Gaming of Part D generic drugs passes more costs on to seniors

Posted by on Thursday, May 24, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Seniors Pay More For Generics in Medicare Prescription Drug Plans Despite Stable Prices

By Clara Son
Avalere, May 22, 2018

New research from Avalere finds that seniors with Medicare prescription drug plans (Part D) pay more for generic drugs even as the market price of these drugs stays stable.

Avalere experts note that seniors are paying more because generic drugs are being placed on higher formulary tiers where patients pay more out of pocket for drugs. The number of generic prescription drugs placed on the lowest tier, where patients pay less for their drugs, declined 53 percentage points between 2011 and 2015. This shift resulted in a 93% increase in total patient cost sharing for these drugs, or a total of $6.2 billion.

This higher cost sharing and movement of generics to higher tiers did not correspond with an increase in the underlying price of generic drugs over that same time period, according to an analysis by Avalere experts of the average volume-weighted price of generics that were included on plan formularies in both 2011 and 2015.

In 2011, 71% of generic drugs were placed on tier 1, the lowest tier in the formulary. By 2015, 19% of covered generics were placed on tier 1, while 46% were placed on tier 2 and 35% were placed on tier 3 or higher. This shift represents a 53 percentage point decrease in the number of generics being placed on the lowest tier between 2011 and 2015.

The use of generic drugs has saved the Medicare Part D program billions of dollars. However, higher tier placement of generic drugs is leading to higher out-of-pocket costs for patients and may reduce savings.…

In response, the Pharmaceutical Care Management Association (PCMA) released the following statement which still does not refute the fact that the industry moved more expensive generics into non preferred tiers in order to keep Part D premiums competitive:…

This report confirms that the industry shifted over half of generic drugs out of the lowest tier into higher tiers wherein patient cost sharing is higher. This benefits the pharmacy benefit managers because the shift in costs to the patients allows them to keep the Part D premiums more competitive, but it certainly has an adverse impact on seniors who are dependent on generic medications that are supposed to be cheaper than the brand names.

In fact, it has been reported that the cost sharing of generic drugs is sometimes greater than the full price of the generic if it were purchased without using the insurance, and the pharmacy benefit managers may have gag clauses prohibiting the pharmacist from telling the patient that it would cost less if they didn’t use their insurance. Would you call this nefarious?

This is one more example of how the private sector takes good care of the industry itself while using the patients as pawns. Not only are prices high, insurance premiums are unaffordable for many, and they also shift more costs to patients’ pockets as they take away their choices in health care, whether through narrow provider networks or through unaffordable deductibles and other cost sharing. To add to the insult, we pay more because of the high costs of administering these shenanigans.

Through a well designed, single payer, improved Medicare for all we would have the full range of choices in health care with no need for the patient to share costs of the health care services and products at the point of service. When people need care, they simply get the care they need. And, of course, everyone is included for life, and we can do that without spending any more than we already do by using equitable public financing.

Now explain again the basis of those disingenuous arguments that are going around that this approach is not feasible. It is the only approach that is feasible if we want everyone to have affordable health care.

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Cost of health care for a typical family of four now over $28,000

Posted by on Wednesday, May 23, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

2018 Milliman Medical Index

By Christopher S. Girod, Susan K. Hart, Scott A. Weltz
Milliman Research Report, May 21, 2018

In 2018, the cost of healthcare for a typical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $28,166, according to the Milliman Medical Index (MMI).

2018 MMI Components of Spending

31% ($8,631) – Inpatient

19% ($5,395) – Outpatient

29% ($8,275) – Professional services

17% ($4,888) – Pharmacy

4% ($995) – Other (Home health, ambulance, DME, prosthetics)

Employers pay more; employees pay a lot more

The MMI’s healthcare expenditures are funded by employer contributions to health plans and by employees through their payroll deductions and out-of-pocket expenses incurred when care is received. Over the long-term, we have seen employees footing an increasingly higher percentage of the total. That trend continues in 2018, with employee expenses increasing by 5.9% while employer expenses increased by only 3.5%.

Employees’ share of healthcare costs

The total cost of healthcare for the MMI family of four is shared by employers and employees. To clearly define each payment source, we use three main categories:

1) Employer subsidy. Employers that sponsor health plans subsidize the cost of healthcare for their employees by allocating compensation dollars to pay a large share of the cost.

2) Employee contribution. Employees who choose to participate in the employer’s health benefit plan typically also pay a substantial portion of costs, usually through payroll deduction.

3) Employee out-of-pocket cost at time of service. When employees receive care, they also often pay for a portion of these services via health plan deductibles and/or point-of-service copays.

Relative Proportions of 2018 Medical Costs

56% ($15,788) – Employer contribution

27% ($7,674) – Employee contribution

17% ($4,704) – Employee out-of-pocket

The Milliman Medical Index is an actuarial analysis of the projected total cost of healthcare for a hypothetical family of four covered by an employer-sponsored preferred provider organization (PPO) plan. Unlike many other healthcare cost reports, the MMI measures the total cost of healthcare benefits, not just the employer’s share of the costs, and not just premiums. The MMI only includes healthcare costs. It does not include health plan administrative expenses or insurance company profit loads.…


Real Median Household Income in the United States

Federal Reserve Bank of St. Louis; FRED – Economic Data

$59,039 (2016)…


Historical Income Tables: Families

United States Census Bureau

Table F-8. Size of Family – Families by Median and Mean Income

Families with four people:
Median income $90,746 (2016)…

The Affordable Care Act was supposed to make health care affordable for all Americans while protecting the segment of health care coverage that seemed to be working well – employer-sponsored health plans. So the typical working family of four now pays through premiums, cost sharing and forgone wage increases (for the employer contribution) an average of $28,166.

For this select population – employed families of four with insurance through work with a median income for a family of four ($90,746) – the average payment is 31 percent of income. Of course, this is a family that is doing well. If a family with a median household income ($59,039) spent the same amount on health care it would be 48 percent of income.

One more significant point. That $28,166 is what is actually spent on health care. It does not include health plan administrative expenses nor insurance company profits, and we know what that means.

