Wednesday, November 07, 2018

Pharmaceutical and Other Health Care Corporations Funnel Dark Money to Republicans to Defeat "Leftward" Democratic Candidates - Partisanship Trumps Social Responsibility

Introduction - Health Care Corporations Profess Social Responsibility

As we noted recently, large health corporations, which must deal with patients, health professionals, and government regulators, usually profess their social resonsibility.  For example,

Biotechnology firm Genentech, now a subsidiary of giant Swiss biotechnology and pharmaceutical company Roche, has an elaborate web page about how the company seeks to do good.  Some quotes:

we’re passionate about applying our skills, time and resources to positively impact the patients we serve, the scientific community and the places where we live and work.


We approach giving back the same way we approach discovering medicines: we start by looking for the root cause of a problem and then we explore how we can contribute to a solution.

And particularly

We believe that the best work happens when everyone has a voice.

Similarly, giant American pharmaceutical company Eli Lilly espouses these core values

Three long established core values guide Lilly in all that we do:

Integrity: We conduct our business consistent with all applicable laws and are honest in our dealings with customers, employees, shareholders, partners, suppliers, competitors and the community.

Excellence: We pursue pharmaceutical innovation, provide high quality products and strive to deliver superior business results.

Respect for People: We maintain an environment built on mutual respect, openness and individual integrity. Respect for people includes our concern for all people who touch or are touched by our company: customers, employees, shareholders, partners, suppliers and communities.

Of course, in the policy arena, large health care corporations also tend to advocate for policies that are to their financial advantage.  Furthermore, top executives of large corporations have been known to donate to political candidates who favor their policy positions, although they used to consciously spread their donations out to all parties and many candidates to avoid any appearance of partisanship, while making themselves visible to whomever might be in power.

However, as the current US political chaos leads to more journalistic investigation, there is increasing evidence that large health care corporations have been secretly backing policy positions that do not correspond to their high-minded public statements about corporate social resonsibility, and are becoming quite political, even partisan in the process.  They do so through the use of dark money

Pharmaceutical Companies, Other Health Care Companies - and a Tobacco Company - Join Effort to Attack Left-Wing Politicians

On November 5, 2018, Lee Fang wrote about how big corporations, including big health care corporations, enthusiastically financially supported a dark money operation that specifically targeted "progressive" or "socialist" candidates:

Republican operatives and representatives from America’s largest business groups — alarmed at a wave of upset electoral victories by Alexandria Ocasio-Cortez and other avowed democratic socialist candidates — have been plotting to stem the tide of left-wing Democrats sweeping the country.

Andrew Wynne, an official at the Republican State Leadership Committee, spoke to business lobby leaders in July, encouraging them not to ignore the latest trends within the Democratic Party. He called for Republicans’ allies to enact a unified plan to defeat progressives in this week’s midterm elections.

'Recent elections have proven the leftward shift,' said Wynne. 'An anti-free market, anti-business ideology has taken over the Democratic Party, particularly this year during the primaries.'

Wynne was particularly exercised about the primary victory by Democrat Alexandia Ocasio-Cortez:

'Alexandria Ocasio-Cortez captured the energy of these voters to win a congressional nomination in New York, defeating the incumbent who many thought could be the next Democratic speaker of the House,' Wynne continued.

He noted that the defeated incumbent in the Ocasio-Cortez race, Rep. Joe Crowley, a moderate Democrat and former chair of the business-friendly New Democrat Coalition, 'was someone who the business community could have a conversation with on the Democratic side.' On the other hand, Wynne warned, Ocasio-Cortez would not be so receptive to business lobbyists.

Of course, these sentiments coming from a Republican operative are not surprising.  What was surprising was how Mr Wynne wanted to fund efforts to comabt these supposedly left-wing politicians.

Officials from the Republican State Leadership Committee, which assists Republicans in capturing power on the state level, explained during the call that they expected to raise $45 million in direct contributions and $5 million to $7 million through an allied dark money group for election campaigns this fall.

The group is organized under the IRS’s 527 rules and operates in a manner similar to Super PACs: It can raise and spend unlimited amounts from individuals and corporations. The latest disclosures suggest the group is well on track to bring in significant corporate support for electing Republican state officials.

Koch Industries, Crown Cork & Seal, Genentech Inc., ExxonMobil, NextEra Energy, Range Resources, Eli Lilly and Co., Marathon Petroleum, Reynolds American, (a tobacco company which is a subsidiary of British American Tobacco), Boeing, General Motors, and Astellas Pharma are among the companies that have already provided at least $100,000 to the committee.

Many of those companies are from industries that have long contributed to GOP causes, including resource extraction, financial services, tobacco, retail, for-profit education firms, and private health care interests.

Furthermore, the Republican State Leadership Committee has been collecting money from other dark money organizations which in turn are funded in part by health care companies:

Several of the largest donors to the Republican State Leadership Committee are themselves dark money groups. The Judicial Crisis Network, a 501(c) nonprofit that does not disclose its donors, has given $1.5 million to the group. The ABC Free Enterprise Fund, a dark money affiliate of a lobbying group that represents non-union construction companies, gave $100,000.

The U.S. Chamber of Commerce has given $1.7 million to the committee. The chamber, notably, does not disclose its donors but has been financed in the past by Goldman Sachs and Dow Chemical, among other major American and foreign companies.

We recently discussed the health care industry contributions to the US Chamber of Commerce, which came from PhRMA, Pharmaceutical Research and Manufacturers of America, the pharma trade association, and from specific companies, including contributions of at least $100K from: Aetna, Abbott Laboratories, AbbeVie, Amgen, Anthem, Celgene, Cigna, CVS, Eli Lilly, Express Scripts, Johnson & Johnson, Merck, Mylan, Procter & Gamble, and UnitedHealth.

So a lot of big health care companies, most of whom profess their devotion to the greater community and social responsibility, have been funneling considerable money as quietly as possible into an effort to thwart one particular group of politicians, that is, candidates from the leftish wing of the Democratic party.

So much for Genetech's claim:

We believe that the best work happens when everyone has a voice.

