Category Archives: Public Policy and Governance

The Public Good

Americans need to reclaim the concept of the public good, and nowhere is that more important than in health policy.

Law Professor Fran Quigley has a new book coming out that examines the interface–or more accurately, the lack of an interface–between Big Pharma, Congress and the common good. Quartz recently published a review of the book, and began by referring to the infamous “Pharma Bro,” Martin Shkreli, who purchased a life-saving drug that had been on the market for some time, and jacked up the price astronomically–because he could.

Shkreli is not an outlier, according to Indiana University law professor Fran Quigley’s new book Prescription for the People. The pharmaceutical industry jacks up prices on life-saving drugs to extort windfall profits from desperate patients as a matter of course. That’s an immoral way to treat medicine, Quigley argues. The solution? Stop treating medicine as private property—and start treating it as a public good, like education or infrastructure.

It’s one thing to allow private companies and markets to set prices for items like big-screen TVs or cars, Quigley explains via email. In those cases, “purchasers can compare prices and walk away from the transaction if they wish.” But a patient with cancer or a child diagnosed with Type II diabetes can’t just walk away. “That kind of choice is not present when the good in question is life-or-death and there are no options for comparison shopping,” he writes.

 One of the great virtues of Quigley’s book is its explanation of the major role government plays in drug research. Big Pharma has long justified high prices by citing the costs of R & D; as Quigley points out, much of that research is funded with our tax dollars–but drug companies, not taxpayers, enjoy the return on that investment.

Furthermore, drug companies don’t actually funnel the bulk of their profits into research and development. Case in point: Reuters has reported that Pfizer made $45.7 billion in revenue in 2014, of which it spent $14.1 billion on sales and marketing and $8.4 billion on research.

The book details the various ways in which drug companies’ concern for the bottom line takes precedence over concern for the public’s health, and it goes into considerable detail about the perverse public policies that have facilitated those companies’ profitability.

The genesis of those favorable policies? Follow the money.

How did we get to this point? “In the last 40 years, the pharmaceutical industry has deployed billions of dollars of lobbying and political campaign contributions” to change laws to their benefit, Quigley says. One of their most remarkable successes was the 1980 Bayh-Dole Act, which allowed corporations to patent publicly-funded research. This means that pharmaceutical corporations essentially receive monopolies to sell government-created products, “truly one of the most bullet-proof business models in modern history,” Quigley says.

Quigley also takes aim at current patent practices.

The US should even consider ending medicine patents altogether, Quigley argues. “The patent system fails miserably in making medicines available to those who need them,” he says. Studies show that 70% of newly marketed drugs make no therapeutic advances on existing medicines; they are “me-too” drugs that try to carve out a portion of already existing markets for things like cholesterol medication, without bringing any improvements to the table. Furthermore, patents prevent competitors from building on previous research. Expanding grants for patent-free, open-source research would focus medical research on innovation, and make research findings available to everyone immediately, Quigley argues.

Quigley is not the only observer who faults the current patent system; economist Dean Baker goes considerably farther:

Are corporate patent and copyright monopolies a form of government-licensed private taxation? Dean Baker of CEPR thinks so: “Government-granted patent and copyright monopolies are actually much more important in determining future flows of income than debt. In the case of prescription drugs alone, patent and related protections raise the price of drugs by close to $370 billion a year over the free market price, a bit less than 2.0 percent of GDP. This is considerably larger than the current interest burden of the debt, which is approximately 1.6 percent of GDP, net of money refunded from the Federal Reserve Board to the Treasury. These monopolies are effectively like privately collected taxes.”

The book is Prescription for the People.

I know Fran Quigley, I know both his passion and his meticulous attention to fact and evidence. He’s a clear writer and a clear thinker. You should buy the book.

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Trump, Moore And The “Grand Old Party”

Yesterday’s post dealt with Roy Moore’s decisive, ten-point victory over Luther Strange in this week’s Alabama GOP primary. Moore won although Strange had the (mostly) full-throated support of Donald Trump.

Moore’s win suggests that– although Trump’s election may have “unleashed” the party’s rabid base– “the Donald” cannot control it.

The GOP’s Congressional leadership is similarly unable to control the members of what has been called the “lunatic caucus”–Representatives sent to Washington from deep-red gerrymandered districts controlled by that same base.

It’s hard for many of us to wrap our heads around the reality of today’s Republican Party. For those of us who once worked for a very different GOP, the current iteration is nothing short of tragic. All political parties have their fringe crazies–the Democrats are certainly not immune–but in the GOP, the crazies have taken control; sane, moderate, fiscally prudent and socially tolerant Republicans have retreated or departed– or been ejected to taunts of “RINO.”

The number of American voters who identify as Republicans has diminished–in 2016, Gallup put it at 26%– but most of those who remain are dramatically different from even their most conservative antecedents. To the extent they have actual policy preferences, rather than the free-floating animus and overt racism that found its champion in Trump, those preferences are represented by Moore and his ilk.

