Editor's Note:
Please note that the following article was published three months ago. I'm re-posting it because I think it is a fair appraisal of the bill and some of its implications.
-SPC
Medicare-for-all: Rep. Pramila Jayapal’s new bill, explained
It’s the most ambitious plan for government-run health care yet.
by Sarah Kliff - Vox - February 26, 2019
Rep. Pramila Jayapal
(D-WA) is introducing the most ambitious Medicare-for-all plan yet —
one that envisions a quick transition to a public health plan with a
robust set of benefits.
The co-chair of the Progressive Caucus is releasing a
proposal Wednesday to transition the United States to a single-payer
health care system, one in which a single, government-run health plan
provides insurance coverage to all Americans.
“We mean a complete transformation of our health care
system and we mean a system where there are no private insurance
companies that provide these core benefits,” Jayapal told reporters
Tuesday. “We mean universal care, everybody in, nobody out.”
Jayapal’s bill envisions a future where all Americans
have health coverage and pay nothing out of pocket when they visit the
doctor or hospital. Her plan, the Medicare for All Act of 2019,
describes a benefit package that is more generous than what other
single-payer countries, like England or Canada, currently offer. The
benefits in Jayapal’s bill are even more generous than those inc
But where the Jayapal plan has great detail into what is
covered, it does not get into a crucial question: how the government
will pay for the new health care program.
The new proposal comes at a moment that Democrats are coalescing around a Medicare-for-all platform.
Frontrunner candidates in the Democratic primary like Sens. Kamala
Harris (D-CA), Cory Booker (D-NJ), and Elizabeth Warren (D-MA) have all
signed on as co-sponsors to Sanders’s single-payer bill in the Senate.
The health care industry has already begun to gird for a major health care fight should a Democrat win in 2020, recently launching a new coalition
of hospitals, insurers, and drugmakers to oppose the Medicare-for-all
agenda. Jayapal says she’s ready: She’s already secured a promise from
House Speaker Nancy Pelosi to hold the first-ever House hearings on
Medicare-for-all later this year.
“We will be pushing it as hard as we can and as fast as
we can,” Jayapal says. “Enough nibbling around the edges. We really need
to transform the system.”
Jayapal’s Medicare-for-all plan has a very generous benefit package — and a quick transition to government-run health care
Jayapal’s single-payer proposal would create a universal
Medicare program that covers all American residents in one
government-run health plan.
It would bar employers from offering separate plans that
compete with this new, government-run option. It would sunset Medicare
and Medicaid, transitioning their enrollees into the new universal plan.
It would, however, allow two existing health systems to continue to
operate as they do now: the Veterans Affairs health system and the
Indian Health Services.
Those who do qualify for the new universal Medicare plan
would transition into the program over the course of two years. This
would start with people under 19 and over 55 moving into the program one
year after it became law — and everyone else one year after that.
It’s worth noting that this is actually a faster
transition than what Sen. Sanders envisions in his proposal, which would
give the United States four years to stand up to a government-run plan.
Eventually, though, everyone would all end up in the same
plan, which includes an especially robust set of benefits. It would
cover hospital visits, primary care, medical devices, lab services,
maternity care, and prescription drugs, as well as vision and dental
benefits. Jayapal’s bill would cover abortion services, as does the newest version of Sanders’s plan.
Jayapal’s plan also includes coverage for long-term care
services for nursing services. The current Medicare program does not
include this benefit, nor does Sanders’s single-payer plan in the
Senate. That would make the health care system she envisions more
generous than the one Sanders has proposed, but also more expensive.
The plan is also significantly more generous than the
single-payer plans run by America’s peer countries. The Canadian health
care system, for example, does not cover vision or dental care,
prescription drugs, rehabilitative services, or home health services.
Instead, two-thirds of Canadians take out private insurance policies to cover these benefits. The Netherlands has a similar set of benefits (it also excludes dental and vision care), as does Australia.
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What’s more, the Jayapal plan does not require consumers
pay any out-of-pocket spending on health aside from prescription drugs.
This means there would be no charge when you go to the doctor, no
copayments when you visit the emergency room. All those services would
be covered fully by the universal Medicare plan.
This too is not in line with international single-payer
systems, which often require some payment for seeking most services.
Taiwan’s single-payer system charges patients when they visit the doctor
or the hospital (although it includes an exemption for low-income
patients). In Australia, people pay 15 percent of the cost of their
visit with any specialty doctor.
The Sanders plan is more generous than the plans Americans currently receive at work too. Most employer-sponsored plans
last year had a deductible of more than $1,000. It is more generous
than the current Medicare program, which covers Americans over 65 and
has seniors pay 20 percent of their doctor visit costs even after they meet their deductibles.
Medicare, employer coverage, and other countries’ plans
show that nearly every insurance scheme we’re familiar with covers a
smaller set of benefits with more out-of-pocket spending on the part of
citizens. Private insurance typically pops up to fill in these gaps — or
to allow citizens to buy faster access to services that the government
plan does cover (for example, to jump to the front of the line for an
elective surgery).
The reason our peer countries went this way is clear:
It’s cheaper to run a health plan with fewer benefits. The plans that
both Jayapal and Sanders have proposed have no analogue among the
single-payer systems that currently exist. By covering a more
comprehensive set of benefits and asking no cost sharing of enrollees,
it is likely to cost the government significantly more than programs
other countries have adopted.
The big question Jayapal doesn’t answer: How do you pay for it?
The Jayapal plan goes into great detail on what kind of
coverage a universal plan ought to offer. But it does not do any work
explaining how to pay for such a generous benefit package.
Jayapal says that this is an issue that will get dealt
with in the future. “Most bills don’t have that when they’re introduced,
that comes later in the process,” she said of a financing plan. “I
actually think the question is not about how we pay for it, the question
is where is the will to make sure every American has the health care
they deserve and have a right.”
Jayapal mentioned a wealth tax or repeal of Republican tax cuts as possible options for paying for the system.
Financing the health care system that both Jayapal
envisions is an immense challenge. About half of the countries that
attempt to build single-payer systems fail. That’s Harvard health
economist William Hsiao’s estimate after working with about 10
governments in the past two decades. Whether he is in Taiwan, Cyprus, or
Vermont, the process is roughly the same: Meet with legislators, draw
up a plan, write legislation. Only half of those bills actually become
law. The part where it collapses is, inevitably, when the country has to
pay for it.
This is what happened when Sanders’s Vermont attempted to create a single-payer plan in 2014.
Much like Jayapal, local legislators outlined a clear vision of the
type of health plan they’d want to extend to all Vermonters. Their plan
was arguably less ambitious; it did require co-pays when patients went
to the doctor.
But Vermont’s single-payer dream fell apart when the
state figured out how much it would need to raise taxes to finance its
new system. Vermont abandoned the government-run plan after finding it
would need to increase payroll taxes by 11.5 percent and income tax by 9
percent.
It’s true — in Vermont and in the United States — that
these increased taxes don’t necessarily mean overall health spending is
rising. It’s entirely possible that health spending will go down as taxes go up, with Americans no longer spending billions on premiums for employer-sponsored coverage.
Single-payer systems change who pays for health
care, often shifting more of the burden onto wealthier individuals to
create a more progressive system. The proposed 9 percent income tax in
Vermont, for example, would be far more expensive for the $100,000
worker than the $30,000 earner.
But who pays how much more is a key question this Jayapal
bill doesn’t answer. Until there is a version that does, we can’t know
whether the health system the Vermont senator envisions could actually
become reality.
The global battle over high drug prices
The Economist - May 21. 2019
THESE
DAYS it is hard to find a government that is not struggling with the
high price of medicines. In England, the government is fighting Vertex, a
drug company, over the cost of a drug for cystic fibrosis, Orkambi. In
America, diabetics have died because of the high cost of insulin. In the
Netherlands, the government for a time stopped buying the
immuno-oncology drug, Keytruda, because it was too expensive—even though
it had helped to develop it. The list price of Orkambi is about $23,000
a month in America, and Keytruda is about $13,600 month (for as long as
treatment continues). It has taken such rich-world dramas to force the
unaffordability of medicines to the top of the global health agenda,
even though poorer countries have complained about it for decades.
On May 20th governments started tackling the issue at the World Health Assembly (WHA), an eight-day policy forum where health ministers define the goals for the World Health Organisation for the coming year. There is a lot for them to discuss, including the expansion of universal health care, antimicrobial resistance, the impact of climate change on health and the deepening crisis of Ebola in the Democratic Republic of Congo. Yet the hottest topic is the high price of new medicines, particularly cancer drugs.
In February the Italian health minister, Giulia Grillo, published a draft resolution on drug pricing. It calls for international action to improve the transparency of prices and R&D costs, as well as the costs of production of medicines. Firms will also be asked to divulge all the different forms of government support they receive. These may range from venture-capital funds and start-up financing to tax incentives and even research conducted by academics. The hope is that greater clarity should lower drug prices. The Italian proposal is backed by many countries, rich and poor.
Pharmaceutical companies currently publish only list prices. These are large, somewhat fictional numbers that are subject to being bargained down. Just how big a discount governments, insurers and other middlemen can secure is confidential. Many have concluded that all the secrecy is putting those who pay for the drugs at a disadvantage. Els Torreele of Médecins Sans Frontières, an NGO, says that different buyers—even those in the same country—can be charged widely differing prices. “Prices are kept secret and buyers are asked to sign confidential agreements,” she says. And despite the fact that, in theory, poor countries might be charged less than rich ones, there are concerns that the reverse may in fact be true.
Drug firms are not pleased. The International Federation of Pharmaceutical Manufacturers and Associations told Stat, a medical-news website, that the draft resolution would “divert attention and resources from finding sustainable solutions to access”. Britain, Germany and Denmark are trying to water down the proposal, probably under pressure from their large pharma industries—even though they are all facing growing drug-pricing problems at home. Pharma companies have long argued that the costs and risks of developing a drug warrant high prices. They argue that greater price transparency will mean that poor countries will no longer get good deals, because firms will not want to undermine their ability to extract high prices from wealthier states.
But the degree to which poor countries get favourable treatment is usually unknown, except for some high-profile cases: vaccines, perhaps, and antiretroviral drugs to treat HIV infections. The WHO estimates that 100m people fall into poverty annually owing to the prices they pay for medicines. Moreover, there is evidence that the prices charged for some drugs are, indeed, unreasonably high. A WHO report at the end of 2018, on cancer medicines, concluded that companies priced their drugs largely according to their expectations of income, rather than what the drug cost to make or how to maximise access to patients. That a firm is making as much profit as possible is, perhaps, unremarkable. However, drug firms are not ordinary companies. Their products are needed to save lives, and they obtain monopolies on their drugs through patent systems granted by governments and, by extension, society.
The WHO also found that, even acknowledging the high cost of developing drugs, cancer medicines are generating returns far in excess of the R&D costs, and far more than is necessary to finance and create incentives for future efforts. It also appears that cancer drugs are more expensive than other medicines—seemingly because buyers are willing to pay more to treat terminal conditions. Australian data show that the cost per prescription for cancer drugs is at least 2.5 times higher than for other medicines.
The pharma industry generates large profits. In America, 12 of the country’s most profitable drug companies reported more than $29bn in profits in the first quarter of this year, according to Axios, a news website.
Advocates argue that transparency will allow people to judge whether governments have made good decisions about the medicines that they buy. In countries with weak governance, more transparent pricing should help to combat corruption.
America has made drug-pricing transparency a priority recently, and drug-makers must now disclose their list prices even on television advertisements. (List prices are important to patients because they may have to pay a proportion of this sum themselves.) Whatever the outcome this week at the WHA, pharma companies will face growing demands to come clean about the cost of life-saving drugs.
On May 20th governments started tackling the issue at the World Health Assembly (WHA), an eight-day policy forum where health ministers define the goals for the World Health Organisation for the coming year. There is a lot for them to discuss, including the expansion of universal health care, antimicrobial resistance, the impact of climate change on health and the deepening crisis of Ebola in the Democratic Republic of Congo. Yet the hottest topic is the high price of new medicines, particularly cancer drugs.
In February the Italian health minister, Giulia Grillo, published a draft resolution on drug pricing. It calls for international action to improve the transparency of prices and R&D costs, as well as the costs of production of medicines. Firms will also be asked to divulge all the different forms of government support they receive. These may range from venture-capital funds and start-up financing to tax incentives and even research conducted by academics. The hope is that greater clarity should lower drug prices. The Italian proposal is backed by many countries, rich and poor.
Pharmaceutical companies currently publish only list prices. These are large, somewhat fictional numbers that are subject to being bargained down. Just how big a discount governments, insurers and other middlemen can secure is confidential. Many have concluded that all the secrecy is putting those who pay for the drugs at a disadvantage. Els Torreele of Médecins Sans Frontières, an NGO, says that different buyers—even those in the same country—can be charged widely differing prices. “Prices are kept secret and buyers are asked to sign confidential agreements,” she says. And despite the fact that, in theory, poor countries might be charged less than rich ones, there are concerns that the reverse may in fact be true.
Drug firms are not pleased. The International Federation of Pharmaceutical Manufacturers and Associations told Stat, a medical-news website, that the draft resolution would “divert attention and resources from finding sustainable solutions to access”. Britain, Germany and Denmark are trying to water down the proposal, probably under pressure from their large pharma industries—even though they are all facing growing drug-pricing problems at home. Pharma companies have long argued that the costs and risks of developing a drug warrant high prices. They argue that greater price transparency will mean that poor countries will no longer get good deals, because firms will not want to undermine their ability to extract high prices from wealthier states.
But the degree to which poor countries get favourable treatment is usually unknown, except for some high-profile cases: vaccines, perhaps, and antiretroviral drugs to treat HIV infections. The WHO estimates that 100m people fall into poverty annually owing to the prices they pay for medicines. Moreover, there is evidence that the prices charged for some drugs are, indeed, unreasonably high. A WHO report at the end of 2018, on cancer medicines, concluded that companies priced their drugs largely according to their expectations of income, rather than what the drug cost to make or how to maximise access to patients. That a firm is making as much profit as possible is, perhaps, unremarkable. However, drug firms are not ordinary companies. Their products are needed to save lives, and they obtain monopolies on their drugs through patent systems granted by governments and, by extension, society.
The WHO also found that, even acknowledging the high cost of developing drugs, cancer medicines are generating returns far in excess of the R&D costs, and far more than is necessary to finance and create incentives for future efforts. It also appears that cancer drugs are more expensive than other medicines—seemingly because buyers are willing to pay more to treat terminal conditions. Australian data show that the cost per prescription for cancer drugs is at least 2.5 times higher than for other medicines.
The pharma industry generates large profits. In America, 12 of the country’s most profitable drug companies reported more than $29bn in profits in the first quarter of this year, according to Axios, a news website.
Advocates argue that transparency will allow people to judge whether governments have made good decisions about the medicines that they buy. In countries with weak governance, more transparent pricing should help to combat corruption.
America has made drug-pricing transparency a priority recently, and drug-makers must now disclose their list prices even on television advertisements. (List prices are important to patients because they may have to pay a proportion of this sum themselves.) Whatever the outcome this week at the WHA, pharma companies will face growing demands to come clean about the cost of life-saving drugs.
Bottle of Lies: How Poor FDA Oversight & Fraud in Generic Drug Industry Threaten Patients’ Health
by Amy Goodman - Democracy Now - May 20, 2019
AMY GOODMAN: We begin
today’s show looking at an explosive new investigation that exposes
widespread unsafe conditions in many Indian and Chinese factories that
manufacture generic drugs that comprise nearly 90% of the pharmaceutical
drug supply in the United States. Nearly 80% of the active ingredients
of all drugs, brand or generic, as well as almost all antibiotics, are
made outside of the United States. Generic drugs are, of course, cheaper
than brand-name drugs. But in her new book, Bottle of Lies: The Inside Story of the Generic Drug Boom,
journalist Katherine Eban works with two industry whistleblowers to
expose how many overseas manufacturers are cutting corners at the cost
of quality and safety.
This comes as the U.S. Food and Drug Administration just issued its own update on the state of pharmaceutical quality that found the drug quality of factories in India and China scored below the world average. FDA officials say that’s because more robust inspections have uncovered problems. Two factories in China and India were linked to recalls of the commonly prescribed blood pressure drugs losartan and valsartan, after testing revealed the drugs were tainted with possible carcinogens. The report prompted the FDA’s director of drug evaluation and research to conclude, quote, “the quality of the drug supply has never been higher.”
So, can generic drugs be trusted? For more, we spend the hour with Katherine Eban to discuss this explosive book, Bottle of Lies. She is the author of a previous book on the pharmaceutical industry titled Dangerous Doses: A True Story of Cops, Counterfeiters, and the Contamination of America’s Drug Supply. She’s a contributor to Fortune magazine, was previously staff writer for The New York Times and New York Observer.
Welcome back to Democracy Now! It’s great to have you with us, Katherine.
KATHERINE EBAN: Thank you. So nice to be here.
AMY GOODMAN: So, this is life-and-death information. Start off by talking about what exactly generic drugs are.
KATHERINE EBAN: So, generic drugs are a version of the brand-name drug. They’re not an identical copy, but generic companies reverse-engineer—they break down—the brand-name drug and figure out how to remake it. They have to use the same molecule. They have to use the same route of administration, whether it’s swallowing a pill, injecting. And then they have to submit an application to the U.S. Food and Drug Administration. And the FDA reviews data to see whether those drugs are bioequivalent. Do they reach the same peak concentration of drug in the blood? And if the FDA deems that they do, they are approved to make a generic version.
AMY GOODMAN: And explain—what is the breakdown of what Americans take? And also, of course, the insurance industry and what it will cover, which determines what we all imbibe?