Or for Lilly's claim:

Respect for people includes our concern for all people who touch or are touched by our company: customers, employees, shareholders, partners, suppliers and communities.
Discussion and Summary

This is now the fifth time we have discussed the role of dark money in health care.

- In 2012 we discussed a case of "dark money" being used to conceal sources of support for particular health policy and political positions.

- Earlier this year,  we discussed the case of huge pharmacy chain CVS,which proclaims its "social responsibility," and its policy of only making charitable contributions to improve "health and healthcare nationwide."  Yet CVS was donating to America First Policies, a supposed non-profit group devoted to promoting the partisan agenda of President Trump, including "repealing and replacing Obamacare," and immigration policies such as building the "wall" and deporting  "illegal immigrants." (Note that these CVS dark money contributions were separate from those discussed above.)

- In September, we discussed how the pharmaceutical trade organization, PhRMA, and some large drug companies donated money to a dark money organization to combat a state initiative to limit pharmaceutical prices, but also to the American Action Network (see above) to "repeal and replace" the Affordable Care Act (ACA, "Obamacare") despite their previous support for and then current neutrality on the ACA.

- In October, we discussed how many health care corporations were donating to dark money groups, predominantly groups, like the US Chamber of Commerce, devoted to distinctly right-wing causes, almost all lately related to the Republican party and in sympathy with the Donald Trump regime.

Health care corporations recent and current funding of dark money groups seems to openly conflict with the corporations' promises of social responsibility.  The slanting of these efforts towards one end of the political spectrum, one party, and now the current president suggest that these corporations may have partisan agendas.

Note that without the various ongoing investigative efforts mainly inspired by the actions of the Trump administration, we would have little idea that this was going on.

May such investigations continue and intensify.  Maybe the recent elections, which gave the opposition to the Republican party and Trump control of the US House of Representatives, will lead to more such investigations.

Furthermore, the increasing knowledge of these corporate actions raises a big question: cui bono? who benefits?

It is obvious why a pharmaceutical company, for example, might want to defeat legislation that would lower its prices.

It is not obvious why it would want to consistenly support actions by one party, or by people at one end of the political spectrum, even if some such people seem "anti-business."  After all, for years big corporations and their executives openly gave money to both US parties and their candidates, apparently in the belief that this would at least allow more visibility for the corporations' priorities no matter who was in power.

Now, the most obvious theory is that the new practice of secret donations only in right-wing, Republican, and/or pro-Trump directions, which must be orchestrated by top corporate management, and which are not disclosed to employees or smaller corporate shareholders, are likely made to support the top managers' self interest more than the broad priorities of the corporations and their various constitutencies.

Thus not only is more investigation needed, at the very least, "public" corporations ought to fully disclose all donations made to outside groups with political agendas.  This should be demanded by at least the corporations' employees and shareholders, but also by patients, health care professionals, and the public at large.

Meanwhile we are left with the suspicion that top health care corporate management is increasingly merging with the current administration in one giant corporatist entity which is not in the interests of health care, much less government by the people, of the people, and for the people.

Friday, November 02, 2018

Nonsense-Based Health Care - in the Service of Political Ideology and Sectarian Beliefs

As an advocate for evidence-based medicine, I am used to disagreeing with officials at US government health agencies on the finer points of evidence and its interpretation.  However, it's 2018, and things are very different.  Now the current regime, and those who back it, have produced a rising tide of outright nonsensical assertions about medicine and health care used seemingly in service of  ideological or sectarian gain.

So let me list some cases, starting with the most recent, and working backwards in time.

Fox News Pundit Said Asylum Seekers Are Infected with Smallpox

This week, as discussed on Vox was:

the statement on Fox News — by an ex-ICE agent — that the migrant caravan of 4,000 men, women, and children mainly from Central America is going to bring smallpox to America.

'They are coming in with diseases such as smallpox, leprosy, and TB that are going to infect our people in the United States,' the former agent, David Ward, said this week.

This is just ridiculous nonsense.  As the Vox article stated,

There is no smallpox in circulation anymore. That’s been true since 1980, when a major global vaccine effort wiped the virus from the planet.


The risk of leprosy — now called Hansen’s disease — being imported from Latin America is similarly remote. And while some foreign-born people do have higher rates of TB, the Centers for Disease Control and Prevention (CDC) screens for TB in people moving to the US.

In case anyone is not convinced, see the CDC page on smallpox (which so far has escaped rewriting by any political appointees, apparently.)

Why would Fox News put this silliness on the air?  The Vox article suggested:

This particular kind of xenophobic fear-mongering, which Donald Trump spread as a presidential candidate, is now surfacing again as we approach the midterms, in an apparent ploy to rile up the conservative base.
So this is medical and epidemiological nonsense purely in service of short-term political gain.

Department of Health and Human Services (DHHS) Suggests Erasing Gender Dysphoria and Denying the Existence of Intersex and Ambiguous Genitalia

In October, 2018, per the New York Times,

The Trump administration is considering narrowly defining gender as a biological, immutable condition determined by genitalia at birth,

In particular, the Department of Health and Human Services (DHHS),

argued in its memo that key government agencies needed to adopt an explicit and uniform definition of gender as determined 'on a biological basis that is clear, grounded in science, objective and administrable.' The agency’s proposed definition would define sex as either male or female, unchangeable, and determined by the genitals that a person is born with, according to a draft reviewed by The Times. Any dispute about one’s sex would have to be clarified using genetic testing.

'Sex means a person’s status as male or female based on immutable biological traits identifiable by or before birth,' the department proposed in the memo, which was drafted and has been circulating since last spring. 'The sex listed on a person’s birth certificate, as originally issued, shall constitute definitive proof of a person’s sex unless rebutted by reliable genetic evidence.'

If carried out, this policy, again coming from the lead US government health care and public health agency, would deny the existence of gender dysphoria.  Per the Washington Post,

In 2013, the American Psychiatric Association’s diagnostic bible adopted 'gender dysphoria' to describe the symptoms and distress experienced by transgender people, eliminating the older designation of 'gender identity disorder.' This change in the Diagnostic and Statistical Manual marked a turning point in the treatment of people who felt they were in the wrong body, and a growing recognition that such feelings were not a mental illness.