Roy Moore embodies what the majority of today’s GOP–its most reliable voters, its “base”–support. And that reality is absolutely terrifying, not just because our democratic system requires two sane, adult parties in order to function, but because Moore’s beliefs aren’t just the ravings of a lunatic (although they certainly are that), they’re incompatible with every principle of the American Constitution and legal system.

Think I’m exaggerating?

Before the primary election, The Daily Beast dug out statements Moore has made over the years. During a speech he gave to a fundamentalist Christian political organization, Operation Save America, he said

“I’m sorry but this country was not founded on Muhammad. It was not founded on Buddha. It was not founded on secular humanism. It was founded on God,” he said according to reports by AL.com.

He has frequently charged that Islam is a “false religion” that goes “against the American way of life.”

“[Islam is] a faith that conflicts with the First Amendment of the Constitution,” Moore said during a 2007 radio interview with Michelangelo Signorile, “The Constitution and Declaration of Independence has a direct reference to the Holy Scriptures.”

His homophobia is notorious. In a custody decision, he wrote that homosexuality is  “an inherent evil against which children must be protected.”

CNN also uncovered a 2005 interview between Moore and Bill Press during C-SPAN2’s After Words where he compared homosexuality to bestiality.

“Just because it’s done behind closed doors, it can still be prohibited by state law. Do you know that bestiality, the relationship between man and beast is prohibited in every state?” Moore told Press. When asked if Moore was comparing homosexuality to bestiality, he replied, “It’s the same thing.”

Moore rejects evolution. He attributes the 9/11 attacks to “God’s retribution” for our national “immorality,” and insists (against all historical evidence and the text of the Constitution) that the Founders established America as a “Christian Nation.”

These and similar sentiments–including a deep commitment to White Supremacy– are the banners under which today’s Republicans march. The GOP is now the party of Donald Trump and Roy Moore and Mike Pence–proud racists dismissive of history, ignorant of science and political philosophy, disinterested in actual governance, and obsessed with their own self-importance.

This is what is left of a once Grand Old Party.

Abraham Lincoln weeps.

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What’s It All About? Chuck Grassley (And Juanita Jean) Explain…

I’ve had several conversations during the past few days that have been depressingly similar: the topic of the GOP’s latest effort to repeal Obamacare comes up, and the person with whom I’m talking says something like “I don’t get it. They know this bill would be a death sentence for thousands of Americans. Polls show that its unbelievably unpopular–even most Republicans don’t support it. Why are they so hell-bent on passing it?”

To which I have had no answer, because I’m equally baffled. Or I was, until Juanita Jean shared Chuck Grassley’s explanation.

Grassley supports the Graham-Cassidy bill and, bless his heart, took to the airwaves to explain why.

“You know, I could maybe give you 10 reasons why this bill shouldn’t be considered,” Grassley said. “But Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.”

Translation: sure, this bill is terrible policy. It won’t help anyone–it will raise premiums for people who are still able to get insurance; it will make it impossible for millions of others to get insurance; it will redistribute federal funds from blue states that expanded Medicaid to red states that refused to do so; and it will allow the states to decide whether insurers can once again refuse you based upon pre-existing conditions. (It will also play havoc with a sixth of the American economy, which is probably why every national healthcare organization opposes it.)

But we promised our rabid base!

Grassley does identify one aspect of this appalling bill that he likes–it allows the states to “tailor” healthcare to the specific needs of their citizens.

Allowing states to shape health care benefits and regulations to match their populations will better account for the geographic and economic diversity of the country.

“What might fit Massachusetts and New York and Maryland doesn’t fit Iowa very well,” Grassley said.

Juanita’s response to that is too good to paraphrase:

You know, because somebody living in Georgia ain’t at all like somebody living in Alabama.  Hell, they don’t even root for the same college football teams so how the dickens do you expect them to have the same health care needs?  Little known fact: cancer does not kill you in Nebraska. I mean, you have to call into work sick for a couple of days, drink some apple cider vinegar, and you’re new and fit by Friday. However, hangnails will land your butt in intensive care in South Dakota.

With her usual laser-like precision, Juanita Jean honed in on the real issue–that black President who had the unmitigated gall to expand access to healthcare!

I have an idea. Let’s repeal the word “Obamacare” and replace it with the words “Affordable Care Act.” Don’t change anything else – just that. Everybody happy now?

During a recent discussion about the human and economic damage passage of the Graham-Cassidy Bill would cause, one of my sons asked a pertinent question: “How do these people sleep at night?”

That’s a question I still can’t answer.

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YES!

Richard Cohen recently had an opinion piece in the Washington Post addressing the undeniable fact that Americans increasingly occupy information “bubbles”–and that we rarely, if ever, intersect with the very different bubbles occupied by others.

He began by describing his long-ago relationship with someone named Charlie. He and Charlie came from very different backgrounds and had very different beliefs; their close friendship was an artifact of the draft–they served together in the Army.

Cohen said he thought about that experience and that friendship when he watched people rescue others from the devastation in Houston.

The storm, the flooding — the utter disaster — gave people a common problem and a common goal. It also reduced them to common socioeconomic status. After a while, people in trouble all look the same — wet, dirty, tired, often dazed. The storm throws them together and reduces them to the essential: people needing help, people looking to help. People. That’s it. People.