People want to know what they would be paying under a single payer Medicare for all system. When they ask, they should be reminded that they first need to understand what they are paying now. They understand the premium that is deducted from their paychecks, but they need to find out how much the employer is paying because that represents a reduction in their wages. They also should look at what they pay out of pocket for deductibles and other cost sharing while keeping in mind that they need to maintain reserves should they receive a major hit in their health. They should also realize that over half of health care in the United States is paid through our taxes, and most of that health care spending is relatively opaque for the average individual. Taxpayer-funded health care spending includes Medicare, Medicaid, CHIP, VA Health, military medicine, Indian Health Service, Public Health Service, much of the cost of health insurance purchased for federal, state, and local government employees, and the tax expenditures from the exclusion of employer contributions for medical insurance premiums and medical care (tax exclusion of $236 billion in 2018!). So that $28,166 represents only the most direct spending on health care for that individual family; they are paying much more through the tax system.

People want to know what the tax for a single payer system would be that would be deducted from their paychecks. Then they want to compare that with the current deduction for their employer-sponsored plan, not considering that that is only a very small fraction of the total amount they are actually paying. Because each person’s situation is different, it is impossible to give a precise dollar amount that they would be paying under an improved Medicare for all, but we can say that the amount will be equitable – fair – based on progressive taxes, and that, for all but the wealthiest, will be less than they are paying now (not to mention that they are assured coverage for life). And for the very wealthy, it would be painless anyway. They wouldn’t even know what are paying for health care through their taxes unless their accountant told them.

So remember the Milliman Medical Index – the typical working family of four is already paying on average over $28,000 for employer-sponsored health care, but also don’t forget how much we are already paying in addition through the tax system. We can’t just walk away. We need to enact an equitable financing system that ensures that everyone receives health care that is affordable. That would be a well-designed, single payer, improved Medicare for all.

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California’s success still leaves over 1 million eligible uninsured

Posted by on Tuesday, May 22, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Older Californians Struggle to Afford Lowest-Cost Plans on Covered California

California Health Care Foundation, May 14, 2018

Under the Affordable Care Act (ACA) California has now covered 93% of our adult population — a record high. Federal ACA subsidies through Covered California have made coverage more affordable for hundreds of thousands of Californians. The ACA further protected consumers’ finances by requiring insurers to pay a minimum level of medical expenses and by outlawing annual and lifetime caps on what insurers pay for care. However, 1.2 million Californians are eligible to purchase coverage on Covered California but remain uninsured, mainly because of cost.

Older Californians who aren’t covered by an employer or by Medi-Cal or Medicare, and who earn just above the maximum income to qualify for federal ACA subsidies (400% of the federal poverty level [FPL] — approximately $48,000 for an individual, $65,000 for a couple), may find it especially challenging to find affordable plans. For example, to purchase the lowest-cost bronze plan on Covered California:

* A 55-year-old single consumer earning $48,361 (401% FPL) would spend between 10% and 15% of her income on premiums, depending on where she lived.

* A 55-year-old married couple earning $65, 122 (401% FPL for a family of two) would pay between 15% and 22% of their income on premiums.

As consumers age, premiums increase:

* A 64-year-old earning $48,361 would pay between 13% and 20% of his income on premiums.

* A 64-year-old married couple earning $65,122 would pay between 20% and 30% of their income on premiums.

In addition, bronze plans come with a $6,300 deductible for individual policies and a $12,600 deductible for family policies.…

California has done a phenomenal job in implementing the Affordable Care Act and has gone beyond the federal requirements in an effort to further expand coverage. Yet 1.2 million Californians who are eligible to purchase coverage on Covered California remain uninsured, mainly because of cost.

Look at the numbers above. Not only are the premiums unaffordable for many of those who earn too much to qualify for subsidies – requiring up to 30 percent of income – but those premiums purchase only low actuarial bronze plans (60% AV) which require additional payments of an average of 40 percent of the costs of care received.

It is not California’s fault nor the fault of any other state that is trying to make the system work. It is the fault of Congress and the administration for refusing to enact a health financing infrastructure that would work well for everyone, not just in California but in the entire nation. But sadly, not only is there inertia on reform that would work, the President and many members of Congress would actually pare back further the inadequate coverage we do have, leaving even more uninsured or underinsured.

We could provide everyone with all essential health care services with no cost sharing barriers without increasing our national health expenditures above their current level merely by enacting a well designed, single payer improved Medicare for all. We are already paying for it; we should have it. But to get there we will have to replace Congress and the administration with competent, caring public stewards.

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Providers representing patients as proxy consumers – What?

Posted by on Monday, May 21, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Beyond Utilization: Reimagining Providers As Consumers To Promote Hospital Price Competition

By Dhruv Khullar, Amitabh Chandra, Rahul Rajkumar
Health Affairs Blog, May 18, 2018

Spending on hospital care accounts for one-third of US health care expenditures, or $1.1 trillion—a sum that exceeds total medical spending for all health care goods and services in some other high-income countries.

While total spending on health care services is a product of how many services we use and how much we pay for each, most efforts to limit cost growth have focused primarily on reducing the delivery of unnecessary or low-value care; there has been relatively little attention given to reducing the level of prices. But higher prices—not necessarily higher rates of utilization—drive excess spending in the United States.

Accountable care organizations (ACOs) have been a major focus of delivery system reform, proposed as a way to promote high-value care and reduce costs. ACOs may encourage integration of care, shift spending toward important non-clinical services (for example, care management), and discourage delivery of unnecessary services. But they have yet to produce substantial cost savings and are unlikely to directly confront the fundamental problem of high prices.

One reason ACOs have thus far generated limited savings may be that they attempt to organize and provide all care within their network of providers. This may allow for better care integration and coordination, but it prevents them from taking advantage of providers outside the ACO who may be able to deliver lower-price, high-quality care because of their greater specialization. We can address this problem if we reimagine ACOs—along with other delivery system innovations such as medical homes—as consumers, with more sophistication, incentive, and bargaining power than patients. Conceptualized this way, ACOs can encourage competition among bundlers of hospital care and help lower prices.