KATHERINE EBAN: Right. So, 90% of our drug supply is generic. The majority of those drugs come from overseas. Forty percent alone of all of our generics are manufactured in India. And if you go to a pharmacy, you will automatically be switched to a generic drug if one is available. What’s interesting to me is, even though the name of the manufacturer will be on the label, consumers will not have information about where those drugs are manufactured.
AMY GOODMAN: Why? Did they ever?
KATHERINE EBAN: I’m not sure that they ever did, but the companies claim it’s proprietary. So, for the U.S. consumer, they’re getting less information about where their drugs are made than where their cereal is made, where their shirt is manufactured. That information is simply not available, and you have to be, unfortunately, an investigative journalist to figure out where those drugs are manufactured.
AMY GOODMAN: I bet a lot of people are shaking their heads right now, and they’re going, “I knew, when I switched to a generic, that I felt differently.” Now, what about those who would say, “What? Are you just working for the generic drug companies, and you’re promoting these way more expensive brand drugs?”
KATHERINE EBAN: Right. Well, this is an issue for brand companies and generic alike, because 80% of the ingredients in all our drugs, whether brand or generic, are being manufactured overseas. So, this is really a quality issue that is affecting brand and generic companies. And, you know, I should hasten to add, I’m an independent investigative journalist. I have received absolutely no money from any manufacturing concerns, which is a statement that is disclosed in my book.
AMY GOODMAN: So, also explain what “active ingredients” means.
KATHERINE EBAN: Right.
AMY GOODMAN: Again, nearly 80% of all active ingredients in all drugs, brand or generic—
KATHERINE EBAN: Right.
AMY GOODMAN: —are made outside the United States. And almost all antibiotics are made outside the United States.
KATHERINE EBAN: Right. So, active ingredient is the key ingredient in the drug. It is the sort of synthesized molecule that makes the drug effective. It’s the central—the central element of the drug that has the effect on the person. So, if active ingredient—what’s common, an active ingredient will be manufactured in China. It will be shipped to India. An Indian manufacturer will make the finished dose, and then it will arrive at our pharmacy. And, of course, that is invisible to the consumer.
AMY GOODMAN: So, why did you decide to write Bottle of Lies? What prompted you?
KATHERINE EBAN: It started in 2008, so a decade ago. And I was contacted by an NPR radio show host, Joe Graedon. He runs a show called The People’s Pharmacy. He was concerned because patients were writing in to his show, calling in, and saying that they had symptoms—in some cases devastating symptoms—after being switched to certain generics. And those complaints greatly concerned Joe Graedon, because there was a lot of commonality between them. A lot of patients were complaining about similar or the same drugs. They were complaining about time-released drugs. So, those are slightly more complex. Some of them were suicidal after being switched to antidepressants. Some of them were having seizures after taking epilepsy drugs. And he had been sending these complaints to the FDA, and basically the response he got back was that everything is fine. So, he really felt that somebody with, as he told me—and I saved my notes from that call—he wanted somebody with investigative firepower to look into them.
AMY GOODMAN: I was just talking to a New York Times reporter last night whose sister has epilepsy but didn’t suffer from seizures for years. She took Dilantin. That’s the brand name. But then she had to switch to the generic. It’s all the insurance company would cover.
KATHERINE EBAN: Right.
AMY GOODMAN: And she immediately started to seize.
KATHERINE EBAN: Right.
AMY GOODMAN: But she was not allowed to go back on Dilantin; at least the insurance company wouldn’t cover it. And he was describing to me about his sister that even when she went into the pharmacy and had her doctor’s prescription for Dilantin, the pharmacy would not fill it and would not allow her to actually pay for it.
KATHERINE EBAN: You know, there’s a real disconnect here. If you decide that you don’t want to eat factory-farmed meat, you as a consumer can go into a supermarket and buy organic, grass-fed meat from a small family farm. But if you decide that you don’t want to buy a foreign-manufactured generic or you want to have a brand instead of a generic, a consumer has really no control or power in this equation, which is one of the reasons why this has been sort of so concealed behind layers of insurance companies and middlemen.
AMY GOODMAN: Yet the FDA says a generic medicine is the same as a brand-name medicine in dosage, safety and quality.
KATHERINE EBAN: Right. And on paper, that is true. On paper, that is the FDA’s standard. And they will point to that standard. But what I set out to find out: What is actually going on in these distant manufacturing plants where our drugs are made?
AMY GOODMAN: We’re going to break, and then we’re going to come back to this discussion.
KATHERINE EBAN: OK.
AMY GOODMAN: I mean, you are a clear investigative journalist on the trail. You worked with whistleblowers, that are astounding, as they go abroad to try to find out how—what kind of conditions these drugs are made in that are the supply for a large sector of the United States. Katherine Eban is author of Bottle of Lies—the book has just come out—The Inside Story of the Generic Drug Boom. This is Democracy Now! We’ll be back with her in a minute.
[break]
AMY GOODMAN: “Things You Can Do,” instrumental by Deltron 3030. This is Democracy Now! I’m Amy Goodman. We’re spending the hour with investigative journalist Katherine Eban. She’s author of the explosive new book Bottle of Lies: The Inside Story of the Generic Drug Boom. It’s just been published. So, take us on a journey with Peter Baker. Tell us who he is.
KATHERINE EBAN: So, Peter Baker was a 32-year-old FDA investigator. They were called consumer safety officers. And in 2012, the FDA looked around and asked: Would any of its investigators like to relocate overseas to their poorly staffed, remote offices in India or China to investigate the drug plants making our generic drugs? And Peter Baker is a motorcycle-riding, tattooed tough guy who was up for an adventure. But he had another reason that he wanted to volunteer, which was that, by reputation, Indian manufacturers were market leaders in aseptic manufacturing, which is the very demanding manufacturing of making sterile drugs. So he volunteered to relocate, and wound up in New Delhi.
AMY GOODMAN: And explain what he found.
KATHERINE EBAN: So he started investigating these plants. And he had a different way of investigating than a lot of FDA investigators. He skipped the guided tours and the opening slideshows, and he went right to the quality control labs.
AMY GOODMAN: Wait, wait, wait. Are these tours announced in advance?
KATHERINE EBAN: That is one of the big problems. The FDA announces its inspections overseas in advance, sometimes giving two months’ advance notice to plants that they are coming.
AMY GOODMAN: So what does that mean? What can they do in that amount of time?
KATHERINE EBAN: They can do a lot. I mean, as one investigator said, “Give them a weekend, they can put up a building.” But, basically, the accusation is that these plants overseas are staging their inspections. And one of the remarkable findings in my book is that they literally have data fabrication teams that come in, in advance of these inspections, shred documents, fabricate documents, invent quality data, invent standard operating procedures, all in advance of the FDA’s arrival.
AMY GOODMAN: So, he goes into a factory.
KATHERINE EBAN: Yeah. One of the first plants that he went into was a company called Wockhardt, and this was a sterile manufacturing plant where the quality controls are incredibly strict, down to employees having to move very deliberately and slowly so as not to disturb the airflow in the plant. It’s that strict and regulated. And it was his second day of the inspection. He was in a hallway, and he saw an employee at the other end of this long, brightly lit hallway with a clear garbage bag, and the man was walking in a furtive manner. And as soon as the employee saw Peter Baker and his colleague, a microbiologist, he turned around and started walking the other way again. And the microbiologist yelled “Stop!” The man broke into a run. He tossed the garbage bag under a stairwell. And Peter Baker opened the garbage bag and found 75 torn batch records which indicated that insulin the company was manufacturing was contaminated with metallic particles but nonetheless had been released to patients in India and the Middle East.
So, Peter Baker is only responsible for U.S. medications, but he followed the trail of these documents. He went to this area of the plant, which had not been disclosed to the FDA, and he found the plant was manufacturing a sterile injectable cardiac drug on the same equipment that had created the metallic particles. So, he basically exposed deep fraud in this plant.
AMY GOODMAN: And so, what happens then? And I kept talking about the number of Americans who take these drugs, but, I mean, these drugs go out to the world.
KATHERINE EBAN: Absolutely. And actually, as a separate part of my investigation, which is also in the book, the plants make differing levels of quality for different markets. So, basically, their manufacturing standard can be whatever they can get away with. In other words, if they’re sending to other parts of the world, they lower their quality, they lower their quality ingredients, they skip manufacturing steps.
AMY GOODMAN: So, what happens when you find this contamination, when an inspector finds this contamination?
KATHERINE EBAN: Well, in this case, because Peter Baker discovered this, the plant was hit with a massive set of observations, in a form called a 483. They were put on import alert, which means their drugs were restricted from coming into the U.S. market. And so, in that instance, the inspection system worked as it should.
AMY GOODMAN: Can you talk about Ranbaxy?
KATHERINE EBAN: Yeah. So, Ranbaxy was India’s largest drug company and the largest maker of generic drugs and the fastest-growing generic drug maker in the U.S. And in 2005, a young information architect named Dinesh Thakur left Bristol-Myers Squibb and took a job at Ranbaxy. So he moved his family to Gurgaon. And—
AMY GOODMAN: To India.
KATHERINE EBAN: To India. And at a certain moment, his boss, who had also come from the brand pharma sector in England, got concerned about the quality of the data at Ranbaxy and had had some evidence that there was fraudulent data in some of the company’s HIV drugs. And so he gave Thakur an assignment, which was to investigate all of the company’s regulatory filings around the world and get to the bottom of whether there was actually data that existed for all of the claims that the company had made to regulators.
AMY GOODMAN: I want to go back to Peter Baker and what happened to him. So, he exposes this contamination at a major plant in India that’s making heart drugs, among others.
KATHERINE EBAN: In the course of five years, he inspected 86 plants in India and China, and he found some aspect of data fraud or deception at 67 of those plants, really almost four-fifths of the plants that he inspected. And he—
AMY GOODMAN: Repeat that. He found?
KATHERINE EBAN: He found some element of data fraud or data deception in almost four-fifths of the plants that he inspected overseas in India and China. And he did it with a completely different inspection method. Instead of looking at the records that the plant was giving him, he went into the manufacturing plant’s computer systems, and he started looking at deleted audit trails. And he tracked the metadata in the computer systems and realized that in many of these plants they were conducting what are called pretests. They were doing an initial offline screen of the drugs to see what the quality was, and then potentially making alterations to the tests, so that when they retested the drugs in the official system of the plant, they would pass quality tests.
AMY GOODMAN: And what happened to Peter Baker?
KATHERINE EBAN: He left the agency in March. Based on the experiences he had in India—he was followed, he was threatened. In one instance, he was poisoned with tainted water at a plant. Some of the investigators that he worked with were spied on. A hotel room was bugged. And based on this sort of aggregate experience, he was actually diagnosed with post-traumatic stress.
AMY GOODMAN: And the perks that inspectors get? I mean, what you described is hardly a perk—poisoned water. But what about how they’re treated? And how important are these companies to the countries, India and China?
KATHERINE EBAN: Well, one of the huge problems, as we discussed, is that the inspections by the FDA are announced two months in advance. And remarkably, the FDA even turns to these plants to arrange local travel, to arrange hotel ground transportation. And so, what happens is that the inspectors arrive. They’re picked up at the airport in a luxury car. They’re taken to a hotel, where their rooms are magically upgraded, and they never see a bill. There are trips to the Taj Mahal, shopping trips, massages, golf outings—a system that, as one of my sources called it, regulatory tourism. And the problem is, when the FDA says our drug supply has never been safer, they are discounting the fact that the findings of the plants are in this system of preannounced inspections.
AMY GOODMAN: And going back to Ranbaxy, this was the largest drug company in India.
KATHERINE EBAN: Yeah.
AMY GOODMAN: Explain what happened to it. And also talk about Lipitor.
KATHERINE EBAN: Yeah. So, Dinesh Thakur, who became a whistleblower, began doing—
AMY GOODMAN: Who worked at Bristol in the United States.
KATHERINE EBAN: That’s right.
AMY GOODMAN: Bristol Squibb, and then was recruited to go to India.
KATHERINE EBAN: That’s right. Once he started this research project, which was to investigate the company’s worldwide regulatory filings, he discovered that more than 40 products in over 200 countries—excuse me, more than 200 products in over 40 countries were filed with data that did not exist, falsified data in which the company was literally taking the brand drug and running tests off the brand drug and submitting it as its own data. I mean wild fabrications.
AMY GOODMAN: So, wait. They would use the brand drug, but in fact they would put the results to the generic they were making.
KATHERINE EBAN: That’s right. And this is—you know, this kind of fraudulent data is what they were using to get approval from the U.S. FDA. So, Dinesh Thakur, once this got exposed, his boss went into a board meeting and presented this to a subcommittee of the board of directors. And the question that he got back is: Could the report be buried, and could the laptop that the report was created on be destroyed? So, the company chose to conceal this. Ultimately, his boss resigned, and he was forced out of the company. And he decided to approach regulators with the information that he had, and ultimately he became a whistleblower for the FDA.
AMY GOODMAN: What happened to the drug company, Ranbaxy?
KATHERINE EBAN: Well, they—not only did they continue manufacturing and selling drugs for more than eight years from Dinesh Thakur’s first approach, the FDA, in the middle of what was a criminal investigation of this company for fraud, greenlighted Ranbaxy to manufacture the biggest generic drug in U.S. history, the first generic version of Lipitor.
AMY GOODMAN: And explain what Lipitor is used for.
KATHERINE EBAN: So, Lipitor is a cholesterol-reducing drug, which millions and millions of Americans take. So, it’s called a [statin]. And it is the biggest-selling drug of all time. And one year after Ranbaxy was given the green light to manufacture this, they made about $600 million in six months. Millions of their doses of Lipitor had to be recalled because they were infused with glass fragments.
AMY GOODMAN: And that’s just what we know. They happened to find this.
KATHERINE EBAN: They were under such scrutiny by the FDA that they ended up disclosing the glass fragments to the FDA, yeah.
AMY GOODMAN: What can—
KATHERINE EBAN: And they had to be recalled.
AMY GOODMAN: What can an individual do? I mean, what do you do if you’re taking the generic form of Lipitor and you feel sick, you feel different from when you took Lipitor?
KATHERINE EBAN: Right. So, you know, there is so little disclosure to consumers. I mean, one thing that every consumer can do is, they have a maintenance drug, and they feel it’s working—
AMY GOODMAN: Explain what you mean by “maintenance drug.”
KATHERINE EBAN: If they have a drug that they take every month, day in and day out—and many Americans do. Let’s say they are dispensed a drug that makes them feel good, that seems to be effective, that has minimal side effects.
AMY GOODMAN: So you’re taking it every day, like for thyroid—
KATHERINE EBAN: That’s right.
AMY GOODMAN: —for heart—
KATHERINE EBAN: Right.
AMY GOODMAN: —for cholesterol.
KATHERINE EBAN: Right. What they need to do is look at the manufacturer on the label, OK? They feel pretty good. We are all getting switched from generic to generic to generic every time we go to a pharmacy. But once you know that there is a manufacturer that is working for you, you need to inform your pharmacy that is the drug you want to continue taking.
The other thing consumers should do, which I do when I’m dispensed a drug and there’s a manufacturer name, I go to Google, and I put in ”FDA warning letter” and the name of that manufacturer, in order to see what have the FDA’s findings been about that drug and about that manufacturer.
AMY GOODMAN: So, you have to do the research yourself. Would you take a generic drug? And also, I mean, how it compares to how these brand drugs are made and where they’re made, in the same places?
KATHERINE EBAN: Right, right. Well, I do take generic drugs. Of course, we all take generic drugs. Because I know the history of a lot of these manufacturers, there are companies whose drugs I don’t take and companies whose drugs I will take.
AMY GOODMAN: When we come back, we’re going to talk about how these drugs are dumped on Africa.
KATHERINE EBAN: Yes, absolutely.
AMY GOODMAN: I want to also talk about the story of Cipla—
KATHERINE EBAN: Yes.
AMY GOODMAN: —and the significance of this. We’re talking to Katherine Eban, who is investigative journalist. Her book is just out. It’s an explosive book. It’s called Bottle of Lies: The Inside Story of the Generic Drug Boom. This is Democracy Now! Back with her in a minute.
[break]
AMY GOODMAN: “It’s Been Awhile” by Staind, here on Democracy Now! I’m Amy Goodman. We’re spending the hour with investigative journalist Katherine Eban, author of Bottle of Lies: The Inside Story of the Generic Drug Boom. It’s just been published. I want to turn to the Indian scientist Yusuf Hamied, chair of the drug manufacturer Cipla, who shook the conscience of the global health community by offering to produce generic AIDS medication at a tiny fraction of the cost. This is Dr. Hamied speaking several years ago.
KATHERINE EBAN: Yeah. First, let me just correct myself, which is, Lipitor, of course, is a statin, not a sartan. We were talking about valsartan earlier, so I misspoke.
But Dr. Yusuf Hamied is really one of the great individuals of the 21st century. He looked around, saw this massive AIDS epidemic, and he saw brand companies protecting their drugs through a minefield of patents, and decided something had to be done. And so what he did was he announced, working with a group of activists, that he was prepared to manufacture AIDS drugs for a dollar a day, which was such a dramatic price cut that that set in motion a series of events that led to, ultimately, a very important U.S. program called PEPFAR, in which U.S. taxpayers—
AMY GOODMAN: This was a George W. Bush program.
KATHERINE EBAN: It was under George W. Bush. It was—President Clinton had a big impact on the events that led to it, because the Clinton Foundation helped, working with Indian manufacturers, to reduce the price further to 38 cents a day. He sort of aggregated the buying power of African governments and U.S. taxpayers and sort of, through this groundbreaking coalition, was able to get U.S. taxpayers to buy in bulk AIDS drugs for Africa as a way to tackle the AIDS epidemic.
AMY GOODMAN: What was the response of the global pharmaceutical community?
KATHERINE EBAN: Well, at first, the global pharmaceutical community was actually dead set against this. They were—wanted to protect their patents. And the outcry was so enormous that, ultimately, they waived their patents so that the India manufacturers could make these AIDS cocktails at a very low price.
