Category Archives: News and Comment

“Have you had a fall recently?” my doctor asks these days.  Well, Doctor, yes I have.  I fell into a donut hole.  I didn’t think I was that feeble.  And I never saw it in front of me.

I wasn’t even aware of my fall until my spouse went to our pharmacy last month to pick up my monthly supply of Eliquis.  She called me at home from the pick-up window and said, “They are charging $111 for your prescription — that can’t be right, is it?”

I had been paying $37 a month for Eliquis, a so-called Tier 3 “preferred brand” medicine that helps prevent clot-formation if you have atrial fibrillation or certain other conditions.  Eliquis costs more but has many advantages over traditional anti-coagulants like warfarin (an inexpensive generic) including less unintentional bleeding, almost no food interactions and no routine blood testing.  I am glad that God invented Eliquis.*

In any event, I told my spouse I would pick up the prescription myself, after I had a chance to look at my Medicare Advantage coverage.  Doing so, I nearly (metaphorically) fell over.   Medicare’s prescription drug coverage gap (popularly called the donut hole) begins when $3,820 has been spent on drugs during the calendar year.  I thought the $3,820 referred to what I have spent on drugs, but no — it means what the drug companies were paid.

This is an important distinction, because after you enter the donut hole, you pay more for all of your medications, not just brand-name drugs.  I am now responsible for 25% of the $441 paid to Bristol-Myers Squibb for my monthly supply of Eliquis, and 37% of the $76 paid to Rising Pharmaceuticals for a 90-day supply of my generic blood-pressure pills.

In the Sea of Donut Holes (with the Blue Cross Meanies)

I will remain in the donut hole until I have paid $5,100 out of my own pocket for drugs, which is not going to happen this calendar year.  So my fall into the donut hole will cost me an additional $303, assuming there are no medical surprises.

Shame on me, someone who is reasonably well-versed when it comes to what I pay and what I get, for not paying more attention to my benefits statements.  The donut-hole rules, as complicated as they are, should not have come as a surprise to me — but I’m still taken aback at how much money the drug companies get for my medications, even the generics.

You may have read elsewhere that provisions in the ACA (it’s alive!) will finally close the drug coverage donut hole in 2020.  But here’s the thing, as Joe Biden likes to say: closing the donut hole on paper does not mean I will pay the same copays all year long.  The fact that I paid (only) $37 for Eliquis before I hit the donut hole is best thought of as a benefit of my particular plan — by law, I was “responsible” for up to 25% of the cost even before I reached the donut hole.  Under some other plan, I could have been paying $111 a month from the outset instead of that $37 copay.

Confused?  I know I am, and I’m not alone.  Wading through the explanation of costs and coverage on medicare.gov calls for a lot of patience if not an accounting degree.  As far as I can tell, not a whole lot is going to change for me in 2020.  I will start out with low copays, but once my total drug costs reach $4,020 (the new threshold), I will pay 25% of whatever price the drug company asks.  I will stay in this (ghost) donut hole until my out-of-pocket costs reach $6,350 (a $1,250 hike from 2019), after which I will pay 5% of the retail price for my medicines.

As there is no standard Medicare drug plan, I can’t predict what all this means for others.  If you take even one non-generic drug, read your coverage documents carefully.  Not that this gives you a lot of choice.

• • • 

One last item, about the politics of all this ridiculousness.  Paul Krugman pointed this out in 2005, when Medicare Part D was signing up its first participants:

Republican Congressional leaders who rammed the bill through in 2003 weren’t actually trying to protect retired Americans against the risk of high drug expenses.  Their purpose was purely political: to be able to say that President Bush had honored his 2000 campaign promise to provide prescription drug coverage by passing a drug bill, any drug bill.

Once you recognize that the drug benefit is a purely political exercise that wasn’t supposed to serve its ostensible purpose, the absurdities in the program make sense.  For example, the bill offers generous coverage to people with low drug costs, who have the least need for help…  Meanwhile, the people who are actually likely to need a lot of help paying their drug expenses were deliberately offered a very poor benefit.  According to a report issued along with the final version of the bill, people are prohibited from buying supplemental insurance to cover the doughnut hole to keep beneficiaries from becoming “insensitive to costs” — that is, buying too much medicine because they don’t pay the price.

This has always been conservative dogma: if we make health care easy to get, people will use too much of it; if we force people to pay for it, they will reconsider whether they really need it; and if we let health care prices seek their own level, that will effectively ration it. 

It is easy to spot the flawed premises here.  It presumes people like going to the doctor and taking medicine and would seek out such activities if there were no restraints.  It presumes ordinary people have the means to shop for health care as well as the expertise to judge its cost-effectiveness.  It presumes that cost-sharing by patients is an appropriate way to get patients to use lower-cost drugs — when the only real choice most patients have is whether to get their prescription filled.  And it equates health care with consumer goods, in that some people can afford the best and some can’t and that’s the way it oughta be in America.