Barriers To Hospital Price Competition And The Limits Of Patient Consumerism

In most industries, consumers apply competitive pressure on vendors to reduce the price and improve the quality of available products. But in health care, the ability of patients to shop effectively and create meaningful competition among providers is limited. This is particularly true for hospital care, for which prices vary widely across the country with little relation to outcomes. Can consumerism work when it comes to hospital care? And can ACOs be part of the solution?

Two principal factors prevent patients from functioning as traditional consumers. First, hospital care is not organized into well-defined, easily understood, clinically meaningful units. Instead, each service is billed for separately, and a complex menu of “charges” for thousands of individual billing codes—entirely divorced from outcomes—makes it difficult to shop for episodes such as childbirth, joint replacement, or treatment of coronary artery disease.

Second, health insurance largely insulates patients from costs, so they are not well-positioned to apply competitive pressure on hospitals for expensive care. Because most hospital spending occurs above out-of-pocket maximums, high-deductible plans are unlikely to help. Even below the deductible, it is not clear that patients shop effectively for health care services.

These two forces—opaque pricing and poorly incented patients—constrain the ability of markets to take on a growing challenge: Prices for hospital services are often not the result of competition among providers. Public payers generally use regulated prices, which offer similar prices to high- and low-quality hospitals. For private payers, prices are largely determined by hospitals’ bargaining leverage, which is problematic in rural areas, in markets where hospitals have considerable brand identity and clout, and in regions with substantial hospital consolidation.

Bundled Payments As A Path To Greater Pricing Competition

What Is The Product Being Delivered?

Bundles include care for the full cycle of a well-defined medical condition and offer several advantages over traditional ways of organizing care: They capture the receipt of care for the duration of a medical episode; they put delivery of effective care largely within the control of providers; and they mimic how consumers generally purchase goods and services in other industries.

How Are Prices Determined?

Bundling services allows for more competitive pricing than ACOs and similar approaches through two channels. First, more providers can compete on a given bundle than can compete to assume responsibility for a large population. Smaller hospitals and ambulatory surgical centers, for example, can offer bundles to compete with larger, incumbent hospitals on specific services but are unlikely to have the capital and scale to compete on all services.

Second, if bundles are standardized by private or public payers—and price and outcomes data are publicly reported—insurers, ACOs, and patients can more effectively compare service delivery cost and quality across providers.

Who Is The Consumer?

Bundled payments allow ACOs and medical homes to function as consumers. ACO providers, usually primary care physicians, often engage other providers to deliver specialized care and must evaluate the price and quality of the services they offer patients. ACOs are in a better position to identify high-value services than are individual patients and could facilitate price competition among contracting providers.

Current iterations of bundled payments take steps toward achieving these goals, but there is more to be done. Medicare bundles are mostly administered retrospectively, so physicians still report fee-for-service claims, which does little to disrupt existing practice patterns.

Future iterations of bundled payments may allow for greater use of complementary pricing initiatives, such as reference pricing, by which payers agree to pay a set price for a bundle and additional costs are borne by consumers.

Bundled services could also allow for expanding Medicare’s competitive bidding program, which currently only includes certain medical equipment and supplies, to include Medicare Part B services offered by providers competing on bundles.

Combining bundles with ACOs and medical homes also allows for progress on some traditional challenges with bundles. For example, it is not clear how bundles should be structured for preventive and primary care services, or for comorbid chronic disease management. Moreover, while bundles encourage care efficiency within the bundle, they do not limit the total number of bundles. However, a payment structure that funds difficult-to-bundle care through capitated payments to physician-led ACOs and medical homes—and gives them the option to shop for and purchase hospital care using bundles—may mitigate these problems and lower the cost of care.

Bundles still need refinement. As with other payment models, risk adjustment and outcomes measurement are challenges. Dividing a single bundled payment among several providers can be difficult, and bundling hospital and postacute care, physician and nursing care, and drugs and devices will require large organizational changes within hospitals and investments in cost accounting. Nevertheless, expanded use of bundled payments is a potential path toward greater price competition for hospital services. Bundles have often been thought of as a mechanism to integrate care, but their greatest impact may be increasing the number of providers in the health care markets, and redefining and strengthening the role of the consumer.


Published Comment:

By Stephen Kemble, M.D.

Two problems with this proposal:

1. Bundles incentivize delivering more bundles of care for low risk patients, which can mean more unnecessary care.

2. The majority of health care is not in the form of discrete episodes of care for acute conditions or specific procedures. It is for care of chronic conditions for which there are no clear end-points for starting and ending a bundle.

I believe the whole idea of trying to control prices via competition is not likely to work. For one thing, in many markets, including rural and poverty areas with a high percentage of Medicaid and uninsured patients, hospitals are already losing money and can’t afford to reduce prices. We should be focusing on reducing administrative cost and burdens combined with price controls, instead of competition, if we want to reduce prices without destroying care for large segments of the population, including those who are poor, chronically ill, or elderly, and who need care the most.…

The policy community remains obsessed with the concept of using competition to harness the power of the consumer in order to bring under control our high health care prices in the United States. The record to date demonstrates the utter failure of this approach, but that does not keep them from trying, no matter how lame their various proposed innovations.

Today’s proposal acknowledges that patients do not function well as consumers in the health care environment, But to save the concept of consumerism, they suggest that the health care providers consolidate, bundle together what can be bundled, while clumping together difficult-to-bundle care as ACOs or medical homes, and then delegating themselves as consumers of their own bundled services, serving as proxies for their patient-consumers. Egad!

Our colleague, Stephen Kemble, in his posted comment, sees through this policy smokescreen. In spite of all the talk about bundling care, most care does not package into neat bundles. Second, the providers that do have bundles to sell want to sell more of them when it is not only prices but also quantity that determines the total health care spending.

Kemble’s most important point is that, instead of relying on competition, “we should be focusing on reducing administrative cost and burdens combined with price controls.” Administrative waste and high prices have been proven to be the two greatest sources of recoverable waste in our runaway health care spending. Competition has not controlled them; in fact, the markets have only made them worse.