AMY GOODMAN: I want to go to a tweet you posted about an executive from the Indian-based company Ranbaxy, the largest pharmaceutical company—
KATHERINE EBAN: Yeah.
AMY GOODMAN: —in India, that was. You wrote, “More telling was a shocking disregard for human life, from some company executives. When discussing the poor quality of the company’s AIDS drugs for Africa, on a conference call, a Ranbaxy medical director said: 'Who cares? It's just blacks dying.’”
KATHERINE EBAN: It’s a very disturbing statement. And this was said out loud on a conference call of Ranbaxy executives in about 2004. But it reflected a larger problem in the generic drug industry, which is, a lot of these companies have what’s called dual-track or multitiered production, which is they make their better drugs for more regulated markets, like the U.S. and the EU, and they will make worse-quality drugs for developing markets or markets that they call ”ROW,” which is “rest of world.”
AMY GOODMAN: ”ROW” means “rest of world.”
KATHERINE EBAN: Correct, yes. So those are developing markets where they have made a calculation that because regulation is so poor, they’re not going to get caught.
AMY GOODMAN: So, when someone travels—another example is, when someone travels overseas, they say, “You can’t believe how cheap I can get drugs there, the very same drugs we get in the United States.”
KATHERINE EBAN: Right, right. But they’re of worse—
AMY GOODMAN: That’s not true.
KATHERINE EBAN: —quality. And I shake my head. Even when I was reporting my book, and I traveled to India, and I had friends say, “Can you bring me back some antibiotics?” And I said, “Do you understand what I’m reporting? Why would I do that to you?”
AMY GOODMAN: So, you tweeted about your smoking gun around Ranbaxy.
KATHERINE EBAN: Yeah.
AMY GOODMAN: Talk about the documents you found.
KATHERINE EBAN: Right. So, the smoking gun was this PowerPoint presentation which was shown to a subcommittee of the board of directors. And it spelled out, in detail, that Ranbaxy had fabricated data, completely invented data, for more than 200 products in more than 40 countries, in an effort to just support business needs. In other words, they needed approvals, and they made up data. Inside the company, this document or presentation came to be known as the SAR, which was short for “self-assessment report.” And it really shaped the behavior of a number of the company’s top executives in an effort to suppress this document.
AMY GOODMAN: And again, say what Ranbaxy made and what happened to it.
KATHERINE EBAN: Yeah. So, I mean, Ranbaxy was manufacturing a huge number of generic drugs for the U.S. market. They were manufacturing generic drugs all over the world. Ultimately, this document, the disclosures around this document and prosecution by the U.S. government, not to mention Dinesh Thakur’s heroic efforts, brought down the company.
AMY GOODMAN: Why aren’t drugs, the active ingredients, generics, the brand drugs, antibiotics—why aren’t they made in the United States for U.S. citizens and noncitizens?
KATHERINE EBAN: Right. So, this has been part of a sort of long exodus of manufacturing from the U.S. market. It really started with antibiotics. One of the issues was environmental regulations, and companies wanted to—you know, very stringent or more stringent environmental regulations in the U.S. So, there’s a lot of waste production in manufacturing of antibiotics and drugs generally, so they shifted manufacturing overseas, to China and to India, and a lot of the manufacturing of other drugs followed. And, in fact, the brand-name companies also ended up shifting manufacturing overseas. They bought up manufacturing plants and found that, you know, almost overnight, they could cut some of their costs, by about 80%—the cost of labor, the cost of ingredients. So that was really one of the reasons behind it.
AMY GOODMAN: Could the government produce these drugs?
KATHERINE EBAN: Absolutely. And Elizabeth Warren, in fact, has a very interesting proposal to get the U.S. government to manufacture essential generic drugs. I mean, looked at one way, this is a national security issue. We need to manufacture our own medicine. What if we pissed off India, and they said, “Sorry, no more antibiotics”? We’d really be in a fix.
AMY GOODMAN: Some of the people you spoke to said they avoid taking prescription drugs.
KATHERINE EBAN: Well, they were more specific than that. And, in fact, this was a number of FDA investigators, who, based on the things that they witnessed in these plants overseas, basically have stopped taking generics manufactured overseas.
AMY GOODMAN: Where do they get them then?
KATHERINE EBAN: They try not to get sick. They are very particular about which companies they take drugs from. And it’s based on their own knowledge.
AMY GOODMAN: Are there lists of records? If you’re not an insider FDA inspector, where can you go online to see what companies am I going to get drugs from? And then, if you can go more specifically, and even if I’m going to get a drug from a company, I don’t want it made at this plant or that plant.
KATHERINE EBAN: Right.
AMY GOODMAN: Is there any way to find this out?
KATHERINE EBAN: I have been talking to people about trying to put together forward-facing data for consumers. You know, I don’t have any announcements to make right now on that front, but my hope is that there will be some forward-facing data available for consumers. Unfortunately, right now it’s all just in one bucket over here and one bucket over there. You know, consumers who get really interested in this can look on the FDA’s website for warning letters. Yeah.
AMY GOODMAN: What’s happened at the FDA? President Trump prides himself on rolling back regulations in the regulatory agencies, the FDA chief among them.
KATHERINE EBAN: Well, one of the things that’s been going on, which really needs further investigation, is that the FDA has been, almost systematically, downgrading the findings of its own investigators in these overseas generic plants. Now, they just put out a report saying that the quality is very high, and everything is fine, and they’ve got this under control. But, in fact, behind the scenes, they are downgrading from the most serious findings to less serious findings. And, you know, the documentation that I was able to get shows they’re making these decisions for political reasons. They’re making them because drafts of warning letters sat on their desks for too long. And this is something that really needs to be, I think, investigated by Congress.
AMY GOODMAN: In the wake of your book, public health advocate and whistleblower Dinesh Thakur, as well as Erin Fox, senior director of Drug Information and Support Services, University of Utah Health Care, have called on Congress and the FDA to hold hearings on generic drug safety.
KATHERINE EBAN: Yeah.
AMY GOODMAN: Do you see that happening anytime soon?
KATHERINE EBAN: I’d like to think that it would. I hope it would. You know, it’s very hard to say what, if anything, is going to happen in this political environment.
AMY GOODMAN: Have any lawmakers responded? And how much in the pocket are lawmakers, Democrat and Republican, of the drug industry?
KATHERINE EBAN: Certainly, there is a lot of lobbying—we all know that—by the pharmaceutical companies. I think that lawmakers who have been on this a long time are inclined to look at the role of the FDA in all of this and their claims that their regulation is adequate. I think there is some appetite to do that.
AMY GOODMAN: So, you’ve been working on this book for years, and you’ve been doing this kind of research way beyond the research you did for this book. What shocked you most, Katherine?
KATHERINE EBAN: Some of the falsifications and fabrications that are going on in these plants. For example, they’re even fabricating their own data proving that the plants are sterile. They’re falsifying their microbiology data. They have to test the environment. They have to test the air. They have to test the water. They’re fabricating that data. So, what is real, and what is fake?
AMY GOODMAN: Is there a particular story that sticks in your mind that you cannot shake?
KATHERINE EBAN: I mean, I would have to say Peter Baker’s investigations into the plant, Wockhardt, which I chronicle in my book.
AMY GOODMAN: Peter Baker, the FDA inspector.
KATHERINE EBAN: Yes, absolutely. I mean, from the moment that he lands at an airport, is followed by company representatives, one of whom—there is a man who yanks open the door of his cab, takes a hard look at him, closes it again. The investigators go to the plant. Several of them fall ill because of tainted water. They learn later that even as they were at night in the hotel room talking about their inspections and their findings, the company had bugged the hotel room. That is the level of the—
AMY GOODMAN: And how much support did he get from the FDA?
KATHERINE EBAN: Minimal, absolutely minimal. In fact, they pulled him off of doing inspections. I mean, he’s one of the most—he’s sort of the Pablo Picasso of FDA investigations.
AMY GOODMAN: And he left just now, just this past March.
KATHERINE EBAN: Yes. That’s right.
AMY GOODMAN: Under the Trump FDA.
KATHERINE EBAN: Yeah.
AMY GOODMAN: I want to thank you for being with us.
KATHERINE EBAN: Thank you.
AMY GOODMAN: We’re going to do Part 2 and post it online at democracynow.org. Investigative journalist Katherine Eban is the author of Bottle of Lies: The Inside Story of the Generic Drug Boom. It’s just been published. Her previous book, Dangerous Doses: A True Story of Cops, Counterfeiters, and the Contamination of America’s Drug Supply.
That does it for our show. Happy Birthday, Simin Farkhondeh! I’m Amy Goodman. Thanks for joining us.
https://www.democracynow.org/2019/5/20/bottle_of_lies_how_poor_fda?
Polling by NPR finds that while rural Americans are mostly satisfied with life, there is a strong undercurrent of financial insecurity that can create very serious problems for many people living in rural communities.
The findings come from two surveys NPR has done with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health on day-to-day life and health in rural America.
After a major poll we did last fall found that a majority (55%) of rural Americans rate their local economy as only fair or poor, we undertook a second survey early this year to find out more about economic insecurity and health. The poll looked beyond the known factors of job loss and the decades-long flight of young people to more urban areas.
Several findings stand out: A substantial number (40%) of rural Americans struggle with routine medical bills, food and housing. And about half (49%) say they could not afford to pay an unexpected $1,000 expense of any type.
Access to health care
One-quarter of respondents (26%) said they have not been able to get health care when they needed it at some point in recent years. That's despite the fact that nearly 9 in 10 (87%) have health insurance of some sort — a level of coverage that is higher now than a decade ago, in large part owing to the Affordable Care Act and the expansion of Medicaid in many states.
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"At a time when we thought we had made major progress in reducing barriers to needed health care, the fact that 1 in 4 still face these barriers is an issue of national concern," says Robert J. Blendon, co-director of the survey and professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health. "Either it is still not affordable for them or the insurance they have doesn't work — or they can't get care from the health providers that are in their community."
Of those not able to get health care when they needed it, the poll found that 45% could not afford it, 23% said the health care location was too far or difficult to get to, and 22% could not get an appointment during the hours needed.
Dee Davis, president and founder of the Center for Rural Strategies in Whitesburg, Ky., says poverty and ill health are endemic where he lives. "People in this congressional district have the shortest life span in the United States; we also are the poorest," Davis says. "We're poor and we're sicker."
But, he adds, the Affordable Care Act — which in Kentucky brought an expansion of Medicaid to many previously uninsured residents — went a long way in helping many rural communities take care of recurring problems. "We're not out of the woods yet but the ACA certainly changed the landscape," Davis says.
Lots of rural people benefited from the ACA, he adds, and if that progress were to be lost, he says: "We're in trouble."
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For purposes of this poll, "rural" was defined as areas that are not part of a Metropolitan Statistical Area, as used in the 2016 National Exit Poll. The NPR poll was conducted in English and Spanish using random-digit dialing Jan. 31-March 2 among a nationally representative, probability-based sample of 1,405 adults ages 18 or older living in the rural U.S. The margin of error for the total respondents is plus or minus 3.5 percentage points at the 95% confidence level.
Financial insecurity
One measure of financial security is the ability to meet unexpected expenses like a car repair or a medical problem or fixing something that has gone wrong in the house. It's not unusual for these expenses to run $1,000 or more, so we asked whether that would be a problem.
Overall, nearly half (49%) said they wouldn't be able to afford that. And more than 6 in 10 rural black and Latinx Americans said they would have a problem paying that off (blacks, 68%; Latinx, 62%), compared with 45% of rural whites.
"When you're living close to the edge, sometimes you fall off," says Davis. "If half the people in rural America can't deal with a $1,000 bill, that's rough."
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It would be an issue for 72-year-old Leitha Dollarhyde, a retired caregiver who lives near Whitesburg, Ky., a rural town of under 2,000 people. She was born about 4 miles from where she lives today.
Her answer, when asked if she could afford an unexpected $1,000 expense? "No. There's no way. My savings account is zero."
Dollarhyde worked all her life, but the jobs just didn't pay enough for her to put anything aside. She raised four children. Today her income — Social Security and Supplemental Security Income — adds up to $790 a month.
"With that income, you watch every penny," she says.
Strong social networks
Yet even with the high levels of financial insecurity that we found, there is abundant optimism and satisfaction with the quality of life in rural America. Almost three-quarters (73%) of rural Americans rate the overall quality of life in their local community as excellent or good. And a majority (62%) are optimistic that people like them can make an impact on their local community.
Davis says that is what he observes in rural Kentucky. "People may be living a more hardscrabble existence than folks in the suburbs or a lot of the folks in cities, but it doesn't mean they're not living a decent life," he says. "Most people are pretty happy with it; they've got friends and neighbors they rely on and they're where they want to be."
Still, social isolation and loneliness are a concern in rural America. We found nearly 4 in 10 (38%) said "many people" in their community feel lonely or isolated, with almost 1 in 5 (18%) saying they "always" or "often" feel either isolated or lonely. People with disabilities (31%) more frequently said they feel lonely or isolated from others compared with those without disabilities (12%).
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A majority of rural Americans say they participate in civic and social activities, including volunteering and service, political activities, community meetings and membership in a variety of groups. The most frequently cited activity was volunteering their time to an organization working to make their local community a healthier place to live (49%).
Whitesburg community activist Nell Fields says that when her husband was recently hospitalized, her neighbors were extraordinary.
"My neighbors come and mow my grass, feed cattle, get eggs every day for the last few weeks," she says. "That says so much to me. [It] makes me feel the emotion now of what it feels like to have such warm, wonderful support and I know that's the blessing of living in rural America."
Declining hospitals
Since 2010, 106 rural hospitals have closed in rural America. As many as 673 more are at risk of closure, according to a 2016 report from iVantage Health Analytics. Currently, there are approximately 1,860 rural hospitals in the U.S.
Eight percent of rural adults polled say hospitals in their local communities have closed down in the past few years. About two-thirds (67%) say the closures were a problem, including 38% who say they were a major problem.
"It means people have to travel greater distances to receive care, and distance can be a barrier to timely and appropriate access to services," says Brock Slabach of the National Rural Health Assembly in Leawood, Kan. "Delayed care can often lead to tragic consequences. This can be a huge barrier for many living in rural areas."
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As an example, he points to the small town of Tonopah, Nev., population 2,478, that is more than three hours away from the nearest hospital by road. The community's hospital closed in 2015 and the ambulance service in town was left to deal with all kinds of medical problems that it is not situated to handle, Slabach says.
In areas where higher-speed Internet access is available, people are turning to telehealth instead of going to a doctor or clinic. But broadband access is a perennial issue in many parts of rural America, with 1 in 5 (21%) saying that accessing high-speed Internet is a problem for their family. Among those who do use the Internet, a majority say they do so to obtain health information (68%).
The medical purposes for using telehealth vary, as a majority of rural telehealth patients (53%) say they have received at least one prescription from their doctor or other health professional using telehealth, while 25% have received a diagnosis or treatment for a chronic condition, 16% have received a diagnosis or treatment for an emergency, and 9% have received a diagnosis or treatment for an infectious disease.
This comes as the U.S. Food and Drug Administration just issued its own update on the state of pharmaceutical quality that found the drug quality of factories in India and China scored below the world average. FDA officials say that’s because more robust inspections have uncovered problems. Two factories in China and India were linked to recalls of the commonly prescribed blood pressure drugs losartan and valsartan, after testing revealed the drugs were tainted with possible carcinogens. The report prompted the FDA’s director of drug evaluation and research to conclude, quote, “the quality of the drug supply has never been higher.”
So, can generic drugs be trusted? For more, we spend the hour with Katherine Eban to discuss this explosive book, Bottle of Lies. She is the author of a previous book on the pharmaceutical industry titled Dangerous Doses: A True Story of Cops, Counterfeiters, and the Contamination of America’s Drug Supply. She’s a contributor to Fortune magazine, was previously staff writer for The New York Times and New York Observer.
Welcome back to Democracy Now! It’s great to have you with us, Katherine.
KATHERINE EBAN: Thank you. So nice to be here.
AMY GOODMAN: So, this is life-and-death information. Start off by talking about what exactly generic drugs are.
KATHERINE EBAN: So, generic drugs are a version of the brand-name drug. They’re not an identical copy, but generic companies reverse-engineer—they break down—the brand-name drug and figure out how to remake it. They have to use the same molecule. They have to use the same route of administration, whether it’s swallowing a pill, injecting. And then they have to submit an application to the U.S. Food and Drug Administration. And the FDA reviews data to see whether those drugs are bioequivalent. Do they reach the same peak concentration of drug in the blood? And if the FDA deems that they do, they are approved to make a generic version.
AMY GOODMAN: And explain—what is the breakdown of what Americans take? And also, of course, the insurance industry and what it will cover, which determines what we all imbibe?
KATHERINE EBAN: Right. So, 90% of our drug supply is generic. The majority of those drugs come from overseas. Forty percent alone of all of our generics are manufactured in India. And if you go to a pharmacy, you will automatically be switched to a generic drug if one is available. What’s interesting to me is, even though the name of the manufacturer will be on the label, consumers will not have information about where those drugs are manufactured.
AMY GOODMAN: Why? Did they ever?
KATHERINE EBAN: I’m not sure that they ever did, but the companies claim it’s proprietary. So, for the U.S. consumer, they’re getting less information about where their drugs are made than where their cereal is made, where their shirt is manufactured. That information is simply not available, and you have to be, unfortunately, an investigative journalist to figure out where those drugs are manufactured.
AMY GOODMAN: I bet a lot of people are shaking their heads right now, and they’re going, “I knew, when I switched to a generic, that I felt differently.” Now, what about those who would say, “What? Are you just working for the generic drug companies, and you’re promoting these way more expensive brand drugs?”