Maybe conservatives would like to talk about cost-sharing with people who take Revlimid for multiple myeloma.  (Medicare spent $3.31 billion on Revlimid in 2017, more than any other drug.  Eliquis came in second at $3.07 billion.)  The copay for one dose of Revlimid is often $7,000 or more, which would immediately push a patient through the donut hole.  Or maybe conservatives should ask people with chronic hepatitis C whether they can just live with it — after all, even the new generic version of ledipasvir costs $15,000 per course.  Finally, with respect to so-called lifestyle diseases, maybe conservatives would like to share their evidence that forcing people to bear the financial burden of past unhealthy behaviors serves to deter those behaviors.  (I think it only serves to punish them.)

The Medicare Part D approach to prescription drug coverage is based on false premises and should be scrapped.  Health care should be a societal burden, not an individual one;  yes, we should all live healthier lives, but no one I know asked to have atrial fibrillation or multiple myeloma or hepatitis C.  Every patient should receive the most cost-effective treatment that has been shown to be medically effective and respects her quality-of-life.  The patient’s personal financial situation and the type of insurance she has should not be factors in selecting her treatment.  This implies no more deductibles, no more donut holes. No more misguided incentives placing burdens where they don’t belong while failing to address the real causes of outlandish medical costs.

So here is where I part ways with the “Medicare for All” and “Public Option” proponents. Medicare may be better than other alternatives but it isn’t good enough.  I am waiting for other presidential candidates besides Bernie Sanders to step up and say so.

_____________

* U.S. Patent 9,326,945 was issued May 3, 2016 to Jatin Patel et al and assigned to Bristol-Myers Squibb.  The next drug God should create (with help from Dr. Patel) is an over-the-counter anti-inflammatory that one can take with Eliquis.
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Field Day

The Urban News, our local multicultural news weekly, reported that Dr. Jamie R. Riley  was forced to resign last month from his position as assistant vice president and dean of students at the University of Alabama.  He had assumed that position in February.*

Dr. Riley is a 38-year-old black man who earned his doctorate in counseling and student services from University of Georgia in 2011.  He had served as the executive director of the international black fraternity Alpha Phi Alpha and also as associate/assistant deans for Johns Hopkins University and University of California Berkeley.

Riley resigned (a) because the nut-right Breitbart News republished old remarks from his Twitter account associating the U.S. flag with our racist history and our racist policing and (b) because the trustees and leaders of the University of Alabama are cowards who think diversity is two four-letter-words with an r in the middle.

You can read Riley’s tweets elsewhere — my favorite source was the black news-magazine The Root, whose headline read “Alabama Dean Quits Because White People Can’t Handle the Truth.”  I thought Riley’s tweets were forthright, certainly nothing Colin Kaepernik and Black Lives Matter haven’t already pointed out.  What Riley tweeted registered only 2.6 on the Malcolm X Threat-to-Whitey Scale.

Nonetheless, here is a sample of the comments posted in Crimson White [sic], the student newspaper of the University of Alabama, in response to the article announcing Dr. Riley’s resignation.  What a field day for the beasts:

  • Good riddance race pimp!
  • Racist man loses job.  Fixed your headline
  • Did this moron forget he was in Alabama and not califorina? [sic]
  • How does a moron like Riley get such a position in the first place? Just a rhetorical question; we all know why.
  • Rily, [sic] a PHD isn’t smart enough to know WHITES (including me) experience racism every day also, especially since Obama ran for President. Riley is a genuine RACIST with no moral compass and a ghetto, hand-out mentality.
  • President Monroe set up a country SPECIFICALLY for blacks (both slaves and non-slaves) to go to for the purpose of escaping racism.  It’s called LIBERIA — and in Monroe’s honor, the capital is Monroeville.  Maybe you ought to move there… yes, even in the 21st century, they STILL accept American blacks as immigrants.

To be fair, there was some pushback on these comments from others in the student body, but only in proportion to President Trump’s job approval ratings, which currently stand at Approve: 40, Disapprove: 56.  Meanwhile, the UA Black Faculty and Staff Association has been keeping the heat on university president Stuart Bell to enact reforms.

Ironically, the title of Riley’s 2011 doctoral dissertation was “Racism, Discrimination, and Prejudice: Through the Voices of Black Men on Predominately White College Campuses.”  For his study, Riley interviewed many black undergraduates about their experiences with campus racism and its social and academic effects.  Riley’s conclusion: “Although they did allude to the additional challenges faced in class due to the level of [racial] press placed on them, they were able to use the environmental press as motivation to work harder and succeed regardless of racially charged encounters.”

I hope that Dr. Riley’s most recent racially charged encounter will somehow motivate him to carry on in the face of hard-work-isn’t-enough racism that is not just campus-wide but nationwide.  I don’t know how a black person sustains the motivation these days.