The discussion of gender dysphoria on the APA website is here.

There are two other big problems with the proposed DHHS definition of gender.  First, it seems to deny the existence of intersex disorders.  These are defined (via Medline) as

a group of conditions where there is a discrepancy between the external genitals and the internal genitals (the testes and ovaries).

These include four categories:
46, XX intersex
46, XY intersex
True gonadal intersex
Complex or undetermined intersex
Second, the DHHS proposed policy seems to deny that fact that some babies are born with ambiguous genitalia.  The Mayo Clinic summary of this condition states,

Ambiguous genitalia is a rare condition in which an infant's external genitals don't appear to be clearly either male or female. In a baby with ambiguous genitalia, the genitals may be incompletely developed or the baby may have characteristics of both sexes. The external sex organs may not match the internal sex organs or genetic sex.

Ambiguous genitalia isn't a disease, it's a disorder of sex development. Usually, ambiguous genitalia is obvious at or shortly after birth, and it can be very distressing for families.

Although these conditions in toto are not common, they are not rare. I would assume the pseudo-experts in charge of the DHHS policy actually know nothing about the biology of sex and gender. But their idea of dichotomizing a person into male or female based on genitalia which may appear ambiguous, or may not correspond to either the person's chromosonal make-up, internal anatomy, or endocrine environment does not make any sense.

As an aside, the WaPo article noted,

At HHS, the issue is being driven by Roger Severino, the agency’s director of civil rights, who has long been critical of the Obama administration’s expansion of transgender rights.

The NY Times article noted that

Mr. Severino, while serving as the head of the DeVos Center for Religion and Civil Society at the Heritage Foundation, was among the conservatives who blanched at the Obama administration’s expansion of sex to include gender identity, which he called 'radical gender ideology.'

In a post on people in health care or public health leadership positions in the Trump regime who are without any qualifications in biomedical science, health care, or public health, we noted that Mr Severino is a lawyer without any such qualifications.  We noted then that Mr Severino and one of his colleagues seemed bent on imposing beliefs of one particular religious group on the management of health care and public health for all citizens of the US, regardless of whether they subscribe to such beliefs.

So the definition of gender now being proposed by DHHS staff seems designed to further a particular set of religious beliefs about gender, but without any consideration of the relevant medical science, or of the interests of people who do not share those religious beliefs.

US District Cout Nominee Said Contraception Causes Cancer and Violent Deaths

In April, NPR reported on a US Senate confirmation hearing for Wendy Vitter, nominated by Trump for a US District Court seat,

Vitter sought to distance herself from a brochure she had appeared to endorse while leading a panel at a pro-life conference in 2013. The panel was called 'Abortion Hurts Women,' and the brochure promoted a variety of unsubstantiated claims linking birth control pills to breast cancer, cervical and liver cancers, and 'violent death.'

On this last point — violent death — the brochure alleged that women who take oral contraceptives prefer men with similar DNA, and that women in these partnerships have fewer sexual relations, leading to more adultery, and 'understandably ... violence.'

Note that

All of these claims have been debunked by leading medical and scientific organizations, as Democratic Sen. Mazie Hirono of Hawaii observed.

'You urged the audience to distribute the materials making these dangerous claims. ... Do you believe the claims that Dr. Lanfranchi makes that abortion causes breast cancer and that birth control causes women to be assaulted and murdered?' she asked.
The reason that Vitter backed these dubious claims was not clear.  She claimed to be "pro-life," and had worked for the Catholic Church.  One might suspect that she was interested in propagating religious beliefs about birth control, even if doing so could adversely affect the lives of people who did not share such beliefs.

Former Senator, Television Commentator  Suggested CPR as Good Treatment for Catastrophic Bleeding After Gunshot Wound

In March, the Washington Post reported that former Republican Senator Rick Santorum

suggested live on CNN that learning CPR was a better way for young people to take action in response to a mass shooting, rather than protesting gun violence and asking “someone else to solve their problem” by passing a “phony gun law.” The panel on CNN’s 'State of the Union' show was discussing the March for Our Lives, which drew upward of 800,000 people to the Mall on Saturday to demand gun-control legislation.


'How about kids, instead of looking to someone else to solve their problem, do something about maybe taking CPR classes or trying to deal with situations where there is a violent shooter and you can actually respond to that?' Santorum said.

CPR, of course, does not do a lot of good for someone who is rapidly losing his or her blood volume due to a bullet wound.  A number of physicians pointed this out, forcefully,

Heather Sher, a Florida-based radiologist who examined the gunshot wounds of at least one Parkland, Fla., shooting victim on the day of the shooting, called Santorum’s comments 'gobsmackingly uninformed.'

'CPR is not effective with catastrophic bleeding,' she said on Twitter. “Speechless! Learn CPR! Everyone should for cardiopulmonary arrest. But for gunshot wounds, a) attend stop the bleeding course by trauma surgeons or b) pass #gunreform (helpful hint: option b is the better option.)”

Jo Buyske, executive director of the American Board of Surgery, described Santorum’s comments as a 'dangerous and wrong message,' saying on Twitter, 'Mr. Santorum, CPR doesn’t work if all the blood is on the ground.'

And Rebecca Bell, a pediatric critical care doctor at the University of Vermont Medical Center, broke it down in layman’s terms:

'Here are some stats made simple for Rick Santorum,' she said on Twitter. 'Survival rate of pulseless trauma victims who get CPR at the scene: VERY, VERY LOW.'

'Survival rate of people who don’t get shot in the first place: MUCH, MUCH BETTER.'
Presumably Mr Santorum was more interested in promoting his ideological opposition to any further gun regulation than understanding the medical context of his pseudo-clinical comments.  Although it probably would do some general good for society if more people could be trained in CPR, training high school students would likely have zero effect on the outcomes of school shootings.

Republican Majorities in Kansas, Utah, Idaho Legislatures Proclaim that Pornography is a Public Health Hazard

In February, the Topeka (KS) Capital-Journal reported,

The Kansas Senate approved a nonbinding resolution Tuesday declaring proliferation of pornography a public health crisis that normalizes violence against women, corrodes interest in marriage and serves as a gateway to human trafficking.