The army had done much the same leveling of differences:

We all had the same goal, which was to get through training. We all dressed alike, ate the same food, showered together and, over time, became a single unit. I mostly hated the Army, but I mostly loved those guys.

Today’s volunteer army doesn’t provide the same experience, and Cohen is realist enough to concede that there is little likelihood of reinstating the draft. (As he puts it, a generation of gluten-avoiders is not going to happily share a latrine with strangers.) Draft or no draft, however, America needs a mechanism that requires dissimilar people to interact, to actually get to know each other.

 But maybe some sort of national service would work — something lasting a year or so. Other nations do that — and they’re not the goose-stepping ones, either. Denmark, Sweden, Austria and Norway have versions of compulsory service….

We need a national service that throws us all together, the urban with the rural, the Fox News types with the MSNBC crowd. That way, Americans can get to know Americans and learn — as previous generations did — that we are all Americans. A common plight and a common goal is how Houstonians got to know Houstonians. A different plight and a different goal is how I got to know Charlie.

A couple of years ago, I worked with one of my graduate students on just such a proposal–pie in the sky as it was–a new G.I. Bill focused upon producing engaged and informed citizens through civilian service. As we argued, there are many ways in which a national program might incentivize the acquisition of civic literacy and change the civic culture.

We proposed a voluntary National Public Service program for high school graduates who would be paid minimum wage during a one year tour of duty. At the end of that year, assuming satisfaction of the requirements, the students would receive stipends sufficient to pay tuition, room and board for two years at a public college or trade school. The public service requirement would be satisfied through employment with a government agency or not-for-profit organization (like public schools or Goodwill Industries); in addition, students would be required to attend and pass a civics course to be developed by the U.S. Department of Education in conjunction with the Campaign for the Civic Mission of the Schools, thus linking service with civic knowledge.

We noted that the groundwork for such a program is already in place through existing programs like AmeriCorps that are in high demand, but limited by funding.

What sorts of outcomes might we expect? Since such a program is likely to be most attractive to those struggling to afford higher education, we could expect broader participation from those whose voices are largely missing from today’s civic conversation. A better-educated population should engage in better, more nuanced policy debates, leading (hopefully) to more thoughtful policy choices. Ultimately, we might even see more meaningful and issue-oriented political campaigns, with less of the intemperate rhetoric that characterizes messages crafted to appeal to uninformed voters.

As an added benefit, a program of this sort would also have an enormous and salutary impact on the level of student debt–currently a huge drag on economic growth.

At a minimum, national service should burst some very stubborn bubbles. At best, it would connect participants to the multi-colored, multi-ethnic, multi-everything fabric that is the strength and glory of the real America.

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Sand In The Gears

The Census is among the multiple, pedestrian duties of the federal government. It is also among the multitude of duties that the Trump Administration is sabotaging, either through incompetence or malice.

Why should we care?

A recent report from the Brookings Institution spells out the uses to which an accurate census is key. As the article notes,

Congress and now the Trump administration have set the 2020 decennial on a course that threatens its basic accuracy. In so doing, they put at risk the integrity and effectiveness of some of the national government’s basic missions.

We rely on the accuracy of the census for both democratic and fiscal decisions: the census  determines how the 435 members of the House of Representatives are allocated among the states, and how members of state legislatures and many city councils are allocated in those jurisdictions.

Consider as well that every year, the federal government distributes about $600 billion in funds to state and local governments for education, Medicaid and other health programs, highways, housing, law enforcement and much more. To do so, the government uses formulas with terms for each area’s level of education, income or poverty rate, racial and family composition, and more. The decennial Census provides the baseline for those distributions by counting the people with each of those characteristics in each state and Census block.

It isn’t only government that relies on the data provided by the census. Businesses– retailers,  commercial real estate developers, banks and many others– use census data to determine  the demographics and locations of potential customers and to inform their planning and investments.

In some cases, the data actually make their projects possible, for example, when an investment qualifies for special tax treatment if it occurs in places with certain concentrations of low or moderate-income households.

Even worse, Trump has demanded that the 2020 Census add questions about the respondent’s citizenship and immigration status. Adding such questions would violate current laws protecting the privacy of the respondents, and would add immensely to the  fear that already prevents many members of immigrant groups from participating in the count. When such groups are undercounted, states, cities and towns with substantial populations of Hispanics and other immigrants are underfunded.

These and other significant, negative consequences of a mismanaged census evidently don’t worry our uninformed and clueless-about-government President. The Trump administration  cut Obama’s 2017 budget request for the Census Bureau by 10 percent and then, this past April, flat-lined the funding for 2018.

It is no coincidence that the Director of the Census Bureau, John Thompson, resigned in May, effective in June. It’s a serious loss, since Dr. Thompson directed the 2000 decennial count and is probably the most able person available to contain the coming damage to the 2020 count. For its part, the administration hasn’t even identified, much less nominated, his successor. It is no surprise that the Government Accountability Office recently designated the 2020 Census as one of a handful of federal programs at “High Risk” of failure.

The Trump Administration: throwing sand in the gears of effective government one agency at a time….

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