Thursday, February 09, 2017

Pushing drugs, American style

Watching the news makes people sick

At the outset I must confess to being addicted to watching the news on television. Although my favorite televised news sources are on PBS, on most nights I supplement the PBS News Hour with the news on one of the traditional network stations or a cable news channel. Something that has repeatedly struck me in watching the evening news on traditional network stations is that advertisers have obviously learned that the vast majority of people who watch the evening news are suffering from indigestion, irritable bowel syndrome, erectile dysfunction, atrial fibrillation not caused by a heart-valve problem, moderate to severe psoriasis, rheumatoid arthritis, osteoporosis, depression, insomnia, restless leg syndrome or dry eye disease. If not afflicted by one of those conditions, they are being assaulted by meatballs or chicken wings.

Not all the commercials are pushing drugs, of course. Interspersed with all the pharmaceutical products are commercials featuring lawyers who are prepared to sue pharmaceutical companies for offering products that have life-changing side effects, and health insurance plans that complement Medicare to provide coverage to pay for all those pharmaceuticals that TV viewers are urged to ask their doctors about. Given the evidence of television commercials, remarkably few of the people who watch the televised news are under the age of sixty-five and have sound minds in sound bodies. 

An often-heard claim of those who are convinced that the Affordable Care and Patient Protection Act has all but destroyed the health-care system in the United States is that the ACA (which they persist in calling Obamacare) has driven insurance premiums through the ceiling, thus bringing financial ruin to small businesses and confronting hard-working Americans with having to choose between health insurance and sending their children to overpriced universities. What is missed in this analysis, of course, is that health insurance is expensive because medical care and pharmaceuticals are expensive. Also left out of consideration is that almost every pharmaceutical product sold in the United States is available in Canada for a fraction of the cost.

Why don’t Canadians pay their share of the cost of drugs?

A claim I have heard many Americans make, clearly a claim that they have learned from the pharmaceutical companies themselves, is that the prices of pharmaceutical products are so high in the United States because it costs pharmaceutical companies a great deal of money to do the research necessary to develop new products. Some American friends have even shown indignation that Americans are subsidizing Canadians, who derive all the benefits of expensive medical research but pay none of the cost. Once, when I was still living in Canada, I received an email from a (former) friend in the United States who accused me, in language unsuitable for anyone not in either the navy or a motorcycle gang, of being a freeloader who was enjoying good health at the expense of poor Americans. That claim was false for two reasons. First, I have almost never been prescribed a pharmaceutical product and tend to avoid over-the-counter medical products. Second, there are better explanations for why pharmaceutical prices are outrageously high in the United States. So the answer to the question “Why don’t Canadians pay their share of the cost of drugs?” is that they in fact do pay their fair share. Americans pay more, not because they are subsidizing freeloading Canadians, but because Americans pay far more for products than it costs to develop and manufacture those products.

Why do Americans pay for overpriced pharmaceuticals?

The pharmaceutical companies typically claim that they must charge high prices for their products because of the high cost of developing them. It cannot be denied that running controlled tests on new products and making sure the products meet safety standards is costly. It should also be pointed out, however, that advertising the products once they are developed is also costly. To that can be added that pharmaceutical companies also tend to pay shareholders rather high dividends. When health care products are manufactured by for-profit corporations that have investors to reward with high dividends, then costs naturally rise. While the claim of many advocates of free-market capitalism is that competition keeps costs down, the opposite is often the case. If two companies are competing for a share of the market, the cost of the competition—the advertising of products to potential consumers of the products and to potential prescribers of those products—can be quite high. 

Neither of those kinds of advertising is necessary. There is no justification whatsoever for running expensive advertisements on television that end with the line “Ask your doctor whether…is right for you.” There is no need to make the patient into a sales representative for a product that the patient may end up buying. If someone has, say, osteoporosis, then it should be sufficient for the physician to suggest a range of possible treatments, and to tell the patient the desired effects and the likely side effects of each of the possible treatments. And that information should be given directly to the physician in the form of the results of clinical trials, not in the form of slick presentations delivered in the context of work-vacations at expensive resorts. The cost of disseminating objective information is relatively low, whereas the cost of trying to persuade a physician to prescribe product A rather than the almost-identical product B is much higher. 