It is astonishing that these market ideologues do not acknowledge the beneficial health financing policies that are just outside their box – automatic lifetime coverage for everyone prepaid through equitable, public financing, in a system that is publicly administered far more efficiently than with our fragmented, multi-payer system. Maybe someone should attach a door knocker onto their box so we can get their attention.

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Richard Painter on single payer Medicare for all

Posted by on Friday, May 18, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

‘I’ve been a pain in the rear for the Republican Party’: A conversation with Richard Painter

By David M. Perry
Pacific Standard, May 17, 2018


A few weeks ago, Richard Painter shocked the Minnesota political establishment by declaring that he would run for the United States Senate as a Democrat. Painter was the White House ethics lawyer under President George W. Bush and has become widely known as a centrist Republican commentator, in his own writing and on media outlets such as MSNBC. He’s now a professor of corporate law at the University of Minnesota. It was no surprise when he announced an exploratory committee to compete for the Senate seat vacated by Al Franken earlier this year, but no one seems to have guessed that he’d switch parties.

Right now, in addition to his long-running criticisms of President Donald Trump, Painter is challenging Minnesota Senator Tina Smith from the left on health care, the environment, and corporate partnerships, especially over the new NFL stadium in Minneapolis. Smith was lieutenant governor of Minnesota before Governor Mark Dayton appointed her to replace Al Franken after the latter’s resignation last December.

I recently sat down with Painter in a suburban coffee shop in Eagan, Minnesota.

David Perry: I’d like to start by asking you to tell me the story of how you decided to run as a Democrat.

Richard Painter: I have a paper trail that goes back to at least 1994. I’ve been writing, and that’s what professors do. I challenge people to find an issue that I’ve really made a substantial change on. I recognize new evidence, for example, of even worse behavior in the banking sector than what I talked about in 1994. But because I worked for President Bush as the ethics lawyer, people assume that somehow everything else that was going on [then] was things that I would agree with.

DP: So you haven’t always been in lockstep with everything in the Republican Party platform?

RP: There are quite a lot of differences. I have tended to speak out on the issues that are in the purview of my professional expertise—business ethics, corporate ethics, and government ethics. Until recently, I didn’t get into what I think is the best health-care system, weighing in on abortion or something. In the past year or two, I started to weigh in on a lot of issues. People assume that, because the Republican president that I worked for had a different position on those issues, that back then I had a different position. That’s just not the case. The whole paper trail is there.

DP: I’d love to hear more about your recent decision to run as a Democrat for the Senate, especially when everyone else was assuming you’d run as a Never-Trump Republican. Can you take me into that decision?

RP: When I actually go to take public positions on issues, and you go down the issues, the Republican Party has moved dramatically from where they were in earlier times. On environmental issues, on women’s reproductive health, on a military spending, we can go through issue after issue after issue where the Republican Party—and it’s a trend that started in 1980 with [President Ronald] Reagan, but it’s accelerated even it it weren’t for Trump—I’m running on a platform that’s very different.

DP: Let’s talk a little about those issues. You’ve come out for single-payer health care, and even used the issue as a way to attack Senator Smith from her left. What does single payer mean to you? If you had the power to create a health-care system, what would you do?

RP: I think it’s in the interest of the consumer and also the small business owner to ask the question: How do we get the highest-quality health care for the best price? And also [how to] not have health-care issues interfere with the ability to start businesses? Right now, when you connect the employment relationship with health care, that means the big business has an enormous advantage over the small business. It makes no sense to connect those two. Why should health care be linked to your job?

DP: So what’s the better solution?

RP: The advantage of having a single-payer system is that there’s negotiating power vis-à-vis providers, drug companies, medical device companies. So I’m looking at it from an efficiency vantage point. I want best quality for best price.

DP: Debates around the best kind of single-payer usually identify one of three models. There’s Medicare for All. There’s the public option model. And there’s the Obamacare exchanges plus subsidies model.

RP: I like Medicare for All. The advantage of Medicare for All, and we might not be able to do it right away, [but in] the ideal system, your employer would have nothing to do with your health care, just like your employer has nothing to do with your kids’ education. Your employer doesn’t send your kids to school. Your kids’ health care shouldn’t depend on your employer. So we separate that relationship.

And of course that may relieve the employer of a lot of expense, so we may have to raise taxes to do it, OK! You gotta find the money somewhere, but employers then would not have to pay this extra amount of money [on health care]. We would separate out the employment relationship from health care and use tax revenue, but does it matter whether I pay higher taxes or I have to pay an insurance company?

That’s issue No. 1. Two is negotiating power to cut costs. You remove all those insurance company execs who are making a lot of money. Granted, this single-payer [system] is gonna have to pay people, but I don’t think you’d pay them as much as the big insurance companies.

DP: It’s not a stock option-based system.

RP: You don’t have the stock and the stock options and the advertising and the legal costs and everything. A lot of the costs that are in the current system are the insurance companies competing against the other. The time it takes for consumers to compare all these different options—you say competition is good, but it’s time comparing insurance options. What you should be doing is comparing doctors.

Now let’s talk about the drug companies and medical device companies.

DP: You’ve been critical of Senator Smith on her support for repealing the Obamacare medical device tax and her support from the chief executive officer of the medical device company Medtronic.

RP: We’ve made enormous advances, but at a certain point, Americans are paying for most of it. The rest of the world gets the medical devices and the drugs for maybe a third of the prices we do. A lot of the money is going to stock options and the investors and the executives, not going to research and development.

DP: So what’s the solution?

RP: I think the single payer negotiates with the drug companies. It’s negotiating power, it’s the ability to get those prices down. To say, for this medical device, this is the price that’s being paid; for this drug, this is the price we’re gonna pay. Which is exactly what Canada is doing and every other country is doing, all the industrialized countries. In the United States, we’re paying two or three times as much.

DP: Let’s talk about connections between health care and other issues of workers and work. What are your thoughts around these more fundamental issues of labor, economic well-being, the Supplemental Nutrition Assistance Program, and food security? Where do you fall on these positions?