______________

* As always, follow the links for background and context.
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I discuss politics far more often on this site than I do in person (save for with my spouse).  I fear that sharing my political thoughts face-to-face, with those whose views are unknown to me and/or are likely to differ, risks derailing whatever reason we happen to be together. It is certainly not that I lack strong beliefs or the will to express them.  It’s a decision.

But I take exception when, in the course of discussion, others claim to know my positions absent any such sharing on my part.  This only seems to happen when I am talking with a conservative — the person may say something like, “Well, you’re a liberal, so you think x.”  The last time this happened, I objected and said that I had not told her my opinion on x.  In response, the person demanded to know whether I had ever voted for a Republican for president — as if my having done so would confer a hint of legitimacy on what I might say.  Or, had I not done so (as she assumed), her stereotype of me would be confirmed and whatever I had to say would be redundant.

Either way, that conversation was over, and it was really over before it began, which is precisely the intended effect of telling other people what they think.

Something important is missing when a relationship lacks openness and one has to hold one’s opinions in check.  My friends, by definition, are those people whom I can share my thoughts with and be myself with.  I have seldom compromised on that stance and I’m too old to start now.  As a result, I don’t have many friends, and that’s the way it is.

All that is preface to this series of posts, in which I intend to address: What kind of liberal am I?  Where do I stand on issues xy and z?  I have several reasons for doing this series. A) I would rather define myself than let others define me, as noted above.  Liberals are not part of some mind-collective — we do not all think the same.  B) It gives me an incentive to research and more carefully consider my stances.  We expect this from our candidates for public office, why not ask the same of ourselves?  C) Perhaps my reasoning and analysis will help readers compare and contrast, and thus sharpen, their own positions.

There is clearly some risk doing this, even though our discussion will not be face-to-face.  People avoid talking politics because politics are about values, and people get tetchy about their values.  (“I’m not here to stir up trouble,” I say, as I slowly lay my six-shooter down on the bar.  “Just tell me where I can find Fast Jack Ballantyne.”  A tense silence hangs over the saloon.  And then… )

Okay, there won’t be any fistfights or shootouts, but it is true that I’m pretty much obliging my readers to take issue with me, which is not exactly the best recipe for making friends or maintaining a following these days.  But as I said before, that’s the way it is.  I will do my best to write thoughtfully and succinctly and hope that this will carry the day.

Due to the length of this intro, my first foray will consider only one topic: abortion rights.  I figured I may as well start with one of the most straightforward, least controversial items on the so-called liberal agenda.

Abortion Rights

Some would contend I have no business weighing in on abortion, since men can never face this decision.  I agree that men should not have sole province to make and interpret laws that mainly impact women.  But we do vote, so it does matter where we stand.

I have always supported choice, but until now I had never read the text of the important Supreme Court decisions on abortion rights, Roe v. Wade (1973) and Planned Parenthood of Southeastern Pa. v. Casey (1992).  When I did, I found I had the wrong idea of what our “settled law” actually comprises.  So allow me to recap. 

The Roe decision established a trimester-based compromise between the interests of the pregnant woman and those of the state — read society — on behalf of the “potential life.”  The first trimester was to be a matter between the woman and her physician, essentially free of state interest.  In the second, a state could “regulate the abortion procedure in ways that are reasonably related to maternal health.”  In the third, abortion could be regulated or prohibited by the state.  The intrusive role of the state in the third trimester (from the 26th week onward) was based on the viability of the fetus, i.e., its ability to survive outside the womb.  To cite Roe:

… Courts have agreed that the right of privacy, however based, is broad enough to cover the abortion decision; that the right, nonetheless, is not absolute, and is subject to some limitations; and that, at some point, the state interests as to protection of health, medical standards, and prenatal life, become dominant. We agree with this approach.

And I agree with this approach as well.  Where I disagree with Roe is the point at which society’s interest (vis-à-vis respect for life) outweighs the liberty of the pregnant woman to obtain an elective abortion.  Fetal viability — about 22 weeks at the very earliest — seems like an unnecessarily late decision point to me.  How long is reasonably long enough for the pregnant woman to assess her situation, decide to pursue abortion, and obtain one? My sense is that, given unhindered access to the procedure, 18 weeks — or roughly the halfway mark of the pregnancy — should suffice for elective abortions, i.e., those that do not involve maternal health or fetal development.  Until that point, society and the state should step aside, except to offer educational material on the likelihood of complications from the procedure vs. gestational stage and in comparison to those of childbirth [1].