KATHERINE EBAN: Right. Well, this is an issue for brand companies and generic alike, because 80% of the ingredients in all our drugs, whether brand or generic, are being manufactured overseas. So, this is really a quality issue that is affecting brand and generic companies. And, you know, I should hasten to add, I’m an independent investigative journalist. I have received absolutely no money from any manufacturing concerns, which is a statement that is disclosed in my book.
AMY GOODMAN: So, also explain what “active ingredients” means.
KATHERINE EBAN: Right.
AMY GOODMAN: Again, nearly 80% of all active ingredients in all drugs, brand or generic—
KATHERINE EBAN: Right.
AMY GOODMAN: —are made outside the United States. And almost all antibiotics are made outside the United States.
KATHERINE EBAN: Right. So, active ingredient is the key ingredient in the drug. It is the sort of synthesized molecule that makes the drug effective. It’s the central—the central element of the drug that has the effect on the person. So, if active ingredient—what’s common, an active ingredient will be manufactured in China. It will be shipped to India. An Indian manufacturer will make the finished dose, and then it will arrive at our pharmacy. And, of course, that is invisible to the consumer.
AMY GOODMAN: So, why did you decide to write Bottle of Lies? What prompted you?
KATHERINE EBAN: It started in 2008, so a decade ago. And I was contacted by an NPR radio show host, Joe Graedon. He runs a show called The People’s Pharmacy. He was concerned because patients were writing in to his show, calling in, and saying that they had symptoms—in some cases devastating symptoms—after being switched to certain generics. And those complaints greatly concerned Joe Graedon, because there was a lot of commonality between them. A lot of patients were complaining about similar or the same drugs. They were complaining about time-released drugs. So, those are slightly more complex. Some of them were suicidal after being switched to antidepressants. Some of them were having seizures after taking epilepsy drugs. And he had been sending these complaints to the FDA, and basically the response he got back was that everything is fine. So, he really felt that somebody with, as he told me—and I saved my notes from that call—he wanted somebody with investigative firepower to look into them.
AMY GOODMAN: I was just talking to a New York Times reporter last night whose sister has epilepsy but didn’t suffer from seizures for years. She took Dilantin. That’s the brand name. But then she had to switch to the generic. It’s all the insurance company would cover.
KATHERINE EBAN: Right.
AMY GOODMAN: And she immediately started to seize.
KATHERINE EBAN: Right.
AMY GOODMAN: But she was not allowed to go back on Dilantin; at least the insurance company wouldn’t cover it. And he was describing to me about his sister that even when she went into the pharmacy and had her doctor’s prescription for Dilantin, the pharmacy would not fill it and would not allow her to actually pay for it.
KATHERINE EBAN: You know, there’s a real disconnect here. If you decide that you don’t want to eat factory-farmed meat, you as a consumer can go into a supermarket and buy organic, grass-fed meat from a small family farm. But if you decide that you don’t want to buy a foreign-manufactured generic or you want to have a brand instead of a generic, a consumer has really no control or power in this equation, which is one of the reasons why this has been sort of so concealed behind layers of insurance companies and middlemen.
AMY GOODMAN: Yet the FDA says a generic medicine is the same as a brand-name medicine in dosage, safety and quality.
KATHERINE EBAN: Right. And on paper, that is true. On paper, that is the FDA’s standard. And they will point to that standard. But what I set out to find out: What is actually going on in these distant manufacturing plants where our drugs are made?
AMY GOODMAN: We’re going to break, and then we’re going to come back to this discussion.
KATHERINE EBAN: OK.
AMY GOODMAN: I mean, you are a clear investigative journalist on the trail. You worked with whistleblowers, that are astounding, as they go abroad to try to find out how—what kind of conditions these drugs are made in that are the supply for a large sector of the United States. Katherine Eban is author of Bottle of Lies—the book has just come out—The Inside Story of the Generic Drug Boom. This is Democracy Now! We’ll be back with her in a minute.
[break]
AMY GOODMAN: “Things You Can Do,” instrumental by Deltron 3030. This is Democracy Now! I’m Amy Goodman. We’re spending the hour with investigative journalist Katherine Eban. She’s author of the explosive new book Bottle of Lies: The Inside Story of the Generic Drug Boom. It’s just been published. So, take us on a journey with Peter Baker. Tell us who he is.
KATHERINE EBAN: So, Peter Baker was a 32-year-old FDA investigator. They were called consumer safety officers. And in 2012, the FDA looked around and asked: Would any of its investigators like to relocate overseas to their poorly staffed, remote offices in India or China to investigate the drug plants making our generic drugs? And Peter Baker is a motorcycle-riding, tattooed tough guy who was up for an adventure. But he had another reason that he wanted to volunteer, which was that, by reputation, Indian manufacturers were market leaders in aseptic manufacturing, which is the very demanding manufacturing of making sterile drugs. So he volunteered to relocate, and wound up in New Delhi.
AMY GOODMAN: And explain what he found.
KATHERINE EBAN: So he started investigating these plants. And he had a different way of investigating than a lot of FDA investigators. He skipped the guided tours and the opening slideshows, and he went right to the quality control labs.
AMY GOODMAN: Wait, wait, wait. Are these tours announced in advance?
KATHERINE EBAN: That is one of the big problems. The FDA announces its inspections overseas in advance, sometimes giving two months’ advance notice to plants that they are coming.
AMY GOODMAN: So what does that mean? What can they do in that amount of time?
KATHERINE EBAN: They can do a lot. I mean, as one investigator said, “Give them a weekend, they can put up a building.” But, basically, the accusation is that these plants overseas are staging their inspections. And one of the remarkable findings in my book is that they literally have data fabrication teams that come in, in advance of these inspections, shred documents, fabricate documents, invent quality data, invent standard operating procedures, all in advance of the FDA’s arrival.
AMY GOODMAN: So, he goes into a factory.
KATHERINE EBAN: Yeah. One of the first plants that he went into was a company called Wockhardt, and this was a sterile manufacturing plant where the quality controls are incredibly strict, down to employees having to move very deliberately and slowly so as not to disturb the airflow in the plant. It’s that strict and regulated. And it was his second day of the inspection. He was in a hallway, and he saw an employee at the other end of this long, brightly lit hallway with a clear garbage bag, and the man was walking in a furtive manner. And as soon as the employee saw Peter Baker and his colleague, a microbiologist, he turned around and started walking the other way again. And the microbiologist yelled “Stop!” The man broke into a run. He tossed the garbage bag under a stairwell. And Peter Baker opened the garbage bag and found 75 torn batch records which indicated that insulin the company was manufacturing was contaminated with metallic particles but nonetheless had been released to patients in India and the Middle East.
So, Peter Baker is only responsible for U.S. medications, but he followed the trail of these documents. He went to this area of the plant, which had not been disclosed to the FDA, and he found the plant was manufacturing a sterile injectable cardiac drug on the same equipment that had created the metallic particles. So, he basically exposed deep fraud in this plant.
AMY GOODMAN: And so, what happens then? And I kept talking about the number of Americans who take these drugs, but, I mean, these drugs go out to the world.
KATHERINE EBAN: Absolutely. And actually, as a separate part of my investigation, which is also in the book, the plants make differing levels of quality for different markets. So, basically, their manufacturing standard can be whatever they can get away with. In other words, if they’re sending to other parts of the world, they lower their quality, they lower their quality ingredients, they skip manufacturing steps.
AMY GOODMAN: So, what happens when you find this contamination, when an inspector finds this contamination?
KATHERINE EBAN: Well, in this case, because Peter Baker discovered this, the plant was hit with a massive set of observations, in a form called a 483. They were put on import alert, which means their drugs were restricted from coming into the U.S. market. And so, in that instance, the inspection system worked as it should.
AMY GOODMAN: Can you talk about Ranbaxy?
KATHERINE EBAN: Yeah. So, Ranbaxy was India’s largest drug company and the largest maker of generic drugs and the fastest-growing generic drug maker in the U.S. And in 2005, a young information architect named Dinesh Thakur left Bristol-Myers Squibb and took a job at Ranbaxy. So he moved his family to Gurgaon. And—
AMY GOODMAN: To India.
KATHERINE EBAN: To India. And at a certain moment, his boss, who had also come from the brand pharma sector in England, got concerned about the quality of the data at Ranbaxy and had had some evidence that there was fraudulent data in some of the company’s HIV drugs. And so he gave Thakur an assignment, which was to investigate all of the company’s regulatory filings around the world and get to the bottom of whether there was actually data that existed for all of the claims that the company had made to regulators.
AMY GOODMAN: I want to go back to Peter Baker and what happened to him. So, he exposes this contamination at a major plant in India that’s making heart drugs, among others.
KATHERINE EBAN: In the course of five years, he inspected 86 plants in India and China, and he found some aspect of data fraud or deception at 67 of those plants, really almost four-fifths of the plants that he inspected. And he—
AMY GOODMAN: Repeat that. He found?
KATHERINE EBAN: He found some element of data fraud or data deception in almost four-fifths of the plants that he inspected overseas in India and China. And he did it with a completely different inspection method. Instead of looking at the records that the plant was giving him, he went into the manufacturing plant’s computer systems, and he started looking at deleted audit trails. And he tracked the metadata in the computer systems and realized that in many of these plants they were conducting what are called pretests. They were doing an initial offline screen of the drugs to see what the quality was, and then potentially making alterations to the tests, so that when they retested the drugs in the official system of the plant, they would pass quality tests.
AMY GOODMAN: And what happened to Peter Baker?
KATHERINE EBAN: He left the agency in March. Based on the experiences he had in India—he was followed, he was threatened. In one instance, he was poisoned with tainted water at a plant. Some of the investigators that he worked with were spied on. A hotel room was bugged. And based on this sort of aggregate experience, he was actually diagnosed with post-traumatic stress.
AMY GOODMAN: And the perks that inspectors get? I mean, what you described is hardly a perk—poisoned water. But what about how they’re treated? And how important are these companies to the countries, India and China?
KATHERINE EBAN: Well, one of the huge problems, as we discussed, is that the inspections by the FDA are announced two months in advance. And remarkably, the FDA even turns to these plants to arrange local travel, to arrange hotel ground transportation. And so, what happens is that the inspectors arrive. They’re picked up at the airport in a luxury car. They’re taken to a hotel, where their rooms are magically upgraded, and they never see a bill. There are trips to the Taj Mahal, shopping trips, massages, golf outings—a system that, as one of my sources called it, regulatory tourism. And the problem is, when the FDA says our drug supply has never been safer, they are discounting the fact that the findings of the plants are in this system of preannounced inspections.
AMY GOODMAN: And going back to Ranbaxy, this was the largest drug company in India.
KATHERINE EBAN: Yeah.
AMY GOODMAN: Explain what happened to it. And also talk about Lipitor.
KATHERINE EBAN: Yeah. So, Dinesh Thakur, who became a whistleblower, began doing—
AMY GOODMAN: Who worked at Bristol in the United States.
KATHERINE EBAN: That’s right.
AMY GOODMAN: Bristol Squibb, and then was recruited to go to India.
KATHERINE EBAN: That’s right. Once he started this research project, which was to investigate the company’s worldwide regulatory filings, he discovered that more than 40 products in over 200 countries—excuse me, more than 200 products in over 40 countries were filed with data that did not exist, falsified data in which the company was literally taking the brand drug and running tests off the brand drug and submitting it as its own data. I mean wild fabrications.
AMY GOODMAN: So, wait. They would use the brand drug, but in fact they would put the results to the generic they were making.
KATHERINE EBAN: That’s right. And this is—you know, this kind of fraudulent data is what they were using to get approval from the U.S. FDA. So, Dinesh Thakur, once this got exposed, his boss went into a board meeting and presented this to a subcommittee of the board of directors. And the question that he got back is: Could the report be buried, and could the laptop that the report was created on be destroyed? So, the company chose to conceal this. Ultimately, his boss resigned, and he was forced out of the company. And he decided to approach regulators with the information that he had, and ultimately he became a whistleblower for the FDA.
AMY GOODMAN: What happened to the drug company, Ranbaxy?
KATHERINE EBAN: Well, they—not only did they continue manufacturing and selling drugs for more than eight years from Dinesh Thakur’s first approach, the FDA, in the middle of what was a criminal investigation of this company for fraud, greenlighted Ranbaxy to manufacture the biggest generic drug in U.S. history, the first generic version of Lipitor.
AMY GOODMAN: And explain what Lipitor is used for.
KATHERINE EBAN: So, Lipitor is a cholesterol-reducing drug, which millions and millions of Americans take. So, it’s called a [statin]. And it is the biggest-selling drug of all time. And one year after Ranbaxy was given the green light to manufacture this, they made about $600 million in six months. Millions of their doses of Lipitor had to be recalled because they were infused with glass fragments.
AMY GOODMAN: And that’s just what we know. They happened to find this.
KATHERINE EBAN: They were under such scrutiny by the FDA that they ended up disclosing the glass fragments to the FDA, yeah.
AMY GOODMAN: What can—
KATHERINE EBAN: And they had to be recalled.
AMY GOODMAN: What can an individual do? I mean, what do you do if you’re taking the generic form of Lipitor and you feel sick, you feel different from when you took Lipitor?
KATHERINE EBAN: Right. So, you know, there is so little disclosure to consumers. I mean, one thing that every consumer can do is, they have a maintenance drug, and they feel it’s working—
AMY GOODMAN: Explain what you mean by “maintenance drug.”
KATHERINE EBAN: If they have a drug that they take every month, day in and day out—and many Americans do. Let’s say they are dispensed a drug that makes them feel good, that seems to be effective, that has minimal side effects.
AMY GOODMAN: So you’re taking it every day, like for thyroid—
KATHERINE EBAN: That’s right.
AMY GOODMAN: —for heart—
KATHERINE EBAN: Right.
AMY GOODMAN: —for cholesterol.
KATHERINE EBAN: Right. What they need to do is look at the manufacturer on the label, OK? They feel pretty good. We are all getting switched from generic to generic to generic every time we go to a pharmacy. But once you know that there is a manufacturer that is working for you, you need to inform your pharmacy that is the drug you want to continue taking.
The other thing consumers should do, which I do when I’m dispensed a drug and there’s a manufacturer name, I go to Google, and I put in ”FDA warning letter” and the name of that manufacturer, in order to see what have the FDA’s findings been about that drug and about that manufacturer.
AMY GOODMAN: So, you have to do the research yourself. Would you take a generic drug? And also, I mean, how it compares to how these brand drugs are made and where they’re made, in the same places?
KATHERINE EBAN: Right, right. Well, I do take generic drugs. Of course, we all take generic drugs. Because I know the history of a lot of these manufacturers, there are companies whose drugs I don’t take and companies whose drugs I will take.
AMY GOODMAN: When we come back, we’re going to talk about how these drugs are dumped on Africa.
KATHERINE EBAN: Yes, absolutely.
AMY GOODMAN: I want to also talk about the story of Cipla—
KATHERINE EBAN: Yes.
AMY GOODMAN: —and the significance of this. We’re talking to Katherine Eban, who is investigative journalist. Her book is just out. It’s an explosive book. It’s called Bottle of Lies: The Inside Story of the Generic Drug Boom. This is Democracy Now! Back with her in a minute.
[break]
AMY GOODMAN: “It’s Been Awhile” by Staind, here on Democracy Now! I’m Amy Goodman. We’re spending the hour with investigative journalist Katherine Eban, author of Bottle of Lies: The Inside Story of the Generic Drug Boom. It’s just been published. I want to turn to the Indian scientist Yusuf Hamied, chair of the drug manufacturer Cipla, who shook the conscience of the global health community by offering to produce generic AIDS medication at a tiny fraction of the cost. This is Dr. Hamied speaking several years ago.
YUSUF HAMIED: You must understand that today in the world there are about 40 million HIV-positive. You must also understand that 8,000-plus are dying every day because of HIV and related illnesses. The problem is not just what Cipla can do. It’s a much wider problem. We’re a small company; we’re not a major company. So I sincerely believe that the effort required is a team effort—the multinational companies, ourselves, the government, or governments of various countries. And it has to be a team effort.AMY GOODMAN: That’s Dr. Yusuf Hamied, Indian scientist. We’re spending the hour with journalist Katherine Eban, author of Bottle of Lies. Talk about Hamied, talk about Cipla, and what he did.
KATHERINE EBAN: Yeah. First, let me just correct myself, which is, Lipitor, of course, is a statin, not a sartan. We were talking about valsartan earlier, so I misspoke.
But Dr. Yusuf Hamied is really one of the great individuals of the 21st century. He looked around, saw this massive AIDS epidemic, and he saw brand companies protecting their drugs through a minefield of patents, and decided something had to be done. And so what he did was he announced, working with a group of activists, that he was prepared to manufacture AIDS drugs for a dollar a day, which was such a dramatic price cut that that set in motion a series of events that led to, ultimately, a very important U.S. program called PEPFAR, in which U.S. taxpayers—
AMY GOODMAN: This was a George W. Bush program.
KATHERINE EBAN: It was under George W. Bush. It was—President Clinton had a big impact on the events that led to it, because the Clinton Foundation helped, working with Indian manufacturers, to reduce the price further to 38 cents a day. He sort of aggregated the buying power of African governments and U.S. taxpayers and sort of, through this groundbreaking coalition, was able to get U.S. taxpayers to buy in bulk AIDS drugs for Africa as a way to tackle the AIDS epidemic.
AMY GOODMAN: What was the response of the global pharmaceutical community?
KATHERINE EBAN: Well, at first, the global pharmaceutical community was actually dead set against this. They were—wanted to protect their patents. And the outcry was so enormous that, ultimately, they waived their patents so that the India manufacturers could make these AIDS cocktails at a very low price.
AMY GOODMAN: I want to go to a tweet you posted about an executive from the Indian-based company Ranbaxy, the largest pharmaceutical company—
KATHERINE EBAN: Yeah.