RP: First of all you take health care out of the equation [by instituting single payer], so people don’t have to worry about that. That’s going to help a lot. Then we talk about what’s left. Certainly childhood nutrition, that’s the kind of thing the government ought to be spending on. I am very much focused on government doing what government should do and do it well. So: Nutrition for children [is] absolutely critical. We ought to be doing a lot more than we currently do with SNAP, like school lunches and breakfasts and other meals for children. That’s a useful role for government.

DP: So philosophically, it sounds like you’re pretty aggressive in terms of using the power of government to set tax policy, to set minimum wages, to create subsidies, and otherwise to intervene pretty strongly to bring everyone up to a basic level.

RP: I would tend to have more spending on education and health care and food assistance—critical functions of government. I’m going to be exercising a lot of scrutiny over both defense spending and large-scale infrastructure projects. I wanna see roads repaired. I wanna see bridges repaired. I wanna see more mass transportation, particularly electric busses. I’m gonna be looking very carefully at very large-scale rail projects.

DP: Last question: You’re running now as a Democrat. You’re running to get a nomination of a party that you haven’t been a part of. You’re running against a lieutenant governor who by all accounts has done a good job helping Governor Dayton shepherd Minnesota to a much better place than where it was eight years ago. What happens if you lose, or if you don’t get the nomination? Are you going to continue to be a Democrat? To vote for Democrats and support Democrats?

RP: I don’t see Republicans on the ballot for federal office, this year, in any state, who should get support. They have all fallen in line behind President Trump. I think it’s critical to our democracy. This isn’t about being a Democrat; I’m an American before party. I’ve been a pain in the rear for the Republican Party, and if I were to continue to be involved in the Democratic Party, I will continue to be a pain in the rear on campaign finance, health care, the environment. I’m not interested in party loyalty issues. I’m interested in policy, in issues, and the right thing to do.…

Richard Painter’s lesson for us? It’s not about party. It’s about policy and ethics. It’s about the right thing to do.

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Healing an ailing pharmaceutical system: prescription for reform for U.S. and Canada

Posted by on Thursday, May 17, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Our pharmaceutical systems are broken, and only fundamental reform can ensure universal access to safer, more innovative, and more affordable drugs

By Adam Gaffney, instructor in medicine, Harvard; Joel Lexchin, professor emeritus, York; US, Canadian Pharmaceutical Policy Reform Working Group
BMJ, May 17, 2018

Key messages

The US and Canadian pharmaceutical systems are dysfunctional

Costs are exorbitant, commercial goals distort drug development, misleading promotion fosters misuse, and medications are too often unaffordable for patients

We propose reforms that would provide universal drug coverage without fees at the point of use while reducing prices through negotiations with drug firms and, when needed, compulsory generic manufacture

Innovation would be enhanced through patent reform and by establishing new public agencies to fund drug development and clinical trials

Drug safety, efficacy, and prescribing quality would be improved by raising standards for approval and safety monitoring

While the proposals face formidable political obstacles, a popular mandate exists for pharmaceutical reform in both nations

Drugs are among medicine’s most powerful tools. Yet the pharmaceutical systems of the United States and Canada are mired in dysfunction. The industry’s pricing practices—charging whatever the market will bear, especially in the US—strain budgets and put vital medicines out of reach for many patients. Despite some notable advances, the industry’s overall rate of real innovation remains incommensurate with our vast drug spending; many new drugs are marketed each year but few represent substantial clinical improvements. And commercial imperatives distort drug trials, research priorities, and drug regulation.

While many recognize the need for change, proposed remedies vary and would fall short of achieving the fundamental reform that these deficiencies call for. The advocacy organization Physicians for a National Health Program therefore encouraged a working group of US and Canadian doctors, scholars, and advocates (the US/Canadian Pharmaceutical Policy Reform Working Group) to come together to craft a wide ranging reform proposal for both nations.

Although some of our recommendations could be implemented within the existing US healthcare financing framework, full implementation would require a universal single payer system. Canada already has a single payer system but it would still require reforms because the system fully covers hospital and doctors’ services but not drugs out of hospital.

Our proposal rests on six principles

• Medical needs, not financial means, should determine access to medications

• Drugs must be affordable to society

• Drug development should be geared toward real innovation that maximizes population health

• The human right to health must take precedence over intellectual property rights (patents)

• The safety and effectiveness of medications must be independently and rigorously evaluated

• Comprehensive and unbiased information on drugs should be available to prescribers and patients.

Achieving change

Jonas Salk, inventor of the polio vaccine, eschewed patenting, declaring: “Could you patent the sun?” Today, in contrast, profiteering too often reigns, to the detriment of population health.

Our proposal calls for a fundamental reorientation of drug policy: it would make drugs more affordable for patients and society, promote innovation, strengthen efforts to assure the safety and effectiveness of medications, and upgrade the evidence available to prescribers and the public. Because drugs developed through the proposed new public pathways would remain in the public domain, they could be produced generically throughout the world, benefiting many nations.

The reforms we advocate face formidable political opposition, especially from drug firms, which made total profits of $67.7bn in 2016. However, most Americans—both Democrats and Republicans—now favor government action to lower drug prices, and 91% of Canadians support a universal pharmaceutical benefit. These are unmistakable popular mandates for change. The trail from sentiment to policy will doubtless be arduous. Yet history is replete with examples of sweeping reforms—often enabled by unpredictable shifts in political circumstances—that overcame entrenched interests. We aim with this proposal to provide a blueprint for reform that anticipates—and may kindle—transformative changes in our nations’ pharmaceutical systems.


For the full proposal as published in BMJ:
or BMJ:…

For PNHP’s press release (identifies the seven critical areas for reform):…

For an economic analysis and supplemental materials:

For a 2 minute video introduction and media coverage of the proposal:

Physicians for a National Health Program (PNHP) and Canadian Doctors for Medicare have produced a comprehensive reform proposal for pharmaceuticals which would make essential drugs accessible and affordable for everyone.

This proposal could not be more timely. Last week President Trump delivered his long-awaited speech on his proposal to supposedly control price gouging of drugs. Pharmaceutical stock prices immediately spiked – a response confirming that Trump supports Big Pharma while neglecting patients desperately in need of therapeutic drugs.