One way to bring medical costs down is to make advertising of medical products illegal, as it is in some countries that have lower costs for pharmaceuticals and hands-on medical care. Another way is to have government-imposed limits on the amount of profit a company can make on a product, as is also the case in some countries that have reasonable consumer-costs for health-related products. A third way is to have a government-run insurance plan that negotiates prices with pharmaceutical companies and imposes a cap on how much a pharmaceutical company can receive for its products. There is no need for a government-run plan to be managed by the central government. In Canada each province has its own plan, and no two provinces have exactly the same setup.

Health care is far too important to be left to the vagaries of markets in a for-profit corporate scheme. The good health of the entire citizenry is far more important than the bank accounts of capitalist shareholders. There are plenty of other markets in which investors can make or lose their money. Pharmaceutical companies, manufacturers of medical devices, clinics, hospitals and retirement homes for the elderly should not be in the private investment sector of the economy. (Neither should correctional facilities, but that is a matter for another day.)

Americans desiring affordable health insurance should first advocate for more affordable treatments, and that is best achieved by a not-for-profit health-care system. They should be asking for, in fact demanding, more government involvement and less private-sector investment in products designed for health. Such a change in outlook would, however, require that Americans first seek a cure for their addiction to free-market capitalism and the delusion that the best way to keep costs down is to let the market determine prices. That strategy has been tried again and again, and it has failed again and again. It is time for Americans to considered an alternative system (not to be confused with “alternative facts”).

Next time you see a television commercial for an expensive treatment that you have seen a hundred times before, instead of simply reaching for the mute button on the remote control, ask your doctor whether socialized medicine is right for you. If you doctor says No, then consider seeking a second opinion. 

Thursday, January 19, 2017

Eve of Destruction

Yeah, my blood’s so mad, feels like coagulatin‘,
I’m sittin’ here, just contemplatin‘,
I can’t twist the truth, it knows no regulation,
Handful of Senators don’t pass legislation,
And marches alone can’t bring integration,
When human respect is disintegratin’,
This whole crazy world is just too frustratin’,
And you tell me over and over and over again my friend,
Ah, you don’t believe we’re on the eve of destruction.
   —P. F. Sloan. “Eve of Destruction” (1964)

On Tuesday, November 6, 1860, Abraham Lincoln became the first Republican to be elected President of the United States. His running mate was Senator Hannibal Hamlin of Maine, an active opponent of slavery who had begun his political life as a Democrat but switched to the Republican Party in 1856, convinced that party was more in line with his staunch anti-slavery views.

Reaction to the election of Lincoln and Hamlin was swift. On Thursday, December 20, 1860, the State of South Carolina seceded from the union. A document entitled South Carolina Declaration of Causes of Secession began with this paragraph:

The People of the State of South Carolina, in Convention assembled, on the 26th day of April, A.D. 1852, declared that the frequent violations of the Constitution of the United States, by the Federal Government, and its encroachments upon the reserved rights of the States, fully justified this State in then withdrawing from the Federal Union; but in deference to the opinions and wishes of the other slaveholding States, she forbore at that time to exercise this right. Since that time, these encroachments have continued to increase, and further forbearance ceases to be a virtue.

Among the specific articles of the Constitution of the United States that the Convention of South Carolina stated was Article 4, Clause 3:

No person held to service or labor in one State, under the laws thereof, escaping into another, shall, in consequence of any law or regulation therein, be discharged from such service or labor, but shall be delivered up, on claim of the party to whom such service or labor may be due.

One of the stated causes for South Carolina’s leaving the union was that there were Northern states that were not honoring this clause but were harboring fugitive slaves. The constitutional obligation of states to return fugitive slaves to their rightful owners was, the document goes on to say, “so material to the compact, that without it that compact would not have been made.” The States that allowed slavery would never have agreed to sign the Constitution of the United States or to be part of the Union unless their rights to own slaves, and to have that ownership honored by all the other States, was ensured.