AMY GOODMAN: —in India, that was. You wrote, “More telling was a shocking disregard for human life, from some company executives. When discussing the poor quality of the company’s AIDS drugs for Africa, on a conference call, a Ranbaxy medical director said: 'Who cares? It's just blacks dying.’”
KATHERINE EBAN: It’s a very disturbing statement. And this was said out loud on a conference call of Ranbaxy executives in about 2004. But it reflected a larger problem in the generic drug industry, which is, a lot of these companies have what’s called dual-track or multitiered production, which is they make their better drugs for more regulated markets, like the U.S. and the EU, and they will make worse-quality drugs for developing markets or markets that they call ”ROW,” which is “rest of world.”
AMY GOODMAN: ”ROW” means “rest of world.”
KATHERINE EBAN: Correct, yes. So those are developing markets where they have made a calculation that because regulation is so poor, they’re not going to get caught.
AMY GOODMAN: So, when someone travels—another example is, when someone travels overseas, they say, “You can’t believe how cheap I can get drugs there, the very same drugs we get in the United States.”
KATHERINE EBAN: Right, right. But they’re of worse—
AMY GOODMAN: That’s not true.
KATHERINE EBAN: —quality. And I shake my head. Even when I was reporting my book, and I traveled to India, and I had friends say, “Can you bring me back some antibiotics?” And I said, “Do you understand what I’m reporting? Why would I do that to you?”
AMY GOODMAN: So, you tweeted about your smoking gun around Ranbaxy.
KATHERINE EBAN: Yeah.
AMY GOODMAN: Talk about the documents you found.
KATHERINE EBAN: Right. So, the smoking gun was this PowerPoint presentation which was shown to a subcommittee of the board of directors. And it spelled out, in detail, that Ranbaxy had fabricated data, completely invented data, for more than 200 products in more than 40 countries, in an effort to just support business needs. In other words, they needed approvals, and they made up data. Inside the company, this document or presentation came to be known as the SAR, which was short for “self-assessment report.” And it really shaped the behavior of a number of the company’s top executives in an effort to suppress this document.
AMY GOODMAN: And again, say what Ranbaxy made and what happened to it.
KATHERINE EBAN: Yeah. So, I mean, Ranbaxy was manufacturing a huge number of generic drugs for the U.S. market. They were manufacturing generic drugs all over the world. Ultimately, this document, the disclosures around this document and prosecution by the U.S. government, not to mention Dinesh Thakur’s heroic efforts, brought down the company.
AMY GOODMAN: Why aren’t drugs, the active ingredients, generics, the brand drugs, antibiotics—why aren’t they made in the United States for U.S. citizens and noncitizens?
KATHERINE EBAN: Right. So, this has been part of a sort of long exodus of manufacturing from the U.S. market. It really started with antibiotics. One of the issues was environmental regulations, and companies wanted to—you know, very stringent or more stringent environmental regulations in the U.S. So, there’s a lot of waste production in manufacturing of antibiotics and drugs generally, so they shifted manufacturing overseas, to China and to India, and a lot of the manufacturing of other drugs followed. And, in fact, the brand-name companies also ended up shifting manufacturing overseas. They bought up manufacturing plants and found that, you know, almost overnight, they could cut some of their costs, by about 80%—the cost of labor, the cost of ingredients. So that was really one of the reasons behind it.
AMY GOODMAN: Could the government produce these drugs?
KATHERINE EBAN: Absolutely. And Elizabeth Warren, in fact, has a very interesting proposal to get the U.S. government to manufacture essential generic drugs. I mean, looked at one way, this is a national security issue. We need to manufacture our own medicine. What if we pissed off India, and they said, “Sorry, no more antibiotics”? We’d really be in a fix.
AMY GOODMAN: Some of the people you spoke to said they avoid taking prescription drugs.
KATHERINE EBAN: Well, they were more specific than that. And, in fact, this was a number of FDA investigators, who, based on the things that they witnessed in these plants overseas, basically have stopped taking generics manufactured overseas.
AMY GOODMAN: Where do they get them then?
KATHERINE EBAN: They try not to get sick. They are very particular about which companies they take drugs from. And it’s based on their own knowledge.
AMY GOODMAN: Are there lists of records? If you’re not an insider FDA inspector, where can you go online to see what companies am I going to get drugs from? And then, if you can go more specifically, and even if I’m going to get a drug from a company, I don’t want it made at this plant or that plant.
KATHERINE EBAN: Right.
AMY GOODMAN: Is there any way to find this out?
KATHERINE EBAN: I have been talking to people about trying to put together forward-facing data for consumers. You know, I don’t have any announcements to make right now on that front, but my hope is that there will be some forward-facing data available for consumers. Unfortunately, right now it’s all just in one bucket over here and one bucket over there. You know, consumers who get really interested in this can look on the FDA’s website for warning letters. Yeah.
AMY GOODMAN: What’s happened at the FDA? President Trump prides himself on rolling back regulations in the regulatory agencies, the FDA chief among them.
KATHERINE EBAN: Well, one of the things that’s been going on, which really needs further investigation, is that the FDA has been, almost systematically, downgrading the findings of its own investigators in these overseas generic plants. Now, they just put out a report saying that the quality is very high, and everything is fine, and they’ve got this under control. But, in fact, behind the scenes, they are downgrading from the most serious findings to less serious findings. And, you know, the documentation that I was able to get shows they’re making these decisions for political reasons. They’re making them because drafts of warning letters sat on their desks for too long. And this is something that really needs to be, I think, investigated by Congress.
AMY GOODMAN: In the wake of your book, public health advocate and whistleblower Dinesh Thakur, as well as Erin Fox, senior director of Drug Information and Support Services, University of Utah Health Care, have called on Congress and the FDA to hold hearings on generic drug safety.
KATHERINE EBAN: Yeah.
AMY GOODMAN: Do you see that happening anytime soon?
KATHERINE EBAN: I’d like to think that it would. I hope it would. You know, it’s very hard to say what, if anything, is going to happen in this political environment.
AMY GOODMAN: Have any lawmakers responded? And how much in the pocket are lawmakers, Democrat and Republican, of the drug industry?
KATHERINE EBAN: Certainly, there is a lot of lobbying—we all know that—by the pharmaceutical companies. I think that lawmakers who have been on this a long time are inclined to look at the role of the FDA in all of this and their claims that their regulation is adequate. I think there is some appetite to do that.
AMY GOODMAN: So, you’ve been working on this book for years, and you’ve been doing this kind of research way beyond the research you did for this book. What shocked you most, Katherine?
KATHERINE EBAN: Some of the falsifications and fabrications that are going on in these plants. For example, they’re even fabricating their own data proving that the plants are sterile. They’re falsifying their microbiology data. They have to test the environment. They have to test the air. They have to test the water. They’re fabricating that data. So, what is real, and what is fake?
AMY GOODMAN: Is there a particular story that sticks in your mind that you cannot shake?
KATHERINE EBAN: I mean, I would have to say Peter Baker’s investigations into the plant, Wockhardt, which I chronicle in my book.
AMY GOODMAN: Peter Baker, the FDA inspector.
KATHERINE EBAN: Yes, absolutely. I mean, from the moment that he lands at an airport, is followed by company representatives, one of whom—there is a man who yanks open the door of his cab, takes a hard look at him, closes it again. The investigators go to the plant. Several of them fall ill because of tainted water. They learn later that even as they were at night in the hotel room talking about their inspections and their findings, the company had bugged the hotel room. That is the level of the—
AMY GOODMAN: And how much support did he get from the FDA?
KATHERINE EBAN: Minimal, absolutely minimal. In fact, they pulled him off of doing inspections. I mean, he’s one of the most—he’s sort of the Pablo Picasso of FDA investigations.
AMY GOODMAN: And he left just now, just this past March.
KATHERINE EBAN: Yes. That’s right.
AMY GOODMAN: Under the Trump FDA.
KATHERINE EBAN: Yeah.
AMY GOODMAN: I want to thank you for being with us.
KATHERINE EBAN: Thank you.
AMY GOODMAN: We’re going to do Part 2 and post it online at democracynow.org. Investigative journalist Katherine Eban is the author of Bottle of Lies: The Inside Story of the Generic Drug Boom. It’s just been published. Her previous book, Dangerous Doses: A True Story of Cops, Counterfeiters, and the Contamination of America’s Drug Supply.
That does it for our show. Happy Birthday, Simin Farkhondeh! I’m Amy Goodman. Thanks for joining us.
https://www.democracynow.org/2019/5/20/bottle_of_lies_how_poor_fda?
Poll: Many Rural Americans Struggle With Financial Insecurity, Access To Health Care
by Patty Neighmond - NPR - May 21, 2019Polling by NPR finds that while rural Americans are mostly satisfied with life, there is a strong undercurrent of financial insecurity that can create very serious problems for many people living in rural communities.
The findings come from two surveys NPR has done with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health on day-to-day life and health in rural America.
After a major poll we did last fall found that a majority (55%) of rural Americans rate their local economy as only fair or poor, we undertook a second survey early this year to find out more about economic insecurity and health. The poll looked beyond the known factors of job loss and the decades-long flight of young people to more urban areas.
Several findings stand out: A substantial number (40%) of rural Americans struggle with routine medical bills, food and housing. And about half (49%) say they could not afford to pay an unexpected $1,000 expense of any type.
Access to health care
One-quarter of respondents (26%) said they have not been able to get health care when they needed it at some point in recent years. That's despite the fact that nearly 9 in 10 (87%) have health insurance of some sort — a level of coverage that is higher now than a decade ago, in large part owing to the Affordable Care Act and the expansion of Medicaid in many states.
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"At a time when we thought we had made major progress in reducing barriers to needed health care, the fact that 1 in 4 still face these barriers is an issue of national concern," says Robert J. Blendon, co-director of the survey and professor of health policy and political analysis at the Harvard T.H. Chan School of Public Health. "Either it is still not affordable for them or the insurance they have doesn't work — or they can't get care from the health providers that are in their community."
Of those not able to get health care when they needed it, the poll found that 45% could not afford it, 23% said the health care location was too far or difficult to get to, and 22% could not get an appointment during the hours needed.
Dee Davis, president and founder of the Center for Rural Strategies in Whitesburg, Ky., says poverty and ill health are endemic where he lives. "People in this congressional district have the shortest life span in the United States; we also are the poorest," Davis says. "We're poor and we're sicker."
But, he adds, the Affordable Care Act — which in Kentucky brought an expansion of Medicaid to many previously uninsured residents — went a long way in helping many rural communities take care of recurring problems. "We're not out of the woods yet but the ACA certainly changed the landscape," Davis says.
Lots of rural people benefited from the ACA, he adds, and if that progress were to be lost, he says: "We're in trouble."
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For purposes of this poll, "rural" was defined as areas that are not part of a Metropolitan Statistical Area, as used in the 2016 National Exit Poll. The NPR poll was conducted in English and Spanish using random-digit dialing Jan. 31-March 2 among a nationally representative, probability-based sample of 1,405 adults ages 18 or older living in the rural U.S. The margin of error for the total respondents is plus or minus 3.5 percentage points at the 95% confidence level.
Financial insecurity
One measure of financial security is the ability to meet unexpected expenses like a car repair or a medical problem or fixing something that has gone wrong in the house. It's not unusual for these expenses to run $1,000 or more, so we asked whether that would be a problem.
Overall, nearly half (49%) said they wouldn't be able to afford that. And more than 6 in 10 rural black and Latinx Americans said they would have a problem paying that off (blacks, 68%; Latinx, 62%), compared with 45% of rural whites.
"When you're living close to the edge, sometimes you fall off," says Davis. "If half the people in rural America can't deal with a $1,000 bill, that's rough."
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It would be an issue for 72-year-old Leitha Dollarhyde, a retired caregiver who lives near Whitesburg, Ky., a rural town of under 2,000 people. She was born about 4 miles from where she lives today.
Her answer, when asked if she could afford an unexpected $1,000 expense? "No. There's no way. My savings account is zero."
Dollarhyde worked all her life, but the jobs just didn't pay enough for her to put anything aside. She raised four children. Today her income — Social Security and Supplemental Security Income — adds up to $790 a month.
"With that income, you watch every penny," she says.
Strong social networks
Yet even with the high levels of financial insecurity that we found, there is abundant optimism and satisfaction with the quality of life in rural America. Almost three-quarters (73%) of rural Americans rate the overall quality of life in their local community as excellent or good. And a majority (62%) are optimistic that people like them can make an impact on their local community.
Davis says that is what he observes in rural Kentucky. "People may be living a more hardscrabble existence than folks in the suburbs or a lot of the folks in cities, but it doesn't mean they're not living a decent life," he says. "Most people are pretty happy with it; they've got friends and neighbors they rely on and they're where they want to be."
Still, social isolation and loneliness are a concern in rural America. We found nearly 4 in 10 (38%) said "many people" in their community feel lonely or isolated, with almost 1 in 5 (18%) saying they "always" or "often" feel either isolated or lonely. People with disabilities (31%) more frequently said they feel lonely or isolated from others compared with those without disabilities (12%).
Don't see the graphic above? Click here
A majority of rural Americans say they participate in civic and social activities, including volunteering and service, political activities, community meetings and membership in a variety of groups. The most frequently cited activity was volunteering their time to an organization working to make their local community a healthier place to live (49%).
Whitesburg community activist Nell Fields says that when her husband was recently hospitalized, her neighbors were extraordinary.
"My neighbors come and mow my grass, feed cattle, get eggs every day for the last few weeks," she says. "That says so much to me. [It] makes me feel the emotion now of what it feels like to have such warm, wonderful support and I know that's the blessing of living in rural America."
Declining hospitals
Since 2010, 106 rural hospitals have closed in rural America. As many as 673 more are at risk of closure, according to a 2016 report from iVantage Health Analytics. Currently, there are approximately 1,860 rural hospitals in the U.S.
Eight percent of rural adults polled say hospitals in their local communities have closed down in the past few years. About two-thirds (67%) say the closures were a problem, including 38% who say they were a major problem.
"It means people have to travel greater distances to receive care, and distance can be a barrier to timely and appropriate access to services," says Brock Slabach of the National Rural Health Assembly in Leawood, Kan. "Delayed care can often lead to tragic consequences. This can be a huge barrier for many living in rural areas."
Don't see the graphic above? Click here
As an example, he points to the small town of Tonopah, Nev., population 2,478, that is more than three hours away from the nearest hospital by road. The community's hospital closed in 2015 and the ambulance service in town was left to deal with all kinds of medical problems that it is not situated to handle, Slabach says.
In areas where higher-speed Internet access is available, people are turning to telehealth instead of going to a doctor or clinic. But broadband access is a perennial issue in many parts of rural America, with 1 in 5 (21%) saying that accessing high-speed Internet is a problem for their family. Among those who do use the Internet, a majority say they do so to obtain health information (68%).
The medical purposes for using telehealth vary, as a majority of rural telehealth patients (53%) say they have received at least one prescription from their doctor or other health professional using telehealth, while 25% have received a diagnosis or treatment for a chronic condition, 16% have received a diagnosis or treatment for an emergency, and 9% have received a diagnosis or treatment for an infectious disease.
https://www.mainepublic.org/post/poll-many-rural-americans-struggle-financial-insecurity-access-health-care
WASHINGTON (AP) — The “Medicare for All” plan embraced by leading 2020 Democrats appears more lavish than what other advanced countries offer, compounding the cost but also potentially broadening its popular appeal.
The plan from Vermont Sen. Bernie Sanders would charge no copays or deductibles for medical care, allowing only limited cost-sharing for some prescription drugs. It would cover long-term care at home and in community settings. Dental, vision and hearing coverage would be included.
But while other countries do guarantee coverage for all, the benefits vary significantly. Canada, often cited as a model, does not cover outpatient prescriptions and many Canadians have private insurance for medications. Many countries don’t cover long-term care. Modest copays are common.
“Medicare for All proposals would leapfrog other countries in terms of essentially eliminating private insurance and out-of-pocket costs, and providing very expansive benefits,” said Larry Levitt, a health policy expert with the nonpartisan Kaiser Family Foundation. “It raises questions about how realistic the proposals are.”
Shifting the sprawling U.S. health care system to a government-run “single-payer” plan is one of the top issues in the 2020 Democratic presidential primary, but the candidates are divided. Some have echoed Sanders’ call, while others want to expand coverage within the current mix of private and government insurance. Independent studies estimate Medicare for All would dramatically increase government spending, from $25 trillion to $35 trillion or more over 10 years. It stands no chance with Republicans controlling the White House and the Senate, but it is getting hearings in the Democratic-led House.
Economist Sherry Glied, dean of New York University’s Wagner school of public policy, says the offer of generous benefits may be needed to persuade Americans satisfied with employer coverage that they would be better off in a new government plan.
“You are going to have to be very generous if you want this to be politically appealing to lots of people,” said Glied, who was a senior health care adviser in the Obama administration.
Glied says components like benefits, copayments and deductibles would all be negotiable.
“People put out talking points and then they see what Congress is willing to swallow,” said Glied. “Who knows where it would come out in the end.”
A second congressional hearing on Medicare for All is scheduled Wednesday before the House Budget Committee. House legislation largely tracks Sanders’ bill. Votes this year appear unlikely. The plan is a punching bag for Republicans trying to tag Democrats as “socialists.”
In a statement, Sanders’ office said it’s fair for the senator to compare Medicare for All to what other countries have because “all those other countries guarantee health care as a right,” as his plan would.
“Sen. Sanders believes providing comprehensive coverage through the government to all residents is the best way to do it,” said the statement.
If the legislation were to advance to votes, “we will hear out concerns from our colleagues and work with them to get this bill passed,” the statement continued. “But we are very clear about what we want and what this country needs. Insurance company CEOs are going to pay well before the American people are.”