Let’s let the people of the United States and Canada know that there is a way that we can fix this problem. Share this great news with others.

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Medicare’s own actuary confirms the deleterious consequences of short-term health plans

Posted by on Wednesday, May 16, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Trump’s Plan for Cheaper Health Insurance Could Have Hidden Costs

By Robert Pear
The New York Times, May 15, 2018

President Trump’s plan to expand access to skimpy short-term health insurance policies, as an alternative to the Affordable Care Act, would affect more people and cost the government more money than the administration estimated, an independent federal study says.

The study, by Medicare’s chief actuary, suggests that the new policies would appeal mainly to healthy people, including many who have had comprehensive coverage under the Affordable Care Act.

The administration estimated in February that a few hundred thousand people might sign up for the “short-term, limited-duration policies,” which would not have to provide the standard health benefits like preventive services, maternity care or prescription drug coverage.

But the chief actuary, Paul Spitalnic, estimates that 1.4 million people could sign up for the short-term policies in the first year, with enrollment reaching 1.9 million by 2022.

The new policies would probably attract people who do not need the full suite of benefits guaranteed by the Affordable Care Act, Mr. Spitalnic wrote in a recent memorandum.

Those remaining in Affordable Care Act marketplaces “would be relatively less healthy,” Mr. Spitalnic said, and as a result, the average premiums for those insurance policies would increase.

The Trump administration estimated the extra cost to the federal government at $96 million to $168 million a year.

But the chief actuary, whose independence is protected by federal law, estimates that the rule proposed by the administration could increase federal spending by $1.2 billion next year and by a total of $38.7 billion over 10 years.

Short-term insurance policies were originally intended for people who were between jobs or needed temporary coverage for other reasons. Under the proposed rule, they could play a larger role.

“There is nothing in the proposed rule that would prevent companies from underwriting and issuing new policies to individuals at the end of the one-year coverage term,” Mr. Spitalnic said.

Under the Affordable Care Act, the most popular type of marketplace plans, so-called silver plans, cover 70 percent of health care costs for a typical population. By contrast, Mr. Spitalnic said, the new short-term plans would cover 50 percent of costs, on average.

Short-term plans can exclude coverage for pre-existing conditions and can omit some benefits deemed essential in the Affordable Care Act.

Thus, for example, some short-term plans offered by UnitedHealth Group do not provide prescription drug coverage and do not pay expenses related to a normal pregnancy or the treatment of mental disorders, according to a brochure from the company.…

American Academy of Actuaries; Re: CMS–9924–P—Short-Term, Limited-Duration Insurance:…

Addendum: the link to the report from Medicare’s chief actuary:…

There have been extensive reports on the Trump administration’s proposed rule that would greatly expand the use of skimpy, bare-bones, short-term health insurance policies. These reports have shown that this rule would greatly expand the prevalence of underinsurance – policies that fail to provide adequate financial protection in the event of medical need. It would result in adverse selection within the standard plans – driving insurance premiums up, thus making them less affordable. This would cause many to forgo insurance altogether – increasing the numbers of uninsured.

The reason today’s report is significant is that it comes from Medicare’s own chief actuary, Paul Spitalnic. He confirms the adverse consequences of expanding the use of short-term policies, yet the rhetoric coming out of HHS/CMS and the White House continues to tout the affordability of these plans while remaining silent on the severe adverse consequences.

I did an extensive search to try to access the chief actuary’s report. If it is available, they did a good job of hiding it (which would be understandable since it is contrary to the administration’s con job that is being being foisted off on the American public). Lacking his report, I have included a link to a highly credible report on this proposed rule submitted to HHS/CMS by the American Academy of Actuaries, which, once again, confirms the deleterious consequences of this proposal. (Edit: the chief actuary’s report has been added as an addendum, above.)

The administration has the true facts at hand, yet they have shown no inclination to act on those facts. We need to hold President Donald Trump, HHS Secretary Alex Azar, and CMS administrator Seema Verma personally responsible for the physical suffering and financial hardship that they are about to inflict on too many of us.

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Urban Institute’s ‘Healthy America Program’

Posted by on Tuesday, May 15, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

The Healthy America Program: Building on the Best of Medicare and the Affordable Care Act

By Linda J. Blumberg, John Holahan, Stephen Zuckerman
Urban Institute, May 14, 2018


Since efforts to “repeal and replace” the Affordable Care Act (ACA) have failed, and bipartisan attempts to improve the law have stalled, some policymakers are now looking beyond incremental fixes. In this paper, Urban Institute researchers present a set of policy ideas that would provide universal access to comprehensive coverage but would also allow people to keep their employer-sponsored coverage, would offer a range of insurer options and ensure broad pooling of health care risk, would not have an employer mandate, would provide income-related federal assistance, and would create a more flexible individual incentive to remain insured than that under the ACA.

The proposal builds on components of the Medicare program and the ACA Marketplaces. However, it simplifies the current health insurance system by integrating Medicaid acute care for nonelderly people and the Children’s Health Insurance Program (CHIP)—while preserving access to their benefits—with coverage for people enrolled in private nongroup insurance and people currently uninsured. This large new Medicare-style marketplace, featuring a public plan and private insurer options, would contain costs by fostering competition among many insurers, capping provider payment rates, and addressing prescription drug pricing. This proposal is less ambitious than a single-payer system (i.e., Medicare for All), but it would get close to universal coverage with much lower increases in federal spending and less disruption for people currently enrolled in employer coverage or Medicare.

They estimate that the plan would result in 15.9 million fewer uninsured people and reduce total health care spending by $28.9 billion in its first full year of implementation.

Healthy America Compared with Other Proposals 

See Table 4 in the full article for other proposals – only Healthy America (HA) and Medicare for All by Sanders (MfA) are included here.

Who is eligible for the new program?

HA – All lawfully present people younger than 65

MfA – All US residents

What’s in the program?

HA – New public plan option, restructured private nongroup insurance market, enhanced premium and cost- sharing subsidies, new incentive to remain insured

MfA – Single-payer system enrolling all US residents in a single plan

Does the separate Medicaid program continue?