The document drawn up by the Convention of South Carolina served as a model for similar documents in other slaveholding states. By the time Abraham Lincoln and Hannibal Hamlin were sworn into office on March 4, 1861, six more states (Mississippi, Florida, Alabama, Georgia, Louisiana and Texas) had already declared themselves to be sovereign nations no longer part of the United States of America. During the first four months of Lincoln’s presidency, four more states (Arkansas, North Carolina, Virginia and Tennessee) seceded from the Union. When the Lincoln-Hamlin ticket was elected in November 1860, there were thirty-three states. By the time they had been in office for ninety-five days, eleven states had declared independence from the United States, and one state (Kansas) had been added. Elected to be President of thirty-three United States, by June 1861 Lincoln was President of twenty-three United States, a nation that had been at war with the Confederate States of America since April 12, 1861. By the time the war—generally called “The War of the Rebellion” in the United States and “The War for Southern Independence” in the Confederate States of America—came to an end, there were an estimated 750,000 American military deaths (in contrast to 405,399 in World War I; 116,516 in World War II; and 58,209 in the war in Vietnam), or nearly 2.4% of the total American population at that time. About a month before the war was declared fully ended in May 1865, President Lincoln had been assassinated and succeeded by his second Vice President, Andrew Johnson, formerly a Democrat from the State of Tennessee, who had run with Lincoln in 1864 on the National Union ticket. President Johnson favored a quick restoration to the Union of all the states that had seceded, but his plans made no provision for the protection of former slaves. The failure to provide this protection enraged the Congress, dominated by Republicans, and the House of Representatives impeached him. The Senate, however, voted by a margin of a single vote to acquit him, allowing him to finish his single term as seventeenth President of the United States.

Although the thirty-six states—West Virginia had been admitted to the Union in 1863 and Nevada in 1864—of the United States were officially united again, it could be argued that the deep conflicts that had divided them have never been resolved. Nearly every politically charged issue in the politics of the early twenty-first century has some dimension of the unresolved controversy of whether there should be national policy or fifty different state policies. Should there be a national Environmental Protection Agency, or should each state have its own policies, or lack thereof, on protecting the environment from human enterprises? Should there be a national Department of Education, or should each state fund its own schools, set its own curriculum, and have its own criteria of whether the educational system is meeting its goals? Should there be a national Bureau of Land Management, or should each state determine how the lands within its borders are used and by whom? Should it be decided by the Supreme Court of the United States that all women in the nation have access to birth control and abortion, or should each state have its own policies? Should there be a national policy on who can have access to which kinds of firearms, or should each state be left to decide its own policies? Should there be a national schedule of which substances people can use for medicinal or recreational purposes, or should each state have its own food and drug policies? Generally speaking, should the central government be subordinate to regional governments, or vice versa? These issues were hotly debated as the United States Constitution was being drawn up, they came to a boiling point during the American Civil War, and they have been simmering ever since. Ever since the Constitution of the United States was written in 1787, there have been heated disputes about the balance of jurisdictions between the central government and state governments, and in many states disputes about the balance of jurisdictions between state and county and municipal governments.

One could be forgiven for thinking that 230 years of failure to arrive at a smoothly working federalism—that is, a mixture of central and regional governments—may stem from the fact that the very idea of federalism is fundamentally flawed. Two possible remedies to this failure are both such a radical departure from what has been in place for twenty-three decades that neither is likely to be adopted, for either one would mean an end to the States of America that are United in name only. One remedy would be to abolish the states altogether and simply have a national government with a unicameral legislature, a single House of Representatives with no Senate (and no electoral college). The other remedy would be to abolish the central government altogether and to have a number of sovereign nations—ideally, far fewer than fifty, since many of the current states have arbitrary borders that were drawn with a straightedge and a compass in Washington, D.C. without any regard to the geographical, economic and cultural integrity of the regions enclosed in those borders.

I personally would be more inclined to favor the first of those two radical solutions; indeed, I would be in favor of abolishing every sovereign nation and replacing them all with a single planetary government with jurisdiction over the entire planet Earth. I do not expect to live long enough to see that solution put into place. It seems more likely that I may live long enough to see at least the beginnings of the opposite radical solution, a dramatically weakened central government with correspondingly strengthened state governments, the result being a very weak union of nearly sovereign states held together only by the glue of the vested interests of major corporations that have no regard for anything but material profits and the foolish pride and dangerous over-confidence of a delusional figurehead with autocratic pretensions.