Two recent reports have called attention to significant differences among countries that cover everyone and are held up as models for Medicare for All.
A report from the Congressional Budget Office will be the focus of Wednesday’s House hearing. Another report, for the nonpartisan Commonwealth Fund, was written by Glied. Among its findings: Other countries don’t necessarily take the same approach as Medicare for All, using a range of strategies to cover all their residents.
“Currently, single-payer bills in the U.S. tend to share the same key goals: centralizing...the system, expanding the public benefits package and eliminating private health insurance entirely,” the Commonwealth report said. “However, these three features are not the norm across countries that have achieved universal coverage for health care.” Many countries retain a role for private insurance, for example.
The report found that one group of countries — including Denmark, Britain and Germany — provide comprehensive benefits, including such services as mental health care. They charge low copays. Those countries are the closest to Medicare for All.
A larger group — including Australia, France, Netherlands, Norway, Singapore, Sweden, Switzerland and Taiwan — offer broad benefits but there may be gaps, and cost sharing is higher. Australia charges $60 for specialist visits. The Netherlands has a $465 deductible. Dental coverage may be limited.
Finally, Canada has a narrow national benefits package. It doesn’t cover outpatient prescriptions, long-term care, mental health, vision and dental. But there’s no cost sharing for hospital and doctors’ services. Canadians rely on private insurance and provincial governments to fill the gaps.
https://apnews.com/15163a801e854345a836d4287809fc44
A loser's approach to Medicare-for-all
by Jon Walker - The Week - May 21, 2019
Presidential candidate and California senator Kamala Harris made headlines recently after seeming to tie herself in rhetorical knots over questions about Medicare-for-all. In separate statements Harris first said she supported the elimination of private health insurance, and then that she didn't.
The inconsistency can partly be chalked up to the usual limitations of trying to communicate complicated policy positions in short soundbites and the changing dynamic of the primary. And Harris isn't the only Medicare-for-all supporter who has been less than totally clear.
Yet it's also symptomatic of the broader Medicare-for-all movement attempting to have it both ways. Passing and implementing single-payer will require specific design choices that dictate financial winners and losers, but advocates have so far been unwilling to orient their politics accordingly. This is true as it relates to private insurers, but also especially in the case of the hospitals and specialists who owe their inflated profits to outrageous pricing schemes and abusive surprise billing practices.
Physicians for a National Health Program (PNHP), one of the most prominent single-payer organizations, has a vision for how they want Medicare-for-all to work. Their plan is that simplifying the way Americans pay for medical care would save a significant amount on paperwork. These administrative savings, plus some reduction in drug prices, would likely be enough to cover the uninsured and improve some benefits. And, although other single-payer countries spend roughly 10 percent of GDP or less on health care, they assume the United States will still spend around 17 percent of our GDP on health care, but just spend it more efficiently.
Dr. Adam Gaffney, president of PHNP, has made clear he doesn't put a priority on Medicare-for-all reducing our hospital spending or the income of American doctors, both of which are the highest in the industrialized world. Gaffney wants hospital spending to basically be frozen at what it is the year Medicare-for-all is adopted, with a promise to then save money down the line by slowing hospital growth.
Effectively, this is the same position of Congressional Democrats, who have so far avoided addressing the question directly in their proposed bills. In an op-ed earlier this month, Bernie Sanders attacked Partnership for America's Health Care Future saying, "they are insurance companies and the pharmaceutical industry's lobbying group," but left out the fact that hospitals and doctors are also represented by the organization. This is a pattern followed by Elizabeth Warren and others who often criticize insurance companies but rarely if ever talk about abuse or price gouging by hospitals.
The big problem is that, paradoxically, this approach of building out Medicare-for-all in the nicest possible way to hospitals actually incentivizes the strongest possible opposition from the health-care industry.
Single-payer groups used the same basic logic and spending design on the state level when they tried to pass California Proposition 186 in 1994, Oregon's Measure 23 in 2002, and Colorado's Amendment 69 in 2016. In that time span health care expenditures have risen from 13.3 percent of GDP to the more than 17 percent it is today.
Up to now, single-payer groups have effectively told hospitals they get to keep all their ill-gotten gains from however long it takes for Medicare-for-all to pass, but will be forced to live within those budgets afterwards. Each time hospitals help kill a single-payer effort, health care spending keeps rising and the next effort starts with the new inflated spending level as the baseline. See the problem?
There are only three ways to deal with a stakeholder when crafting legislation. You can straight buy them off by giving them more than they would have without the law. You can decide they can't be won over so you just need to fight them head on. Or you can force the stakeholder to reach a compromise by making them afraid that, if they don't work with you, something even worse for them will happen.
The current strategy for Medicare-for-all proponents vis-à-vis health care providers is none of the above.
While the PHNP approach is relatively nice to hospitals, it does call for reductions to hospital revenue in the future. At the same time, there is almost no effort to prepare for that fight by pointing out the insane prices they charge with no consistency or the fact that they are so comically bloated they don't even know what their procedures actually cost. And so far, instead of scaring hospitals into a negotiated compromise, single-payer groups have let hospitals know that walking away will always result in a better offer next time.
This has all the downsides of trying to buy off a major stakeholder with none of the benefits. By letting hospitals and specialists keep so much money, it makes it very difficult to make Medicare-for-all a clear financial winner for everyone else. To keep total health care spending the same, these previous state ballot measures required large income or payroll taxes roughly the same size as currently private health insurance premium spending.
The size of these new taxes kills the ability to build a large coalition. Even if many people with employer-provided insurance are able to fully understand how a new payroll tax would replace their current premiums and deductibles, many would see that as a wash. Similarly, for American businesses and many unions there is no gain. If the new payroll tax is the same size as premiums, Medicare-for-all would not make hiring American workers more cost competitive compared to other countries. At the same time, businesses and unions would lose a major worker retention tool.
Some in the Medicare-for-all movement seem to realize this. PERI researchers, in their plan to pay for Medicare-for-all, propose requiring employers to give the government only 92 percent of what they had been paying in private premiums. But without getting serious about hospital and doctor prices, that still doesn't generate enough revenue, so PERI also needed to include a large new national sales tax as well as a wealth tax. Tough to convince voters to support a new sales tax just to keep doctor salaries the highest in the world.
For comparison, public entities in the United Kingdom cover everyone while spending just 7.7 percent GDP. Public entities in the United States spend 8.5 percent on GDP to only partially cover about half the population. If we adopted UK level prices/salaries for providers we could not only provide universal coverage but also eliminate private premiums, deductibles, and cut government spending.
Health care costs are a top issue for voters. Polling shows the American people are open to transformative health reforms and ready to respond to a message about finally reining in prices. A poll last summer found 71 percent of Americans believed that hospitals charging too much is a major reason health care costs are rising, slightly more than the percentage who blamed health insurance companies.
A coalition of regular people and businesses can be built behind a plan like Medicare-for-all that is serious about bringing down prices, but only if the single-payer movement stops trying to half-heartedly win over hospitals and doctors. A strategy that gives hospitals so much money you need big tax increases but not enough to buy their support is a loser.
https://theweek.com/articles/838736/losers-approach-medicareforall
‘Medicare for All’s’ rich benefits ‘leapfrog’ other nations
- Associated Press - May 21, 2019
WASHINGTON (AP) — The “Medicare for All” plan embraced by leading 2020 Democrats appears more lavish than what other advanced countries offer, compounding the cost but also potentially broadening its popular appeal.
The plan from Vermont Sen. Bernie Sanders would charge no copays or deductibles for medical care, allowing only limited cost-sharing for some prescription drugs. It would cover long-term care at home and in community settings. Dental, vision and hearing coverage would be included.
But while other countries do guarantee coverage for all, the benefits vary significantly. Canada, often cited as a model, does not cover outpatient prescriptions and many Canadians have private insurance for medications. Many countries don’t cover long-term care. Modest copays are common.
“Medicare for All proposals would leapfrog other countries in terms of essentially eliminating private insurance and out-of-pocket costs, and providing very expansive benefits,” said Larry Levitt, a health policy expert with the nonpartisan Kaiser Family Foundation. “It raises questions about how realistic the proposals are.”
Shifting the sprawling U.S. health care system to a government-run “single-payer” plan is one of the top issues in the 2020 Democratic presidential primary, but the candidates are divided. Some have echoed Sanders’ call, while others want to expand coverage within the current mix of private and government insurance. Independent studies estimate Medicare for All would dramatically increase government spending, from $25 trillion to $35 trillion or more over 10 years. It stands no chance with Republicans controlling the White House and the Senate, but it is getting hearings in the Democratic-led House.
Economist Sherry Glied, dean of New York University’s Wagner school of public policy, says the offer of generous benefits may be needed to persuade Americans satisfied with employer coverage that they would be better off in a new government plan.
“You are going to have to be very generous if you want this to be politically appealing to lots of people,” said Glied, who was a senior health care adviser in the Obama administration.
Glied says components like benefits, copayments and deductibles would all be negotiable.
“People put out talking points and then they see what Congress is willing to swallow,” said Glied. “Who knows where it would come out in the end.”
A second congressional hearing on Medicare for All is scheduled Wednesday before the House Budget Committee. House legislation largely tracks Sanders’ bill. Votes this year appear unlikely. The plan is a punching bag for Republicans trying to tag Democrats as “socialists.”
In a statement, Sanders’ office said it’s fair for the senator to compare Medicare for All to what other countries have because “all those other countries guarantee health care as a right,” as his plan would.
“Sen. Sanders believes providing comprehensive coverage through the government to all residents is the best way to do it,” said the statement.
If the legislation were to advance to votes, “we will hear out concerns from our colleagues and work with them to get this bill passed,” the statement continued. “But we are very clear about what we want and what this country needs. Insurance company CEOs are going to pay well before the American people are.”
Two recent reports have called attention to significant differences among countries that cover everyone and are held up as models for Medicare for All.
A report from the Congressional Budget Office will be the focus of Wednesday’s House hearing. Another report, for the nonpartisan Commonwealth Fund, was written by Glied. Among its findings: Other countries don’t necessarily take the same approach as Medicare for All, using a range of strategies to cover all their residents.
“Currently, single-payer bills in the U.S. tend to share the same key goals: centralizing...the system, expanding the public benefits package and eliminating private health insurance entirely,” the Commonwealth report said. “However, these three features are not the norm across countries that have achieved universal coverage for health care.” Many countries retain a role for private insurance, for example.
The report found that one group of countries — including Denmark, Britain and Germany — provide comprehensive benefits, including such services as mental health care. They charge low copays. Those countries are the closest to Medicare for All.
A larger group — including Australia, France, Netherlands, Norway, Singapore, Sweden, Switzerland and Taiwan — offer broad benefits but there may be gaps, and cost sharing is higher. Australia charges $60 for specialist visits. The Netherlands has a $465 deductible. Dental coverage may be limited.
Finally, Canada has a narrow national benefits package. It doesn’t cover outpatient prescriptions, long-term care, mental health, vision and dental. But there’s no cost sharing for hospital and doctors’ services. Canadians rely on private insurance and provincial governments to fill the gaps.
https://apnews.com/15163a801e854345a836d4287809fc44
A loser's approach to Medicare-for-all
by Jon Walker - The Week - May 21, 2019
Presidential candidate and California senator Kamala Harris made headlines recently after seeming to tie herself in rhetorical knots over questions about Medicare-for-all. In separate statements Harris first said she supported the elimination of private health insurance, and then that she didn't.
The inconsistency can partly be chalked up to the usual limitations of trying to communicate complicated policy positions in short soundbites and the changing dynamic of the primary. And Harris isn't the only Medicare-for-all supporter who has been less than totally clear.
Yet it's also symptomatic of the broader Medicare-for-all movement attempting to have it both ways. Passing and implementing single-payer will require specific design choices that dictate financial winners and losers, but advocates have so far been unwilling to orient their politics accordingly. This is true as it relates to private insurers, but also especially in the case of the hospitals and specialists who owe their inflated profits to outrageous pricing schemes and abusive surprise billing practices.
Physicians for a National Health Program (PNHP), one of the most prominent single-payer organizations, has a vision for how they want Medicare-for-all to work. Their plan is that simplifying the way Americans pay for medical care would save a significant amount on paperwork. These administrative savings, plus some reduction in drug prices, would likely be enough to cover the uninsured and improve some benefits. And, although other single-payer countries spend roughly 10 percent of GDP or less on health care, they assume the United States will still spend around 17 percent of our GDP on health care, but just spend it more efficiently.
Dr. Adam Gaffney, president of PHNP, has made clear he doesn't put a priority on Medicare-for-all reducing our hospital spending or the income of American doctors, both of which are the highest in the industrialized world. Gaffney wants hospital spending to basically be frozen at what it is the year Medicare-for-all is adopted, with a promise to then save money down the line by slowing hospital growth.
Effectively, this is the same position of Congressional Democrats, who have so far avoided addressing the question directly in their proposed bills. In an op-ed earlier this month, Bernie Sanders attacked Partnership for America's Health Care Future saying, "they are insurance companies and the pharmaceutical industry's lobbying group," but left out the fact that hospitals and doctors are also represented by the organization. This is a pattern followed by Elizabeth Warren and others who often criticize insurance companies but rarely if ever talk about abuse or price gouging by hospitals.
The big problem is that, paradoxically, this approach of building out Medicare-for-all in the nicest possible way to hospitals actually incentivizes the strongest possible opposition from the health-care industry.
Single-payer groups used the same basic logic and spending design on the state level when they tried to pass California Proposition 186 in 1994, Oregon's Measure 23 in 2002, and Colorado's Amendment 69 in 2016. In that time span health care expenditures have risen from 13.3 percent of GDP to the more than 17 percent it is today.
Up to now, single-payer groups have effectively told hospitals they get to keep all their ill-gotten gains from however long it takes for Medicare-for-all to pass, but will be forced to live within those budgets afterwards. Each time hospitals help kill a single-payer effort, health care spending keeps rising and the next effort starts with the new inflated spending level as the baseline. See the problem?
There are only three ways to deal with a stakeholder when crafting legislation. You can straight buy them off by giving them more than they would have without the law. You can decide they can't be won over so you just need to fight them head on. Or you can force the stakeholder to reach a compromise by making them afraid that, if they don't work with you, something even worse for them will happen.
The current strategy for Medicare-for-all proponents vis-à-vis health care providers is none of the above.
While the PHNP approach is relatively nice to hospitals, it does call for reductions to hospital revenue in the future. At the same time, there is almost no effort to prepare for that fight by pointing out the insane prices they charge with no consistency or the fact that they are so comically bloated they don't even know what their procedures actually cost. And so far, instead of scaring hospitals into a negotiated compromise, single-payer groups have let hospitals know that walking away will always result in a better offer next time.
This has all the downsides of trying to buy off a major stakeholder with none of the benefits. By letting hospitals and specialists keep so much money, it makes it very difficult to make Medicare-for-all a clear financial winner for everyone else. To keep total health care spending the same, these previous state ballot measures required large income or payroll taxes roughly the same size as currently private health insurance premium spending.
The size of these new taxes kills the ability to build a large coalition. Even if many people with employer-provided insurance are able to fully understand how a new payroll tax would replace their current premiums and deductibles, many would see that as a wash. Similarly, for American businesses and many unions there is no gain. If the new payroll tax is the same size as premiums, Medicare-for-all would not make hiring American workers more cost competitive compared to other countries. At the same time, businesses and unions would lose a major worker retention tool.
Some in the Medicare-for-all movement seem to realize this. PERI researchers, in their plan to pay for Medicare-for-all, propose requiring employers to give the government only 92 percent of what they had been paying in private premiums. But without getting serious about hospital and doctor prices, that still doesn't generate enough revenue, so PERI also needed to include a large new national sales tax as well as a wealth tax. Tough to convince voters to support a new sales tax just to keep doctor salaries the highest in the world.
For comparison, public entities in the United Kingdom cover everyone while spending just 7.7 percent GDP. Public entities in the United States spend 8.5 percent on GDP to only partially cover about half the population. If we adopted UK level prices/salaries for providers we could not only provide universal coverage but also eliminate private premiums, deductibles, and cut government spending.
Health care costs are a top issue for voters. Polling shows the American people are open to transformative health reforms and ready to respond to a message about finally reining in prices. A poll last summer found 71 percent of Americans believed that hospitals charging too much is a major reason health care costs are rising, slightly more than the percentage who blamed health insurance companies.
A coalition of regular people and businesses can be built behind a plan like Medicare-for-all that is serious about bringing down prices, but only if the single-payer movement stops trying to half-heartedly win over hospitals and doctors. A strategy that gives hospitals so much money you need big tax increases but not enough to buy their support is a loser.
https://theweek.com/articles/838736/losers-approach-medicareforall
Economists in Support of a Medicare for All Health Care System
An Open Letter to the Congress and People of the United States
May 21, 2019
As economists, we understand that a single-payer “Medicare for All” health insurance system for the U.S. can finance good-quality care for all U.S. residents as a basic right while still significantly reducing overall health care spending relative to the current exorbitant and wasteful system. Health care is not a service that follows standard market rules. It should therefore be provided as a public good.
Evidence from around the world demonstrates that publicly financed health care systems result in improved health outcomes, lower costs, and greater equity. As of 2017, the U.S. spent $3.3 trillion annually on health care. This equaled 17 percent of U.S. GDP, with average spending at about $10,000 per person. By contrast, Germany, France, Japan, Canada, the U.K., Australia, Spain and Italy spent between 9 – 11 percent of GDP on health care, averaging $3,400 to $5,700 per person. Yet average health outcomes in all of these countries are superior to those in the United States. In all of these countries, the public sector is predominant in financing heath care.
For these reasons the time is now to create a universal, single-payer, Medicare for All health care system in the United States.