Also in February, the Washington Post noted that in 2016 the Utah State Senate passsed, at the behest of Republican Sen Todd Weiler, a resolution that

declare[d] pornography 'a public health crisis.' That nonbinding resolution, unanimously passed by both chambers of the state legislature, warned 'this biological addiction leads to increasing themes of risky sexual behaviors, extreme degradation, violence, and child sexual abuse images and child pornography.'

In March, according to the AP, per the Spokane (WA) Spokesman,

A group of Idaho lawmakers on Friday approved a proposal declaring pornography a public health risk.

'Pornography has and does have adverse impacts on all members of society. It leads to the abuse men, women and children, destroys marriages and has impacts on young and old,' said Rep. Lance Clow, a Republican from Twin Falls who is backing the resolution. 'Families are being torn apart by this epidemic.'

The problem is that there is no good evidence that pornography has important negative effects on public health, or is an addictive disorder.  As the WaPo pointed out,

David Ley does not buy it. The Albuquerque-based clinical psychologist and author of 'The Myth of Sexual Addiction' said those who have adopted the public health framing are 'cherry-picking the research.'

He pointed out that the American Psychiatric Association’s diagnosis guide, the Diagnostic and Statistical Manual of Mental Disorders, does not include pornography addiction. And yet Utah, he noted, has numerous porn addiction treatment programs.

In an article in the latest edition of the peer-reviewed journal 'Porn Studies,' Ley argues that people who seek treatment for porn addiction actually view less erotica than average, but guilt associated with religiously based sexual values creates an internal conflict with the pleasure they get from watching it, so “they just feel worse about it.'

Furthermore, the WaPo article also suggested that the notion that pornography is a public health crisis and/or an addictive disorder comes from more religious beliefs rather than evidence about public health.

About 60 percent of Utahns and nearly 90 percent of the state’s lawmakers are members of the Church of Jesus Christ of Latter-day Saints, which has declared 'depiction, in pictures or writing, that is intended to inappropriately arouse sexual feelings' to be 'a tool of the adversary,' the descriptor Mormons often use for Satan.
Again, people are free to have these religious beliefs, but should politicians impose these beliefs on those who do not subscribe to them, in a country which supposedly bars government support of particular religions?  And should they do so at the risk of distracting from real public health problems?


Since 2016, we have seen increasing attempts to distort or ignore medical science, clinical and epidemiological research findings to support the political ideology of the ruling party and the religious beliefs of their extreme fundamentalist supporters.  As we have discussed, most recently here, the Trump regime has seen fit to put ill-informed people in positions of power in health care and public health agencies.  Some of these people have put their political and/or religious agendas ahead of the public's health.  Our examples above show a continuing inclination by the administration, its sympathizers in state governments, and its enablers in the media to distort or ignore science and research again to promote idological or religious beliefs. This promotion is likely to be at the expense of patients and people who do not share these ideological views or religious beliefs. 

These trends endanger the mission of US government health related agencies, and are hostile to the notion that health care and public health should serve all people, regardless of their religious beliefs, race, ethnicity, or sex.

Furthermore, these trends undermine fundamental principles of US government enshrined in the Constitution, including prohibiting the government from establishing a religion or preventing the free expression of any religion, and equal application of the laws and provision of due process to all people, again regardless of their religious beliefs, race, ethnicity or sex. This is obviously hugely dangerous, (and made more so by the regime's and its allies' threats to other core values of US society, to US law, and the US Constitution.)

To prevent the decline and fall of US health care, and maybe the entire US experiment in representative democracy, health care professionals, academics, patients and citizens concerned about health care will have to join up with the larger populace to defend our core values while they still have any force. 

Sunday, October 28, 2018

Issues at the 18th International Anti-Corruption Conference

Many issues brought up at the 18th International Anti-Corruption Conference (IACC) in Copenhagen, Denmark, were relevant to the problems of conflicts of interest, crime and corruption in health care which we often discuss on Health Care Renewal, and hence bear repeating here.

The discussion certainly got at the complexity of fighting corruption, seemingly one of many necessities that has come into light in the new political era.  Unfortunately, while the complexity is fascinating, it suggests this fight will hardly be simple.  Since warnings about corruption go back thousands of year, we already knew it would not be easily, if ever totally won.

Reported in the order they came up at the conference...

Whistle-Blowing Holding Leadership Accountable

At the Opening Ceremony, Lars Lokke Rasumussen, the Prime Minister of Denmark, underlined the importance of journalists and activists holding leadership accountable. Yet the corrupt will tend to defend their interests by attacking such people. (Thus we have noted that corruption in health care, in particular, has long been a taboo topic, the anechoic effect.) Things can get very bad when a country is governed by the corrupt, and worse when these rulers are despotic.

The hazards of being a whistle-blower, activist, and/or journalist holding the powerful accountable were emphasized by Huguette Labelle, Chair, International Anti-Corruption Conference Council, in that same session, who remembered those who have lost their lives for doing so.  Also at that session, Delia Matilde Ferreira Rubio, Transparency International Chair, warned that despots may hijack the narrative, turning watchdogs into their lapdogs, and into attack dogs against their political opponents. On the other hand, watchdogs who refuse to cooperate may be punished or killed.

At the Day 2 Plenary 3 Session on Exposing the Corrupt, Knocking Out Impunity, Barbara Trionfi, Executive Director, International Press Institute, noted that deception, propaganda, and disinformation may be used to mobilize attacks against whistle-blowers and real journalists, perhaps government responses to such attacks might help, at least if the government has not been totally captured.

At the Day 3 workshop on Is the American Anti-Corruption Model Broken, Frank Vogl, Advisory Council Member, Transparency International, noted that there are now daily threats in the US to the free press, while the opposition party is assailed as a “mob.” Moreover, the US government institutions, such as the Department of Justice and the FBI, that often used to protect the free press, among others, from threats of violence, are themselves under constant attack from the top of the administration.