HA – Medicaid acute care program ends, with enrollees folded into other programs; long- term services and supports program continues as under current law

MfA – No

Are states required to make maintenance-of- effort contributions?

HA – Yes, but only for spending on acute care for the nonelderly

MfA – No

Does the separate Medicare program continue?

HA – Yes

MfA – No

Does the private insurance market remain?

HA – Yes, for group and nongroup private insurers; no firewall between employer coverage and new program

MfA – No

What benefits are offered?

HA – ACA essential health benefits

MfA – All medically necessary acute care and dental, vision, and hearing care; long-term services and supports stay the same as under current Medicaid program

How much are household premiums?

HA – Premiums range from 0 to 8.5% of income; premium subsidies are tied to 80% actuarial value plan

MfA – None

What are the cost-sharing requirements?

HA – Cost-sharing subsidies increase actuarial value above 80% for people with incomes up to 300% of FPL; cost- sharing options with actuarial value below 80% also available

MfA – None

Are people automatically enrolled?

HA – Only SNAP and TANF enrollees, who face no premiums, are autoenrolled; others without premiums can enroll in public plan at any time

MfA – Yes

Do individuals face a penalty for remaining uninsured?

HA – Yes, structured as loss of a tax benefit, which can be partially refunded if people enroll in coverage later

MfA – No, all are enrolled in a single plan

Are there limits on provider payment rates?

HA – Yes, for nongroup insurance markets

MfA – Yes

Do employers face a penalty for not insuring workers?

HA – No

MfA – No

Are there minimum standards for employer coverage?

HA – No

MfA – Not applicable; employer insurance eliminated

Does the program provide universal coverage?

HA – Close to universal for legal residents (not for undocumented people)

MfA – Yes

From the Discussion

Several proposals are being put forward to fix the ACA or to fundamentally reshape the US health insurance system. Proposals of significant restructuring are necessarily more complex than those focused on making the ACA work better. In Healthy America, we try to strike a balance by retaining Medicare and employer-sponsored insurance while significantly changing Medicaid and nongroup health insurance. Our goals are to keep what people like, change what is not working, and limit the increase in new federal costs.…

Full Report (24 pages):…

Those looking for solutions other than a single payer improved Medicare for all may find Urban Institute’s Healthy America Program to be an attractive incremental approach since it leaves Medicare and employer-sponsored plans intact while making adjustments to Medicaid and the nongroup health insurance market. For single payer advocates, merely reading the comparisons between the two proposals is enough to show that the Urban proposal falls intolerably short of the reform goals of single payer.

A detailed critique of the full proposal could be prepared, but if you merely skim though the full report, it’s obvious that it is not worth the effort since they leave in place most of our highly flawed health care financing infrastructure.

Read the full report if you want to, but if you are primarily interested in refreshing in your mind what actually will work, spend your time reading once again the Physicians’ Proposal for Single-Payer Health Care Reform:

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Framing health financing as wealth transfer ignores the moral imperative of social insurance

Posted by on Monday, May 14, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Health policy reform or wealth transfer?

By Gary Galles
The Orange County Register, May 9, 2018

Americans have been fighting over health insurance reform for years. Single-payer proposals, as most recently proposed in California’s legislature, are just the latest example. However, while rhetoric has focused on how many would supposedly gain or lose insurance, wealth transfers have been the real issue. As economist Henry Aaron estimated a quarter-century ago, implementing comprehensive national health insurance would redistribute more income than any single public policy then in existence.

We know insurance is not the real issue because claimed “reforms” violate so many principles of insurance.

The price controls reform proposals incorporate are also about transferring wealth, not health insurance. My age makes my actuarial risk six times that of my students. If, as Obamacare required, I could not be charged more than three times what they were, that really forces the young to subsidize the old, explaining why Obamacare imposed penalties to force acceptance of a bad deal.

Mandating coverage of pre-existing conditions also shows “reforms” are seldom really about insurance. It doesn’t reduce people’s risk exposure, it forces others to cover costs already known to be higher and deflects the blame to insurance companies who must charge others more. Such after-the-fact possibilities are not offered in fire, automobile or life insurance. Similarly, casinos don’t let you bet once the roulette ball or dice have stopped.

In addition, if health policy was truly aimed to benefit all Americans, rather than benefiting some by pick-pocketing others, it would not have been pushed with so many lies, damned lies and statistics.

Our health insurance debate has become so contentious largely because it has allowed massive wealth transfers to be mis-represented as improving health insurance. It helped dishonestly sell Obamacare, and now portrays reducing massive theft from those government targeted to hold the bag as imposing heartless harm on others. Such mis-representation cannot generate policies that advance either Americans’ or Californians’ well-being.

Gary M. Galles is a professor of economics at Pepperdine University, an adjunct scholar at the Ludwig von Mises Institute, a research fellow of the Independent Institute, a member of the Foundation for Economic Education faculty network, and a member of the Board of Policy Advisors at the Heartland Institute.


Published comment:

By Don McCanne, M.D.

Wealth transfers have been the real issue? Isn’t the real issue rather ensuring that everyone has affordable access to essential health care services, as all other wealthy nations do?

We take for granted public services such as primary and secondary education, fire and police protection, public parks, highways and streets, national defense, Medicare, Social Security, the services of the National Institutes of Health, to mention a few. Most of the taxes used to fund these services are progressive to some degree – those with higher incomes pay more than those with lower incomes. Yet we do not refer to wealth transfer as being the primary policy that drives the existence of these services; it its the services themselves that are the primary public policies.

Health care stands out partly because of its very high costs. The cost of health care for the typical family of four receiving employer-sponsored PPO coverage is now $27,000 (Milliman). Median household income is now about $59,000. Although those are not identical family units, these numbers do make the general point that average-income families cannot possibly pay their proportionate share of global health care costs if they were evenly distributed amongst all of us (risk pooling).

