pharmaceutical assistance programs to give free drugs to those with the lowest incomes. But more than half the states have no programs, and those that do lace them with restrictions.
Under Gore's plan, Medicare would cover 50 percent of the cost of prescriptions, first up to $2,000 and later up to $5,000, for seniors willing to pay a premium that would start at $25 a month. As with Bush's plan, seniors with very low incomes would get help. Both candidates offer help for those with catastrophic expenses: Gore's benefit would kick in after seniors have spent $4,000 on drugs, Bush's after they've spent $6,000 for all services. Neither, however, includes a way to control pharmaceutical prices. Controls of any sort are anathema to the drug companies.
The fight over whose plan provides the bigger benefit obscures the real fundamental Medicare issue, and that is the future structure of the program itself. Under the guise of "consumer choice," Bush wants to transform Medicare from a social insurance program with a defined benefit available to everyone into a voucher plan under which seniors would be given a fixed amount to buy whatever insurance they could afford. Even if a voucher were sufficient to pay for a policy today, there is no assurance that it would do so in the future. In effect, the Bush proposal could make seniors, rather than government, bear the cost of healthcare inflation. Gore speaks of putting Medicare in a lockbox, which presumably means he wants to maintain it as a social insurance program.
Unresolved in the candidates' discussions is the larger question: Is healthcare a right in America or a commodity available only to those who can pay? On this the public may be way ahead of its leaders. When the Kaiser Family Foundation asked people earlier this year if healthcare, like public education, should be provided equally to everyone, 84 percent said yes. The candidates, however, are listening to the special interests, whose money speaks louder than the people.
We have the Bill of Rights and we have civil rights. Now we need a Right to Care, and it's going to take a movement to get it.
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