Authoritarian/ Despotic Rulers Hijacking the Anti-Corruption Cause in an Era of Conspicuous Corruption

At the Day 1 Fighting Corruption in“Post-Truth” America workshop, Danielle Brian, Executive Director of the Project for Government Oversight, noted that pre-2016, her organization was mainly concerned with the problem of conflicts of interest created by the revolving door, especially to and from the defense industry and big pharma. Since the election, the administration generated an atmosphere of “conspicuous corruption in which shame does not matter, and in which human rights are now under threat." (See what we recently posted about fighting corruption under a corrupt regime.)

 At the Day 2 Fight Against Corruption as a Threat to Democracy workshop, one participant suggested that fighting corruption at best requires stable, functional specific anti-corruption institutions. While some countries have such institutions at the national level, the US does not. So at the Day 3 workshop on Is the American Model of Anti-Corruption Broken, Harvard Univeristy Professor Matthew Stephenson noted that the current US susceptibility to corruption may be partly due to the country's history of relying on norms rather than laws to address corruption. The Trump administration has set itself up as a norm violator, with so far little pushback.

Furthermore, people subject to corruption may tend to go down extremist pathways, as noted at the "Post-Truth" workshop by Sarah Chayes, former Senior Fellow at the Carnegie Endowment for Peace.  At that workshop, Nora Gilbert, Director of Strategic Projects and Partnerships, Represent.US, asked whether populist anti-corruption rhetoric, e.g., about “unrigging the system,” could be leveraged without going down the authoritarian pathway?  If not,  corruption may generate despotism, which in turn generates more corruption, a positive feedback cycle.

The concern about how emphasis on fighting corruption could have the unintended effect of boosting authoritarian or despotic rulers was the subject of the Fight Against Corruption as a Threat to Democracy workshop. The audience was asked not to attribute quotes to participants, but I noted the following sorts of observations.  The war on corruption can be seen as a war on politicians, parties, and institutions, and so can increase cynicism while risking pulling the whole system down. Even so, since strong supporters of certain politicians tend to disbelieve any negativity about them, including corruption allegations, such a war can leave the most corrupt offenders standing.

Yet corruption is itself a huge threat to a reasonable democratic political system, because it robs people of votes, free speech, and the rule of law. Corrupt politicians do not shrink from protecting themselves by attacking votes, speech, and legal actions that threaten them.

Ideally, it is thus better to tackle moderate corruption early, because a scorched earth attack on severe corruption may be as hazardous as the corruption itself. (Not to toot our own horn, but at Health Care Renewal, we have been trying to challenge health care conflicts of interest, corruption, and crime long before the current unpleasantness.)

Trans-National Kleptocratic Networks

At the Fight Against Corruption as a Threat to Democracy workshop, Sarah Chayes noted that now in the US and many other places, corruption is now systemic, the standard operating system of trans-national kleptocratic networks. At an IACC a decade ago, embedded networks of influence were shown to be vehicles of corruption.  They have apparently gone global. They may use extreme measures to preserve their power. One they have become especially good at is exploiting identity divides.

At the Day 2 Plenary Session, Breaking the Global Corruption Web, Sarah Chayes further discussed how the networks were enabled in an era of predatory capitalism in which everything has its price. The networks' work is facilitated by finance firms, shell corporations, and reputation and money launderers. Rajiv Joshi, Managing Director, the B Team, noted that the Lewis Powell memo of 1972 provided the blueprint, by showing how big US corporations to use their public relations/ propaganda resources to capture the US government.

Claudia Escobar, former Magistrate of the Court of Appeals of Guatemala, stated that the networks intertwine private companies, government, and organized crime. (Note that we have discussed some of the links between organized crime and the current US administration.) The melding of these entities was further emphasized by Monique Villa, Executive Director, Thompson Reuters Foundation, who urged us to always follow the money: asking again and again, cui bono? Who benefits? 

Deception, Propaganda, and Disinformation

Corruption is enabled by deception, propaganda, and disinformation. A participant at the Fight Against Corruption as a Threat to Democracy workshop noted that traditionally democratic systems seem to depend on the idea that lies are easily counteracted. In an era of public relations, propaganda, and disinformation, lies are the currency.

This was underlined by Kumi Naidoo, Secretary-General Designate, Amnesty International, speaking at the Breaking the Global Corruption Web plenary. He accused some parts of the global media, plus social media technology corporations, of complicity with the global kleptocratic network. He suggested that in the US, the in your face corruption of the Trump administration is enabled by the large minority of Americans who only believe what they see on extreme right-wing media and social media.

Yet as Thomas Hughes, Executive Director, Article 19, pointed out in the Day 2 Plenary, Exposing the Corrupt, Knocking Out Impunity, the way to attack deception, propaganda, and disinformation may not be government regulation which risks censorship, especially if the government is corrupt, much less despotic. Will Fitzgibbon, Reporter, International Consortium of Investigatve Journalist, suggested it would be better to form alliances, preferably international, of journalists and whistle-blowers, like the group that published the Panama Papers.


I would submit that the issues brought up at the conference suggested three themes, all disturbing.

Embedded Networks of Influnece Morphed into Global Kleptocratic Networks

First, corruption has become increasingly systemic and global.  The embedded networks of influence, which seemed to be national pheonomena a decade ago, are now global and supercharged, encompassing government, the private sector, and organized crime.  Thus they can be termed global kleptocratic networks.  Here in the US, it is most disturbing that the country seems to be governed by one such network.  Our president and his family continues to run the Trump Organization, a global, albeit mysterious set of businesses which has had documented links to both domestic US and overseas organized crime (look here).

The Positive Feedback Loop Encompassing Corruption and Despotism

As corruption increases, wouldbe and actual despots increase their populist appeal by claiming to be anti-corruption (in the US, we heard "drain the swamp.")  Yet despotic regimes often foster even more corruption, but then might blame it on others, while continuing to proclaim their drainage skills.

Enabling by Public Relations, Propaganda and Disinformation in an Era of Social Media

Shady business practices and shady politics have long been enabled by public relations (which Bernays thought sounded better than "propaganda") and the disinformation campaigns that grew from it.  Now this has been further ramped up by social media.