Rather than framing this primarily as wealth transfer it should be framed as social insurance covering the health care needs of the people. If the funding were not equitable (progressive), too many would have to do without health care. The most efficient and effective methods of financing happen to be either a single payer system – an improved Medicare that covers everyone – or a national health service – socialized medicine. Most Americans would prefer Medicare for all, and would consider it their earned right, just as we consider Medicare in retirement to be our earned right rather than being primarily a government wealth transfer program.…

Although it is usually not wise to repeat the deceptive rhetoric of the opponents of health care justice, it can be helpful to understand it and be able to respond when it is in your face. Professor Galles uses wealth transfer – a concept he apparently considers to be evil – to reject the concept of pooling risk for health care.

It’s really simple. Because health care needs are unequally distributed, we need to pool risk by transferring from the healthy to the infirm. Because average health care costs are beyond the means of those with average incomes we need to fund the risk pool equitably based on ability to pay.

This is a concept that is accepted throughout society. Tax-financed public services are largely funded progressively through tax policy. That is not evil, but good. It makes it possible to provide those services for everyone. We don’t suggest that individuals with lower incomes should be denied fire or police protection merely because it would results a transfer of wealth.

Galles condemns what he calls wealth transfer when it makes health care services available to those who otherwise could not afford them. Yet he remains silent on the massive wealth transfer that necessitates these public policies – the transfer of wealth from the workers whose productivity has grown the economy, to those already wealthy rentiers who provide little personal contribution other than their excess capital gained by market abuses. That’s the shameful wealth transfer that our public policies should be addressing.

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APA panel: Single-payer system is the solution for mental health care

Posted by on Friday, May 11, 2018

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Single-Payer System Is the Solution for Mental Health Care, Panelists Say

By Kelly Davio
AJMC, May 7, 2018

In a discussion during the American Psychiatric Association 2018 Annual Meeting, held in New York, New York, a panel of psychiatrists argued that private insurance is failing patients with mental health disorders, and that a single-payer system would provide better access and better care for the most seriously ill patients.

J. Wesley Boyd, MD, PhD, a psychiatrist who focuses on adult outpatient psychiatry in the Cambridge Health Alliance, explained that mental health disorders, which affect 1 in 5 adults, are the leading cause of disability in the United States. Additionally, only 20% of children and youth with mental health disorders will get treatment, and “The effects can be lifelong and potentially devastating, both in terms of inability to retain work, possible interactions with the justice system, you name it…the stakes are very high.” In Boyd’s view, “The insurance industry is not doing anyone a favor when it comes to mental health care.”

Insurance companies create obstacles to needed mental health care, Boyd argued, starting with prior authorizations. “Anytime I have called for a prior authorization, I set aside 40 minutes to do that. I call a number, inevitably it’s a wrong number…I’m counting on being transferred at least twice before I get the person I need.” To Boyd, the difficulty in reaching the right person to authorize care is not merely a hassle, but potentially a deliberate attempt by insurers to curb access to care. “They want to make it as difficult for us as possible,” he said.

According to Boyd, payment for psychiatric services by private insurers is so low that many facilities lose money for the services that they provide, and consequently reduce access to the services that they offer.

Boyd discussed a study that he and his colleagues conducted in which they phoned 64 in-network Blue Cross Blue Shield (BCBS) mental health facilities in the Boston area to assess a patient’s ability to gain treatment. Researchers able to get an appointment only 12% of the time. In 23% of cases, they received no return call after trying twice to reach the clinic. In 23% of cases, facilities’ representatives explained that the patient would be required to receive primary care at the facility in order to be eligible for mental health services.

Monica Malowney, MPH, a consultant with the Public Consulting Group, added that in her own study, in which she and colleagues called 360 adult psychiatrists in 3 major cities using a provider list from BCBS, only 119 clinicians were reachable on a first round of calls. In another such study that focused on 913 psychiatrists in 5 major US cities who provide care to children, the researchers were able to get an appointment only 17% of the time.

Stephen Kemble, MD, who is retired from psychiatric practice, argued that value-based payment reform is compounding the problem of accessible care for patients with serious mental illnesses. According to Kemble, value-based models incentivize clinicians to avoid risky, more complex, socially disadvantaged patients because they may cost more to treat than other patients; “If you’re paid upfront, you want to avoid sick people. [You’re] cherry-picking.”

Kemble questioned whether the fee-for-service model itself is really to blame for the problem of high-cost, unnecessary care. Other drivers, such as lack of access to appropriate outpatient care, leads to unnecessary emergency department visits and hospitalizations.

Furthermore, the administrative burdens that come with a shift to value-based care, said Kemble, are creating physician burnout. In his experience in Hawaii, he has found that few private practice psychiatrists are willing to invest in the upgrades required to comply with reporting procedures associated with new payment models, so many clinicians simply stop accepting Medicare and Medicaid instead. As a result, he said, access in Hawaii is increasingly limited to community mental health centers and hospital clinics, so a number of seriously ill patients are unable to get urgently needed care.

Leslie Gise, MD, clinical professor of psychiatry at the John A Burn School of Medicine at the University of Hawaii and a staff psychiatrist at the Maui Health System, added that the current state of the healthcare system disproportionately disadvantages women in gaining access to mental healthcare, in part by charging women more for their coverage. The Affordable Care Act did not fully do away with the problem of “gender rating” enrollees, Gise said, because there are only nominal penalties for violating the law, an higher costs to employers to provide insurance to women can result in lower wages for female workers.

Furthermore, women who divorce often lose their private health insurance, she said, and the linkage of marital status and health insurance contributes to declines in women’s health. “Everyone should have adequate healthcare for life. Divorce should have nothing to do with it.”

A well-designed single-payer system that would cover all people for life, said Gise, would provide better outcomes, greater equality, and cost-reduction for the healthcare system at large.…

There has been a greater recognition of the need for mental health services at the same time that it has become clear that private insurers are failing us in providing adequate access to mental health care for those in need. It is hoped that our policymakers will listen to the recommendations of this panel that presented their case at the annual meeting of the American Psychiatric Association.

Their conclusion: “a single-payer system would provide better access and better care” for those in need of mental health services.

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Physicians for a National Health Program's blog serves to facilitate communication among physicians and the public. The views presented on this blog are those of the individual authors and do not necessarily represent the views of PNHP.

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