Public financing for health is not a matter of raising new money for healthcare, but of reducing total healthcare outlays and distributing payments more equitably and efficiently. Implementing a unified single-payer system would reduce administrative costs and eliminate individuals' and employers' insurance premiums and out-of-pocket costs. If combined with public control of drug prices and a dramatically simplified global budgeting system, a sensible Medicare financing system would reduce healthcare costs while guaranteeing access to comprehensive care and financial security to all.
As such, we support publicly and equitably financed health care through a Medicare for All system at the Federal level, as described in H.R. 1384 and S. 1129. We encourage Congress to move forward with implementing a public financed Medicare for All plan to achieve the equitable and affordable universal health care system that the American people need.
Signed,
1 Randy Albelda, Professor of Economics, University of Massachusetts Boston
2 Carolyn B. Aldana, Professor Emeritus, California State University, San Bernardino 3 Mona Ali, Associate Professor of Economics, SUNY New Paltz
4 Larry Allen, Professor of Economics, Lamar University
5 Jack Amariglio, Emeritus Professor of Economics, Merrimack College
An Open Letter to the Congress and People of the United States
May 21, 2019
As economists, we understand that a single-payer “Medicare for All” health insurance system for the U.S. can finance good-quality care for all U.S. residents as a basic right while still significantly reducing overall health care spending relative to the current exorbitant and wasteful system. Health care is not a service that follows standard market rules. It should therefore be provided as a public good.
Evidence from around the world demonstrates that publicly financed health care systems result in improved health outcomes, lower costs, and greater equity. As of 2017, the U.S. spent $3.3 trillion annually on health care. This equaled 17 percent of U.S. GDP, with average spending at about $10,000 per person. By contrast, Germany, France, Japan, Canada, the U.K., Australia, Spain and Italy spent between 9 – 11 percent of GDP on health care, averaging $3,400 to $5,700 per person. Yet average health outcomes in all of these countries are superior to those in the United States. In all of these countries, the public sector is predominant in financing heath care.
For these reasons the time is now to create a universal, single-payer, Medicare for All health care system in the United States.
Public financing for health is not a matter of raising new money for healthcare, but of reducing total healthcare outlays and distributing payments more equitably and efficiently. Implementing a unified single-payer system would reduce administrative costs and eliminate individuals' and employers' insurance premiums and out-of-pocket costs. If combined with public control of drug prices and a dramatically simplified global budgeting system, a sensible Medicare financing system would reduce healthcare costs while guaranteeing access to comprehensive care and financial security to all.
As such, we support publicly and equitably financed health care through a Medicare for All system at the Federal level, as described in H.R. 1384 and S. 1129. We encourage Congress to move forward with implementing a public financed Medicare for All plan to achieve the equitable and affordable universal health care system that the American people need.
Signed,
1 Randy Albelda, Professor of Economics, University of Massachusetts Boston
2 Carolyn B. Aldana, Professor Emeritus, California State University, San Bernardino 3 Mona Ali, Associate Professor of Economics, SUNY New Paltz
4 Larry Allen, Professor of Economics, Lamar University
5 Jack Amariglio, Emeritus Professor of Economics, Merrimack College
-
6 Eileen Appelbaum, Co-Director and Senior Economist, Center for Economic and Policy
Research
-
7 Peter Arno, Senior Fellow & Director Health Policy Research, Political Economy
Research Institute, University of Massachusetts, Amherst
-
8 Michael Ash, Professor of Economics & Public Policy, University of Massachusetts
Amherst
-
9 Glen Atkinson, Emeritus Professor of Economics, University of Nevada, Reno
-
10 M V Lee Badgett, Professor of Economics, University of Massachusetts Amherst
-
11 Ron Baiman, Assistant Professor of Economics, Benedictine University
-
12 Dean Baker, Senior Economist, Center for Economic and Policy Research
-
13 Radhika Balakrishnan, Professor, Rutgers University
-
14 Nina Banks, Associate Professor of Economics, Bucknell University
-
15 David Barkin, Distinguished Professor, Universidad Autonoma Metropolitana
-
16 Charles Barone, Professor Emeritus, Dickinson College
-
17 Deepankar Basu, Associate Professor, University of Massachusetts Amherst
-
18 Lourdes Beneria, Professor Emerita, Cornell University
-
19 Peter H. Bent, Assistant Professor, American University of Paris
-
20 Suzanne Bergeron, Professor, University of Michigan Dearborn
-
21 Cyrus Bina, Distinguished Research Professor of Economics, University of Minnesota
(Morris Campus), and Fellow, Economists for Peace and Security
-
22 Josh Bivens, Research Director, Economic Policy Institute
-
23 Robert A. Blecker, Professor of Economics, American University
-
24 Peter Bohmer, Faculty in Economics and Political Economy, The Evergreen State College
-
25 Howard Botwinick, Associate Professor of Economics, SUNY Cortland
-
26 Roger Even Bove, Ph.D. in Economics, West Chester University (retired)
-
27 James K. Boyce, Professor Emeritus, University of Massachusetts Amherst
-
28 Robert Brenner, Director, Center for Social Theory and Comparative History, UCLA
-
29 Michael Brün, Instructor, Heartland Community College
-
30 Antonio Callari, Professor, Franklin and Marshall College
-
31 Al Campbell, Emeritus Professor of Economics, University of Utah
-
32 Martha Campbell, Associate Professor of Economics, Emeritus, SUNY Potsdam
-
33 Jim Campen, Professor of Economics, Emeritus, University of Massachusetts Boston
-
34 José Caraballo, Professor, University of Puerto Rico
-
35 Scott Carter, Professor of Economics, The University of Tulsa
-
36 James F Casey, Associate Professor of Economics, Washington and Lee University
-
37 John Dennis Chasse, Professor Emeritus, SUNY College at Brockport
-
38 Robert Chernomas, Professor of Economics, University of Manitoba
-
39 Kimberly Christensen, Economics Professor, Sarah Lawrence College
-
40 Douglas Cliggott, Lecturer, Economics, University of Massachusetts
-
41 Nathaniel Cline, Associate Professor, University of Redlands
-
42 Richard Cornwall, Professor Emeritus, Middlebury College
-
43 James Crotty, Emeritus Professor, University of Massachusetts
-
44 Dr. James Cypher, Professor of Economics, Universidad Autonoma de Zacatecas, Mexico,
and Emeritus Professor, California State University
-
45 Omar Dahi, Hampshire College
-
46 Anita Dancs, Associate Professor of Economics, Western New England University
-
47 Paul Davidson, Emeritus Professor Chair of Honor, University of Tennessee
-
48 Charles Davis, Professor of Labor Studies, Indiana University
-
49 Carmen Diana Deere, Distinguished Professor Emerita, University of Florida
-
50 George DeMartino, Professor, JKSIS, University of Denver
-
51 Firat Demir, Professor, University of Oklahoma
-
52 James G. Devine, Professor of Economics, Loyola Marymount University
-
53 Geert Dhondt, Associate Professor, John Jay College, CUNY
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54 Peter Dorman, Professor of Political Economy, Evergreen State College
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55 Richard Du Boff, Professor Emeritus, Bryn Mawr College
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56 Marie C. Duggan, Professor of Economics, Keene State College
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57 Amitava Krishna Dutt, Professor of Economics and Political Science, University of Notre
Dame
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58 Nina Eichacker, Assistant Professor, University of Rhode Island
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59 David P Ellerman, Visiting Scholar, University of California at Riverside
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60 Gerald Epstein, Professor of Economics, University of Massachusetts Amherst
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61 Thomas Ferguson, Professor Emeritus, University of Massachusetts Boston
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62 Ellen Fitzpatrick, Professor, Merrimack College
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63 Sean Flaherty, Professor of Economics, Franklin and Marshall College
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64 Nancy Folbre, Professor Emerita of Economics, University of Massachusetts Amherst
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65 Mariko Frame, Assistant Professor of Economics, Merrimack College
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66 Dania V. Francis, Assistant Professor, University of Massachusetts Amherst
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67 Gerald Friedman, Professor of Economics, University of Massachusetts Amherst
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68 James K. Galbraith, Professor, University of Texas at Austin
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69 Barbara Garson, Author, Money Makes the World Go Round
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70 Armagan Gezici, Associate Professor of Economics, Keene State College
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71 Helen Lachs Ginsburg, Professor Emerita of Economics, Brooklyn College/CUNY
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72 Mwangi Wa Githinji, Associate Professor, University of Massachusetts-Amherst
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73 Art Goldsmith, Professor of Economics, Washington and Lee University
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74 Neva Goodwin, Co-director, GDAE, Tufts University
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75 Ulla Grapard, Professor of Economics and Women's Studies, Emerita, Colgate University
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76 Robert Guttmann, Augustus B Weller Professor of Economics, Hofstra University
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77 Robin E Hahnel, Professor Emeritus, American University
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78 John Battaile Hall, Professor of Economics, Portland State University
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79 Jay Hamilton, Assistant Professor, John Jay College
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80 Greg P. Hannsgen, Founder and Blogger, Greg Hannsgen's Economics Blog, and
Research Associate, Levy Economics Institute of Bard College
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81 John T. Harvey, Professor of Economics, Texas Christian University
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82 Baban Hasnat, Professor of International Business, SUNY Brockport
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83 F. Gregory Hayden, Professor, University of Nebraska-Lincoln
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84 Carol E. Heim, Professor of Economics, University of Massachusetts Amherst
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85 John Forrest Henry, Senior Scholar, Levy Economics Institute, and Adjunct Professor,
University of Missouri-Kansas City
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86 P. Sai-wing Ho, Professor, University of Denver
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87 Joan Hoffman, Professor, John Jay College of Criminal Justice CUNY
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88 Barbara Hopkins, Professor, Wright State University
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89 Candace Howes, Professor of Economics, Connecticut College
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90 Eric Hoyt, Ph.D. in Economics, University of Massachusetts Amherst, and Research
Director, Center for Employment Equity
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91 Joseph Michael Hunt, Instructor, Environmental and Health Policy, Harvard Uiversity
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92 Dorene Isenberg, Professor of Economics, University of Redlands
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93 Tae-Hee Jo, Associate Professor, SUNY Buffalo State
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94 Fadhel Kaboub, Associate Professor of Economics, Denison University, and President,
Global Institute for Sustainable Prosperity
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95 Stephanie A Kelton, Professor of Economics and Public Policy, Stony Brook University,
and Senior Economic Advisor, Bernie2020 Presidential Campaign
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96 Haider A Khan, John Evans Distinguished University Professor, University of Denver
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97 Mu-Jeong Kho, University College London, the University of London
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98 Marlene Kim, Professor, University of Massachusetts Boston
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99 Mary C. King, Professor of Economics Emerita, Portland State University
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100 Charalampos Konstantinidis, Associate Professor, University of Massachusetts Boston
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101 Kazim Konyar, Professor of Economics, California State University, San Bernardino
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102 Brent Kramer, Adjunct Assistant Professor, City University of New York
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103 Patrick L Mason, Professor of Economics, Florida State University, and Director, African
American Studies Program
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104 David Laibman, Professor Emeritus, Economics, City University of New York, and
Editor, Science & Society
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105 Thomas Lambert, Lecturer, University of Louisville
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106 Anthony Laramie, Professor of Economics, Merrimack College
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107 Margaret Levenstein, Research Professor, Institute for Social Research and School of
Information, University of Michigan
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108 An Li, Assistant Professor, Sarah Lawrence College
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109 Victor D. Lippit, Professor Emeritus of Economics, University of California, Riverside
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110 James Luke, Professor of Economics, Lansing Community College
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111 Daniel MacDonald, Assistant Professor, California State University San Bernardino
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112 Arthur MacEwan, Professor Emeritus of Economics, University of Massachusetts Boston
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113 Allan MacNeill, Professor, Webster University
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114 Zagros Madjd-Sadjadi, Full Professor of Economics, Winston-Salem State University, and
Former Chief Economist, City and County of San Francisco
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115 Yahya M. Madra, Associate Professor of Economics, Drew University
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116 Theresa Mannah-Blankson, Assistant Professor of Economics, Messiah College
-
117 Thomas Masterson, Director of Applied Micromodeling, Levy Economics Institute of
Bard College
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118 Gabriel Mathy, Assistant Professor, American University
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119 Peter H Matthews, Dana Professor of Economics, Middlebury College
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120 Scott McConnell, Associate Professor of Economics, Eastern Oregon University, and
Owner/CEO, Side A Brewing
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121 Elaine McCrate, Economics Professor Emerita, University of Vermont
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122 Terrence McDonough, Professor Emeritus, National University Ireland Galway
-
123 Martin Melkonian, Adjunct Associate Professor, Economics, Hofstra University
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124 Peter B. Meyer, Professor Emeritus of Urban Policy and Economics, University of
Louisville
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125 Thomas Michl, Professor of Economics, Colgate University
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126 John Miller, Professor of Economics, Wheaton College
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127 Katherine A. Moos, Assistant Professor of Economics, University of Massachusetts
Amherst
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128 Tracy Mott, Professor, University of Denver
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129 Michele Naples, Professor of Economics, The College of New Jersey
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130 Daniel H. Neilson, Faculty in Economics, Bard College at Simon's Rock
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131 Edward J. Nell, Emeritus Professor, New School for Social Research
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132 Julie A. Nelson, Professor, University of Massachusetts Boston
-
133 Reynold F. Nesiba, Professor of Economics, Augustana University
-
134 John Casey Nicolarsen, Visiting Professor, Sarah Lawrence College
-
135 Eric Nilsson, Professor, California State University San Bernardino
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136 Erik Olsen, Associate Professor, University of Missouri Kansas City
-
137 Paulette Olson, Professor Emerita, Wright State University
-
138 Lenore Palladino, Senior Economist, Roosevelt Institute
-
139 Christian Parenti, Associate Professor Department of Economics, John Jay College CUNY
-
140 Mark Paul, Assistant Professor of Economics, New College of Florida
-
141 Eva Paus, Professor of Economics, Mount Holyoke College
-
142 Karen A Pfeifer, Professor Emerita of Economics, Smith College
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143 Lynda Pickbourn, Assistant Professor of Economics, Hampshire College
-
144 Bruce Pietrykowski, Professor of Economics, University of Michigan-Dearborn
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145 Chiara Piovani, Associate Professor, University of Denver
-
146 Robert Pollin, Distinguished Professor of Economics, University of Massachusetts
Amherst, and Co-Director, Political Economy Research Institute (PERI)
-
147 Devin T. Rafferty, Assistant Professor, Saint Peter's University, and Founding Director,
MS Finance Program
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148 Pratistha Joshi Rajkarnikar, Postdoc Scholar, Global Development and Environment
Institute, Tufts University
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149 Michael Robinson, Professor of Economics, Mount Holyoke College
-
150 John Roche, Associate Proferssor Emeritus, St John Fisher College
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151 Leonard Rodberg, Emeritus Professor of Urban Studies, Queens College/CUNY
-
152 Leanne Roncolato, Assistant Professor of Economics, Franklin and Marshall College
-
153 Frank Roosevelt, Emeritus Professor of Economics, Sarah Lawrence College
-
154 Jaime Ros, Emeritus Professor, University of Notre Dame, and Professor of Economics,
National Autonomous University of Mexico
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155 Nancy E Rose, Professor Emeritus, California State University San Bernardino
-
156 Trevor R. Roycroft, Ph.D., Professor Emeritus, Ohio University
-
157 David F. Ruccio, Professor of Economics, University of Notre Dame
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158 Jeffrey D. Sachs, Professor, Columbia University
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159 Gregory M Saltzman, Professor of Economics and Management, Albion College
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160 John Sarich, The Cooper Union for the Advancement of Science and Art
-
161 John Schmitt, Vice President, Economic Policy Institute
-
162 Jeremy Schwartz, Associate Professor, Loyola University Maryland
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163 Elliott Sclar, Emeritus Professor, Columbia University
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164 Stephanie Seguino, Professor of Economics, University of Vermont
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165 Mark Setterfield, Professor of Economics, New School for Social Research
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166 Anwar Shaikh, Professor, New School for Social Research
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167 Barry G. Shelley, Senior Lecturer, Pardee School of Global Studies, Boston University
-
168 Zoe Sherman, Assistant Professor of Economics, Merrimack College
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169 Heidi Shierholz, Senior Economist and Director of Policy, Economic Policy Institute
-
170 Hee-Young Shin, Assistant Professor, Wright State University
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171 Nicholas Shunda, Associate Professor of Economics, University of Redlands
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172 Kellin Stanfield, Assistant Professor of Economics, Hobart and William Smith Colleges
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173 Howard Stein, Professor, University of Michigan, Ann Arbor
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174 Jose A. Tapia, Associate Professor, Drexel University
-
175 Linwood Tauheed, Associate Professor, University of Missouri Kansas City
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176 Daniele Tavani, Associate Professor, Colorado State University
-
177 Pavlina R. Tcherneva, Program Director and Associate Professor of Economics, Bard
College, and Research Associate, Levy Economics Institute
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178 Chris Tilly, Professor of Urban Planning, UCLA Luskin School of Public Affairs
-
179 E. Ahmet Tonak, Visiting Professor, Economics, University of Massachusetts Amherst
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180 Mariano Torras, Professor, Adelphi University
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181 Andres Torres, Distinguished Lecturer, Lehman College (retired)
-
182 Mayo Toruno, Professor Emeritus, California State University San Bernardino
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183 Eric Tymoigne, Associate Professor of Economics, Lewis & Clark College
-
184 Vamsi Vakulabharanam, Associate Professor of Economics, University of Massachusetts
Amherst
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185 William Van Lear, Economics Professor, Belmont Abbey College
-
186 Ramaa Vasudevan, Associate Professor, Colorado State University
-
187 Tanadej Vechsuruck, Assistant Professor, University of Rhode Island
-
188 William Waller, Professor of Economics, Hobart and William Smith Colleges
-
189 John P. Watkins, Professor of Economics, Westminster College, and Adjunct Professor of
Economics, University of Utah
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190 David F. Weiman, Professor of Economics, Barnard College, Columbia University
-
191 Scott A. Weir, Ph.D. in Economics, Retired
-
192 Jeannette Wicks-Lim, Associate Research Professor, Political Economy Research Institute
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193 Noé Wiener, Lecturer, University of Massachusetts Amherst
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194 Robert B. Williams, Professor of Economics, Guilford College
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195 John Willoughby, Professor, Department of Economics, American University
-
196 Benjamin Wilson, Assistant Professor, SUNY Cortland
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197 Lucas Wilson, Professor, Mount Holyoke College
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198 Valerie Wilson, Director, Program on Race, Ethnicity & the Economy, Economic Policy
Institute
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199 Andrew J Winnick, Professor Emeritus, California State University Los Angeles
-
200 Jon D. Wisman, Professor of Economics, American University
-
201 Richard D. Wolff, Professor of Economics Emeritus, University of Massachusetts
Amherst
-
202 L. Randall Wray, Professor of Economics and Senior Scholar, Bard College and Levy
Economics Institute
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203 Brenda Wyss, Associate Professor, Wheaton College Massachusetts
-
204 Yavuz Yasar, Associate Professor, University of Denver
-
205 Tai Young-Taft, Assistant Professor of Economics, Bard College at Simon's Rock, and
Research Scholar, Levy Economics Institute of Bard College
-
206 June Zaccone, Associate Professor of Economics, Emerita, Hofstra University
-
207 Ajit Zacharias, Senior Scholar, Levy Economics Institute
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208 German A. Zarate-Hoyos, Associate Professor, SUNY Cortland
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209 Gabriel Zucman, Assistant Professor of Economics, University of California, Berkeley
https://www.nesri.org/sites/default/files/Economists%20for%20Medicare%20for%20All%20letter.pdf
We Are Applauding the ‘Gift’ of an Affordable Education. Something Has Gone Wrong.
by The Editorial Board - NYT - May 20, 2019
Around
the turn of the last century, the steel magnate Andrew Carnegie paid to
build 1,689 libraries across the United States. Many are still in use,
celebrated as monumental works of philanthropy.