The good news is that the problems of corruption and crime in health care can now be more easily seen as just part of  larger problems.  The bad news is that this has only come into view as the problems of US and global corruption become profound.  Furthermore, as we think about more corruption, the issue seems much more complex.  At least conferences like the 18th IACC provided a venue to being to address the complexity before we are totally overwhelmed.

NOTE (Oct 29, 2018) -  Discussion section revised and enlarged to include the three themes above.

Wednesday, October 17, 2018

Update: How to Challenge Health Care Corruption Under a Corrupt Regime

Summary: the Corruption of Health Care Leadership as a Major Cause of Health Care Dysfunction

As we wrote in August, 2017, Transparency International (TI) defines corruption as

Abuse of entrusted power for private gain

In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
the scale of corruption is vast in both rich and poor countries.

Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.

The report got little attention.  Health care corruption has been nearly a taboo topic in the US, anechoic, presumably because its discussion would offend the people it makes rich and powerful. As suggested by the recent Transparency International report on corruption in the pharmaceutical industry,
However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

Presumably the leaders of other kinds of corrupt organizations can do the same. 

When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects some other places, mainly  presumably benighted less developed countries.  At best, the corruption in developed countries that gets discussed is at low levels.  In the US, frequent examples are the "pill mills"  and various cheating of government and private insurance programs by practitioners and patients.  Lately these have gotten even more attention as they are decried as a cause of the narcotics (opioids) crisis (e.g., look here).  In contrast, the US government has been less inclined to address the activities of the leaders of the pharmaceutical companies who have pushed legal narcotics (e.g., see this post). 

However, Health Care Renewal has stressed "grand corruption," or the corruption of health care leaders.  We have noted the continuing impunity of top health care corporate managers.  Health care corporations have allegedly used kickbacks and fraud to enhance their revenue, but at best such corporations have been able to make legal settlements that result in fines that small relative to their  multi-billion revenues without admitting guilt.  Almost never are top corporate managers subject to any negative consequences.

We have been posting about this for years at Health Care Renewal, while seeing little progress on this issue.  For example, we had long complained that US law enforcement had not been devoting enough effort going after the corruption of the leadership of large health care organizations, thus effectively allowing these leaders' impunity. However, in the later years of the Obama administration the US Department of Justice during the Obama administration made some modest attempts to decrease such impunity, including the formation of a Health Care Corporate Strike Force.

As reported by,

the strike force was created in the fall of 2015, with five dedicated lawyers working on about a dozen of the most complex corporate fraud cases in the health care space.

Andrew Weissmann, the then-chief of the DOJ’s fraud section, told a health care conference in April 2016 that the section was placing 'a heightened emphasis' on corporate health care fraud investigations. He pointed to the recently established Corporate Fraud Strike Force that he said would focus resources in investigation and prosecution of larger corporate health care law violations, as opposed to smaller groups or individuals.
This little bit of progress was not to last.  Unfortunately, that strike force was downsized by the Trump administration as we noted in July, 2017.  Then as we noted in May, 2018, even the previously modest efforts by the US government to challenge corrupt acts by large US health care organizations were decreasing.  By that date, we found only one significant settlement made during the year.  That month, a report by Bloomberg, appeared with the headline, "White-Collar Prosecutions Fall to 20-Year Low Under Trump," on May 25, 2018.

Increasing Evidence of Corruption in the Trump Administration

Meanwhile, the Trump administration itself increasingly appeared corrupt.  In January, 2018, we first raised the question about how health care corruption could be pursued under a corrupt regime.  We noted sources that summarized Trump's. the Trump family's, and the Trump administration's corruption..  These included a website, entitled "Tracking Trump's Conflicts of Interest" published by the Sunlight Foundation, and two articles published in the Washington Monthly in January, 2018. "Commander-in-Thief," categorized Mr Trump's conflicted and corrupt behavior.  A Year in Trump Corruption," was a catalog of the most salient cases in these categories in 2017.

In July, 2018, we addressed the Trump regime's corruption again  By then, more summaries of Trump et al corruption had appeared.   In April, 2018, New York Magazine published "501 Days in Swampland," a time-line of  starting just after the 2016 presidential election. In June, 2018, ProPublica reviewed questionable spending amounting to $16.1 million since the beginning of Trump's candidacy for president at Trump properties by the US government, and by Trump's campaign, and by state and local governments. Meanwhile, Public Citizen released a report on money spent at Trump's hospitality properties.

The Global Anti Corruption Blog Update

This month, the Tracking Corruption and Conflicts of Interest in the Trump Administration–October 2018 UpDate appeared in the Global Anti-Corruption Blog.  It is voluminous, requiring about 26 single-spaced pages to print, with numerous references.  But then again...

 Poster displayed in front of Trump International Chicago Hotel, displaying the slogan: "Subtlety is not our strength.  Indulgence is."

So let me try to summarize the main points of Trump's indulgence, keyed to the four sections of the report.

1. U.S. Government Payments to the Trump Organization

One of the most direct ways that President Trump can profit from the presidency is by making decisions that effectively require U.S. government agencies to purchase goods or services from the Trump Organization. Though unseemly and costly to taxpayers, this is one of the less destructive forms of potential profiteering by President Trump, since it does not significantly distort U.S. policy.

Examples included the Secret Service and Department of Defense renting expensive space in Trump Tower in New York;  the Secret Service paying the Trump Organization in order to protect President Trump during the many occaisions (208 days at that point) he has spent at Trump Organization luxury properties; payments to the Trump Organization for Secret Service and other government staff presence at overseas Trump properties when visited by the President on ostensibly government business; and payments to the Trump Organization when Trump and his family fly on his private planes for non-government business.

Note that these payments seem in gross violation of Article II, section 1 of the US Constitution, which states:

The President shall, at stated Times, receive for his Services, a Compensation, which shall neither be encreased nor diminished during the Period for which he shall have been elected, and he shall not receive within that Period any other Emolument from the United States, or any of them.
This has been called the "domestic emoluments clause," and is supposed to prohibit a kind of conflict of interest, that is, a President getting paid by some part of the US government, or by state governments separate from his regular salary and benefits.  Nonetheless, Trump has been effectively paid, again and again, through the Trump Organization by the US government.