I was curious to know, when during pregnancy do women in the U.S. obtain abortions?  The CDC has published 2015 data for “selected regions” (which unfortunately excludes New York, California, Florida and Pennsylvania) from which I prepared the chart below:

About two-thirds of abortions in 2015 were performed during the first 8 weeks of gestation and 90% were performed in the first trimester.  Only 3% were done at 18 weeks or later. The CDC did not indicate which procedures were elective and which were performed for reasons of maternal health or fetal abnormality. [2]

• • •

But Roe is not the law of the land — Casey is.  The authors [3] of Casey took great pains to insist that it upheld the tenets of Roe, but even a casual reading of the text reveals a shift toward state interests and extending them to early pregnancy.  The Casey decision held that “the State has legitimate interests from the outset of the pregnancy in protecting the health of the woman and the life of the fetus that may become a child.” (Emphasis mine.)  Casey set aside Roe‘s trimesters as obsolete and emphasized the state’s role in promoting live childbirth far more than it espoused women’s liberty.

We have Casey to thank for mandatory waiting periods, consent requirements and the misleading and/or inaccurate anti-abortion counseling that must be endured before the procedure [4].  The Casey majority held that such practices were not an “undue burden” on the woman seeking an abortion.  Tell that to Missouri resident Robin Utz, who shared her heart-rending story on The Moth Radio Hour and her own website, Defending Grace.  Her sad experience is evidence enough that the state has gone where it does not belong.  Yet her state, Missouri, is going even farther:  As of August 28, 2019, it will be illegal to perform an 8-week abortion in Missouri, and there will be no exceptions for rape or incest or fetal anomalies.  I do not see how this law possibly squares with Roe or Casey — or me.

So what kind of liberal am I with respect to abortion rights?  As you can tell, pretty liberal.  I would not vote for anyone who favors more restrictions.  I would support state and/or federal funding (i.e., Medicaid) for early medically-induced abortions, even if elective, for low-income U.S. citizens.  I want the states to end their puritanical intimidation of women seeking abortions and those who provide abortions.  If states want fewer abortions within their borders, I suggest they increase funding for education and make contraception more affordable and accessible.  That said, I do not view abortion as the moral equivalent of contraception, and I doubt most people do.

• • •

I now introduce the Liberal EEG, a high-tech app that will help me explain my stances to conservatives who don’t have time to read or listen.  Here is how it works — I contemplate the issue at hand and, while I’m thinking about it, I place two fingertips on my left temple and two fingertips on a special sensing area displayed on my phone.  The Liberal EEG app reads the electrical signals produced by the left half of my brain and stores them in a file on my phone.  It then emails this file to the I.T. department of Ben & Jerry’s Ice Cream in Burlington, Vermont, where my brain signals are processed and interpreted.

I get the result the next day [5] conveniently boiled down to one number between 0 and 5, where 0 is wishy-washy and 5 is so liberal that 90% of conservatives would put “Hanoi” in front of my name.  Here is my Liberal EEG reading on the current topic:

ABORTION RIGHTS ➤ 

My score might have been higher if I had ever rallied for the cause or donated time or money to it.  In any event, if the topic ever comes up, I can now just tell my conservative friend that I’m a 4.2 on this and we can continue the discussion if she wants.

• • •

That’s it for the first installment of What Kind of Liberal Am I?  Thank you for reading, and I suggest you follow the informative links in the text for more details.  This need not be a one-sided conversation — other points of view are welcome, with or without the help of a Liberal EEG reading.

Future topics will include immigration, minority rights, gun rights, wealth inequality, health care and the environment, but not necessarily in that order.  Until next time.

__________

[1] The complication rate increases with gestational stage and the pregnant woman’s age.  For medically-induced abortions performed at 8 weeks or less, the complication rate is under 1%.
[2]  I was surprised to learn there were an estimated 19 abortions per 100 live births in the U.S. in 2015.  I would have guessed that the number was much lower, maybe 5 per 100.  Even so, 19 is the lowest rate since Roe was decided in 1973.  The peak rate occurred in the 1980s at about 35 per 100 live births.  In a given year, about 15 of every 1,000 women of child-bearing age has an abortion (2014 data from Guttmacher Institute).
[3]  The majority opinion in Casey was written by O’Connor, Kennedy and Souter, with Stevens and Blackmun concurring.  Rehnquist, White, Scalia and Thomas would have overturned Roe.  Only Thomas remains on the bench.
[4] “Even in the earliest stages of pregnancy, the State may enact rules and regulations designed to encourage her to know that there are philosophic and social arguments of great weight that can be brought to bear in favor of continuing the pregnancy to full term . . . Regulations which do no more than create a structural mechanism by which the State, or the parent or guardian of a minor, may express profound respect for the life of the unborn are permitted, if they are not a substantial obstacle to the woman’s exercise of the right to choose.  Unless it has that effect on her right of choice, a state measure designed to persuade her to choose childbirth over abortion will be upheld if reasonably related to that goal.”
[5]  They also send me a 50-cent coupon toward my next quart of Ben & Jerry’s ice cream.  Great app.
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