They should be seen as monuments to the failure of public policy. The United States could have built a lot more libraries by taxing the incomes of Carnegie and his fellow Gilded Age plutocrats, but, at the turn of the last century, there was no federal income tax.
Now history is repeating itself. A new generation of plutocrats has amassed great fortunes, in part because the federal government has minimized the burden of taxation. Americans once again are reduced to applauding acts of philanthropy necessitated by failures of policy.
Robert Smith, a wealthy financier, announced on Sunday during graduation ceremonies at Morehouse College that he would repay the student loans taken by the 396 men in this year’s graduating class. The promise, which may cost Mr. Smith up to $40 million, was an act of generosity gratefully received by the new graduates of the historically black, all-male Atlanta college.
They should be seen as monuments to the failure of public policy. The United States could have built a lot more libraries by taxing the incomes of Carnegie and his fellow Gilded Age plutocrats, but, at the turn of the last century, there was no federal income tax.
Now history is repeating itself. A new generation of plutocrats has amassed great fortunes, in part because the federal government has minimized the burden of taxation. Americans once again are reduced to applauding acts of philanthropy necessitated by failures of policy.
Robert Smith, a wealthy financier, announced on Sunday during graduation ceremonies at Morehouse College that he would repay the student loans taken by the 396 men in this year’s graduating class. The promise, which may cost Mr. Smith up to $40 million, was an act of generosity gratefully received by the new graduates of the historically black, all-male Atlanta college.
But
their gratitude underscores the reality that hundreds of thousands of
other members of the class of 2019 will be carrying unrelieved burdens
of debt as they begin their adult lives.
On average, recipients of bachelor’s degrees in 2016 left school owing about $30,301, according to the most recent federal data. Parents on average incurred another $33,291 in debt.
The substitution of philanthropy for public policy is most glaring in the realm of health care, where it has become appallingly common for Americans to beg friends and strangers for the money necessary to pay for treatment. The fund-raising website GoFundMe estimates that it hosts about 250,000 fund-raisers for medical expenses each year. Over the past nine years, the site has processed about $5 billion in donations — about a third of which went toward medical expenses. The site’s chief executive has said that GoFundMe wasn’t developed as a substitute for health insurance, and he regrets the necessity. “We shouldn’t be the solution to a complex set of systemic problems,” he said. “They should be solved by the government working properly.”
The same dynamic is at work in higher education. Since 2001, a handful of elite institutions led by Princeton University have committed to tap their endowments to provide funding for students to graduate without loans. Last year, Michael Bloomberg pledged $1.8 billion to Johns Hopkins to reduce the reliance of Hopkins students on borrowed money. But most American colleges, including Morehouse, lack the resources to make such a commitment. This is not merely a problem for students and their families. Economic growth requires an educated work force. Americans who entered their working primes in the 1990s were far more likely to have college degrees than their peers in other developed nations. Now the United States has fallen behind much of the developed world — and one reason is that the average cost of obtaining a college degree is among the highest for any developed nation.
The sea change at American public colleges and universities is particularly striking. Over the last quarter century, average tuition rose by 85 percent, adjusting for inflation, while average state spending measured on a per-student basis declined by roughly 5 percent.
On average, recipients of bachelor’s degrees in 2016 left school owing about $30,301, according to the most recent federal data. Parents on average incurred another $33,291 in debt.
The substitution of philanthropy for public policy is most glaring in the realm of health care, where it has become appallingly common for Americans to beg friends and strangers for the money necessary to pay for treatment. The fund-raising website GoFundMe estimates that it hosts about 250,000 fund-raisers for medical expenses each year. Over the past nine years, the site has processed about $5 billion in donations — about a third of which went toward medical expenses. The site’s chief executive has said that GoFundMe wasn’t developed as a substitute for health insurance, and he regrets the necessity. “We shouldn’t be the solution to a complex set of systemic problems,” he said. “They should be solved by the government working properly.”
The same dynamic is at work in higher education. Since 2001, a handful of elite institutions led by Princeton University have committed to tap their endowments to provide funding for students to graduate without loans. Last year, Michael Bloomberg pledged $1.8 billion to Johns Hopkins to reduce the reliance of Hopkins students on borrowed money. But most American colleges, including Morehouse, lack the resources to make such a commitment. This is not merely a problem for students and their families. Economic growth requires an educated work force. Americans who entered their working primes in the 1990s were far more likely to have college degrees than their peers in other developed nations. Now the United States has fallen behind much of the developed world — and one reason is that the average cost of obtaining a college degree is among the highest for any developed nation.
The sea change at American public colleges and universities is particularly striking. Over the last quarter century, average tuition rose by 85 percent, adjusting for inflation, while average state spending measured on a per-student basis declined by roughly 5 percent.
A
number of the Democratic candidates for president have proposed large
increases in federal funding for higher education to offset the rise of
tuition costs and the decline of state funding.
The problem facing policymakers is not merely a lack of will, but also a lack of money. The federal government collected 16.5 percent of the nation's economic output last year — well below the 17.4 percent average federal share over the last half century. The primary reason for the shortfall, of course, is the steady reduction of income taxation. No one has benefited more from that trend than financiers like Morehouse College’s 2019 graduation speaker.
Mr. Smith co-founded the private equity firm Vista Equity Partners, which invests in software companies, and he has amassed his fortune thanks in part to a provision of federal tax law known as the “carried interest loophole” — a provision he has publicly supported.
Private equity firms skim a percentage of the returns from the investments they manage. That money is their compensation, but instead of being taxed as earned income, at a rate of up to 37 percent, it is taxed as investment income, at a rate of no more than 20 percent.
The loophole is projected to cost the government about $15.6 billion in lost revenue between 2016 and 2025. President Trump promised to close it during the 2016 campaign, and he promised to close it as part of his 2017 tax bill. But he did not keep that promise. Instead, the White House and congressional Republicans honored the wishes of the finance industry.
Closing that loophole would be a much better graduation present for the class of 2019.
An affordable college education should not require an act of largess. It should not require our applause. It merely requires adequate public investment, funded by equitable taxation.
https://www.nytimes.com/2019/05/20/opinion/morehouse-college-debt.html
The problem facing policymakers is not merely a lack of will, but also a lack of money. The federal government collected 16.5 percent of the nation's economic output last year — well below the 17.4 percent average federal share over the last half century. The primary reason for the shortfall, of course, is the steady reduction of income taxation. No one has benefited more from that trend than financiers like Morehouse College’s 2019 graduation speaker.
Mr. Smith co-founded the private equity firm Vista Equity Partners, which invests in software companies, and he has amassed his fortune thanks in part to a provision of federal tax law known as the “carried interest loophole” — a provision he has publicly supported.
Private equity firms skim a percentage of the returns from the investments they manage. That money is their compensation, but instead of being taxed as earned income, at a rate of up to 37 percent, it is taxed as investment income, at a rate of no more than 20 percent.
The loophole is projected to cost the government about $15.6 billion in lost revenue between 2016 and 2025. President Trump promised to close it during the 2016 campaign, and he promised to close it as part of his 2017 tax bill. But he did not keep that promise. Instead, the White House and congressional Republicans honored the wishes of the finance industry.
Closing that loophole would be a much better graduation present for the class of 2019.
An affordable college education should not require an act of largess. It should not require our applause. It merely requires adequate public investment, funded by equitable taxation.
https://www.nytimes.com/2019/05/20/opinion/morehouse-college-debt.html
Culture of Secrecy Shields Hospitals With Outbreaks of Drug-Resistant Infections
By Andrew Jacobs and Matt Richtel - NYT - April 8, 2019
In January, the Centers for Disease Control and Prevention sent out an urgent public alert
about a deadly bacteria, resistant to virtually every known antibiotic,
that sickened more than a dozen Americans who had elective surgery at
Grand View Hospital in Tijuana, Mexico.
But when similar outbreaks take place at hospitals on American soil, the C.D.C. makes no such public announcement. That is because under its agreement with states, the C.D.C. is barred from publicly identifying hospitals that are battling to contain the spread of dangerous pathogens.
The rise of a deadly drug-resistant fungus called Candida auris, a focus of a New York Times report last weekend, has raised fresh questions about the secrecy enveloping infectious outbreaks at American medical institutions.
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Patient advocates say hospitals and health authorities are often slow to alert the public about drug-resistant germs, potentially endangering patients.
But when similar outbreaks take place at hospitals on American soil, the C.D.C. makes no such public announcement. That is because under its agreement with states, the C.D.C. is barred from publicly identifying hospitals that are battling to contain the spread of dangerous pathogens.
The rise of a deadly drug-resistant fungus called Candida auris, a focus of a New York Times report last weekend, has raised fresh questions about the secrecy enveloping infectious outbreaks at American medical institutions.
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Patient advocates say hospitals and health authorities are often slow to alert the public about drug-resistant germs, potentially endangering patients.
“They
might not get up and go to another hospital, but patients and their
families have the right to know when they are at a hospital where an
outbreak is occurring,” said Lisa McGiffert of the Patient Safety Action Network. “That said, if you’re going to have hip replacement surgery, you may choose to go elsewhere.”
Kevin Kavanagh, board chairman of the advocacy group Health Watch USA, contrasted the C.D.C.’s handling of the infections in Tijuana with a 2016 outbreak of a different drug-resistant pathogen, known as carbapenem-resistant Enterobacteriaceae, or CRE, at a rural hospital in Kentucky. It was not until early 2018 that the C.D.C. issued a report on that outbreak — and even then, the agency did not name the hospital where it occurred.
CRE sometimes kills up to half of people infected. No deaths were reported in the Kentucky outbreak, but at least two dozen patients at the hospital were colonized with the bug, meaning they were not sick but could have spread it to others.
Kevin Kavanagh, board chairman of the advocacy group Health Watch USA, contrasted the C.D.C.’s handling of the infections in Tijuana with a 2016 outbreak of a different drug-resistant pathogen, known as carbapenem-resistant Enterobacteriaceae, or CRE, at a rural hospital in Kentucky. It was not until early 2018 that the C.D.C. issued a report on that outbreak — and even then, the agency did not name the hospital where it occurred.
CRE sometimes kills up to half of people infected. No deaths were reported in the Kentucky outbreak, but at least two dozen patients at the hospital were colonized with the bug, meaning they were not sick but could have spread it to others.
The
report identified a cleaning cart as a possible source for the spread
of the pathogen, which had traveled between the hospital’s emergency
room and its surgical ward.
The C.D.C. declined to
comment, but in the past officials have said their approach to
confidentiality is necessary to encourage the cooperation of hospitals
and nursing homes, which might otherwise seek to conceal infectious
outbreaks.
Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny.
In California, State Senator Jerry Hill, a Democrat and longtime advocate for tougher restrictions on antibiotic use, found himself stymied in his effort to improve the industry’s reporting on drug-resistant infections. A bill he introduced in the State Legislature would have required hospitals to regularly disclose resistant infections and deaths. In 2017 the Senate passed the bill, 40 to 0, but it had powerful opponents, including the California Hospital Association, the Infectious Disease Association of California and the state’s Department of Health. The bill then moved to the Assembly, where last year it stalled for lack of support.
Federal legislation that seeks to combat antibiotic resistance through stronger surveillance and better data collection has also stalled. The bill, introduced by Senator Sherrod Brown, Democrat of Ohio, has yet to emerge from a Senate health committee. “We’ve ignored this looming crisis by doing nothing,” Senator Brown said.
Hospital administrators and public health officials say the emphasis on greater transparency is misguided. Dr. Tina Tan, the top epidemiologist at the New Jersey Department of Health, said that alerting the public about hospitals where cases of Candida auris have been reported would not be useful because most people were at low risk for exposure and public disclosure could scare people away from seeking medical care.
“That could pose greater health risks than that of the organism itself,” she said.
Those pushing for increased transparency say they are up against powerful medical institutions eager to protect their reputations, as well as state health officials who also shield hospitals from public scrutiny.
In California, State Senator Jerry Hill, a Democrat and longtime advocate for tougher restrictions on antibiotic use, found himself stymied in his effort to improve the industry’s reporting on drug-resistant infections. A bill he introduced in the State Legislature would have required hospitals to regularly disclose resistant infections and deaths. In 2017 the Senate passed the bill, 40 to 0, but it had powerful opponents, including the California Hospital Association, the Infectious Disease Association of California and the state’s Department of Health. The bill then moved to the Assembly, where last year it stalled for lack of support.
Federal legislation that seeks to combat antibiotic resistance through stronger surveillance and better data collection has also stalled. The bill, introduced by Senator Sherrod Brown, Democrat of Ohio, has yet to emerge from a Senate health committee. “We’ve ignored this looming crisis by doing nothing,” Senator Brown said.
Hospital administrators and public health officials say the emphasis on greater transparency is misguided. Dr. Tina Tan, the top epidemiologist at the New Jersey Department of Health, said that alerting the public about hospitals where cases of Candida auris have been reported would not be useful because most people were at low risk for exposure and public disclosure could scare people away from seeking medical care.
“That could pose greater health risks than that of the organism itself,” she said.
Nancy Foster, the vice president for quality and patient safety
at the American Hospital Association, agreed, saying that publicly
identifying health care facilities as the source of an infectious
outbreak was an imperfect science.
“That’s a lot
of information to throw at people,” she said, “and many hospitals are
big places so if an outbreak occurs in a small unit, a patient coming to
an ambulatory surgical center might not be at risk.”
Still, hospitals and local health officials sometimes hide outbreaks even when disclosure could save lives. Between 2012 and 2014, more than three dozen people at a Seattle hospital were infected with a drug-resistant organism they got from a contaminated medical scope. Eighteen of them died, but the hospital, Virginia Mason Medical Center, did not disclose the outbreak, saying at the time that it did not see the need to do so.
Art Caplan, a bioethicist at the NYU School of Medicine, said the issue of full disclosure can be tricky, especially when large hospitals that see huge numbers of seriously ill patients are compared with smaller institutions. “If you’re a hospital of last resort, you’re going to see repeat customers with tough infections, many of them drug resistant,” he said.
Still, he thought there was a greater value in promoting transparency. Public awareness about the lives lost to drug resistant infections, he said, could pressure hospitals to change the way they deal with infection control.
“Who’s speaking up for the baby that got the flu from a hospital worker or for the patient who got MRSA from a bedrail?” he asked, referring to a potentially deadly bacterial infection. “The idea isn’t to embarrass or humiliate anyone, but if we don’t draw more attention to infectious disease outbreaks, nothing is going to change.”
https://www.nytimes.com/2019/04/08/health/candida-auris-hospitals-drug-resistant.html
Still, hospitals and local health officials sometimes hide outbreaks even when disclosure could save lives. Between 2012 and 2014, more than three dozen people at a Seattle hospital were infected with a drug-resistant organism they got from a contaminated medical scope. Eighteen of them died, but the hospital, Virginia Mason Medical Center, did not disclose the outbreak, saying at the time that it did not see the need to do so.
Art Caplan, a bioethicist at the NYU School of Medicine, said the issue of full disclosure can be tricky, especially when large hospitals that see huge numbers of seriously ill patients are compared with smaller institutions. “If you’re a hospital of last resort, you’re going to see repeat customers with tough infections, many of them drug resistant,” he said.
Still, he thought there was a greater value in promoting transparency. Public awareness about the lives lost to drug resistant infections, he said, could pressure hospitals to change the way they deal with infection control.
“Who’s speaking up for the baby that got the flu from a hospital worker or for the patient who got MRSA from a bedrail?” he asked, referring to a potentially deadly bacterial infection. “The idea isn’t to embarrass or humiliate anyone, but if we don’t draw more attention to infectious disease outbreaks, nothing is going to change.”
https://www.nytimes.com/2019/04/08/health/candida-auris-hospitals-drug-resistant.html
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