2. Use of the Power of the Presidency To Promote Trump Brands

Donald Trump and his family can also enrich themselves by taking advantage of the unique status and exposure of the President of the United States to promote Trump family brands.


While distasteful, this brand-promotion activity is also one of the less harmful ways in which the Trump Administration may seek to profit from the Presidency, as it does not involve significant distortions of U.S. policy. Nonetheless, the overt attempts to use the presidency as a marketing opportunity indicate a troubling underlying attitude.

Examples included the White House website promoting Melania Trump's jewelry line; WH senior advisor KellyAnne Conway, speaking in the Briefing Room, endorsing Ivanka Trump's fashion line; various activities that served to promote Trump Organization luxury properties, particularly Mar-a-Lago and Bedminster; promotion of Ivanka Trump's fashion line via her official participation in a World Bank Women Entrepreneurs Finance Initiative; the Voice of America and State Department promoting Ivanka Trump's book; the Trump Organization's apparently illegal use of the Presidential Seal to promote golf products; Trump Organization's discount promotion of golf merchandise to WH staff; and Trump Campaign and Republican National Committee events at Trump properties.

3. U.S. Government Regulatory and Policy Decisions that Benefit the Business Interests of the Trump Family and Senior Advisors

Federal government decisions—on regulation, law, enforcement, and discretionary spending—may be influenced or manipulated in ways that benefit the private commercial interests of the Trump Organization or other businesses closely tied to President Trump, his family, or his senior advisors. This is a much more serious problem, as it involves not only enrichment of the Trump family and associates at taxpayer expense, but also potential distortions of U.S. policy.

This has occurred on such a massive scale that

The extent of the Trump Organization’s business interests makes it impossible to summarize all of the potential conflicts of interest that might arise. For example, the Trump Organization has been involved in labor disputes; Trump businesses regularly apply for visas for foreign workers (see here, here, and here); and Trump businesses are subject to countless federal safety and environmental regulations. (See here for an in-depth analysis of many of these potential conflicts.) As head of the executive branch, President Trump might have influence over numerous decisions that affect the Trump Organization’s business interests. 

Some of the examples provided were government actions that affected the Housing and Urban Development (HUD) subsidies being received by Trump Organization properties; the Dakota Access Pipeline, which was being built by a company in which Trump owned stock; the Clean Water Act, whose rollback would benefit Trump Organization golf courses; the General Services Administration lease held by the Trump Organization to operate the Trump International Hotel in Washington, DC; the decision to demolish the current FBI headquarters, possibly allowing a competitor to the Trump International Hotel in Washington to be built across the street; various business interests of Ivanka Trump and her husband; the proposed infrastructure project which could variously affect the Trump Organization; the Justice Department investigation of Deutsche Bank, a large source of loans to Trump and his family; offshore oil drilling which could affect the attractiveness of Trump properties like Mar-a-Lago; Fannie Mae and Freddie Mac, controlled by the government, but whose investors include a large hedge fund in which Trump has a stake;  the travel ban so as not to affect countries in which the Trump Organization has operations; H2B visa applications which supply workers to Trump properties; the tax reform plan which greatly affected Trump's taxes; and the choice of US Attorneys in jurisdictions in which the Trump Organization operates and whose offices may be in a position to investigate Trump, the Trump Organization, and Trump associates.

Furthermore, government decisions may have affected the financial fortunes of Trump associates such as Commerce Secretary Wilbur Ross, special advisor Carl Icahn, confidant Rupert Murdoch, Tennessee Valley Authority nominee Kenneth Allen, Department of Homeland Security Secretary  Kirstjen Nielsen, Interior Secretary Ryan Zinke, former director of the Centers for Disease Control Brenda Fitzgerald, Housing and Urban Development Secretary Ben Carson, etc, etc, etc

4. Private and Foreign Interests Seeking To Influence the Trump Administration Through Dealings with Trump Businesses

Another significant concern is that individuals, private firms, and foreign governments may believe—rightly or wrongly—that they can curry favor with the Administration and increase their odds of favorable policy decisions by engaging in private business transactions with companies owned by or connected to President Trump—or, in the case of foreign governments, granting favorable regulatory treatment to Trump business operations in their countries. This is one of the most serious concerns related to the Trump family’s interest in profiting from the presidency, as it gives rise both to the appearance of corruption and the risk of actual corruption.

While again the scope of  this problem was again "too broad to summarize," let me give some examples:

- Bookings made at the Trump International Hotel in Washington DC by foreign governments including Bahrain, Saudi Arabia, Kuwait, Turkey, Malaysia, the Phillipines, and Afghanistan.

- Events at other Trump properties, the renting and purchasing of Trump properties, Trump Organization developments in countries including Indonesia, India, Panama, Turkey, United Arab Emirates, Scotland, Dominican Republic, and Taiwan.

- Trump Organization seeking trademarks in China.

- Membership in Trump golf courses

-  Trump real estate transactions with secretive buyers

- A large number of business dealings by Jared Kushner, Trump's son-in-law involving China, Qatar, Russia, Israel, and Japan

- former Trump lawyer and "fixer" Michael Cohen's consulting company's dealings with Russia, and allegedly creating a "slush fund" to be used by Trump

Note that any of the payments made to Trump via the Trump Organization by foreign govenments could  violate the "foreign emoluments clause" of the US Constitution, that is, Article I, Section 9

No Title of Nobility shall be granted by the United States: And no Person holding any Office of Profit or Trust under them, shall, without the Consent of the Congress, accept of any present, Emolument, Office, or Title, of any kind whatever, from any King, Prince, or foreign State.

This again is supposed to prohibit a species of conflict of interest, any payment to a US government official, including the President, by a foreign government, without the express consent of the US Congress. 

There are several lawsuits in progress on this matter, but no action has been taken by the Trump regime, or its supporters in Congress, to curtail these foreign emoluments.  

In addition, the Trump Organization has had dealings with US state governments that may violate the domestic emoluments clause of the US constitution.  These included tax breaks recently given to new Trump hospitality properties by the state of Mississippi.

Meanwhile Corruption, Even of a President, Remains a Virtually Taboo Topic

The scope of conflicts of interest and corruption affecting US President Donald Trump, his vast business empire, his family and associates seems incomprehensively big.

And still, corruption remains a nearly taboo topic. 

In November, 2017, we noted that once again, a report by Transparency International that showed that in an international survey of corruption perceptions, substantial minorities of US respondents thought that US corruption was increasing, and was a particular affliction of the executive and legislative branches of the national government, other government officials, and top business executives.  There was virtually no coverage of these results in the US media, just as there was virtually no coverage of a 2013 survey that showed 43% of US respondents believed that US health care was corrupt.

Similarly, the reports about Trump related corruption listed above have generated little discussion.  Despite the extensive and ever-increasing list of apparently corrupt acts by the Trump and cronies, grand corruption at the top of US government, with its potential to corrupt not just health care, but the entire country and society, still seems like a taboo topic.  The US news media continues to tip-toe around the topic of corruption, in health care, of top health care leaders, and in government, including the top of the US executive branch.  As long as such discussion seems taboo, how can we ever address, much less reduce the scourge of corruption?  The first step against health care corruption is to be able to say or write the words, health care corruption.

But even if we can take that step, when the fish is rotting from the head, it makes little sense to try to clean up minor problems halfway towards the tail. Why would a corrupt regime led by a president who is actively benefiting from corruption act to reduce corruption? The only way we can now address health care corruption is to excise the corruption at the heart of our government.

Wednesday, October 10, 2018

The Politicization of Pharma, and Other Health Care Corporations - Walk on the Dark (Money) Side

Introduction - Health Care Corporations Profess Social Responsibility

As we noted recently, large health corporations, which deal with patients, health professionals, and government regulators, usually profess their social resonsibility.  For example,

Giant health care insurance company Aetna advertises its social corporate responsibility, including

As a health care leader, we believe that our corporate responsibility starts with helping people live healthier lives. And that means using our resources to make the communities and world we live in better places.


Our social responsibility efforts encompass how we treat our employees, improve the lives of customers, and effect positive change in community health.
Similarly, giant pharmaceutical company Merck advertises its corporate social responsibility,

Corporate responsibility is at the heart of our company's mission to discover, develop and provide innovative products and services that save and improve lives. It underscores our commitment to developing and rewarding our employees, protecting the environment, and operating with the highest standards of ethics and transparency.

Of course, in the policy arena, large health care corporations also tend to advocate for policies that are to their financial advantage.  Furthermore, top executives of large corporations have been known to donate to political candidates who favor their policy positions, although they often seemed to consciously spread their donations out to avoid any appearance of partisanship.

However, as the current US political chaos leads to more journalistic investigation, there is increasing evidence that large health care corporations have been secretly backing policy positions that do not correspond to their high-minded public statements about corporate social resonsibility, and are becoming quite political, even partisan in the process.  They do so through the use of dark money

Health Care Corporations Giving to Dark Money Organizations: Dark Money Illuminated

Dark money is meant to be secret, of course.  So it is not easy to find anything out about who gives to dark money organizations, and to whom they give in turn. 
 However, recently Issue One produced a report entitled "Dark Money Illuminated." It was based on an extensive attempt to pierce the veil hiding dark money. Its introduction states:

Dark money groups hold enormous sway over what issues are, and are not, debated in Congress and on the campaign trail. But the donors behind these groups rarely discuss their motivations for bankrolling these efforts, leaving the public in the dark about who funds these increasingly prominent and potent organizations.

To attempt to get the most accurate picture of the scope of dark money influence on US politics, its authors:

reviewed FEC filings, tax returns, annual reports submitted by labor unions to the Department of Labor, documents submitted to Congress by registered lobbyists, corporate filings, press releases and other sources.

This allowed them:

to be able to identify transactions — and donors — that have never previously been associated with these dark money groups.

So they were able to identify the 15 largest dark money groups in terms of donations received, and to get data on a substantial numer of donations to them, albeit likely only a fraction of the donations to dark money groups that have been made, from 2010 to 2017.  Health care corporations turned out to be major suppliers of funding to dark money group according to this data.  The report includes a summary of the top 67 donors to dark money groups, which included:

- Pharmaceutical Research and Manufacturers of America (PhRMA), the pharmaceutical industry trade association, donated over $13 million.

- Aetna, a large for-profit health insurance company, donated over $8.5 million.

- Merck, a large pharmaceutical firm, donated over $4 million.

- Anthem, a large for-profit insurance company, donated $2 million.

Perusal of the whole data base revealed significant donations by many more health care corporations (list below includes the three companies listed above).

Aetna - $3.3 million to the American Action Network

Express Scripts - $75K to Americans for Tax Reform

American Healthcare LLC - $5K to Patriot Majority USA

Abbott Laboratories  - $500K to US Chamber of Commerce (USCC)

AbbeVie - $250K to USCC

Aetna - $5.3M to USCC

Allergan - $55K to USCC

Amgen - $302K to USCC

Anthem - $2M to USCC

Celgene - $262.5K to USCC

Cigna - $325K to USCC

CVS - $825K to USCC

Eli Lilly - $350K to USCC

Express Scripts - $150K to USCC

Gilead - $13K to USCC

Johnson & Johnson - $475K to USCC

Merck - $4.4M to USCC

Mylan - $210K to USCC

Procter & Gamble - $500K to USCC

UnitedHealth - $252K to USCC

Zimmer Biomet - $75K to USCC

Where Does the Money Go?

As is evident above, health care companies donated to a limited number of the big 15 dark money organizations, the American Action Network, Americans for Tax Reform, Patriot Majority USA, but mostly the US Chamber of Commerce.

The first two organizations were all identified by Issue One as affiliated with right-wing / Republican/ pro-Trump causes.

American Action Network

the American Action Network was not publicly rolled out by high-profile Republicans until February 2010 — one month after the U.S. Supreme Court’s Citizens United decision.
The self-described 'action tank' was founded by veteran Republican fundraiser Fred Malek, the former Marriott Hotels president and CEO who has helped raise campaign cash for a number of GOP presidential candidates over the years.

Former Republican Sen. Norm Coleman of Minnesota served as the American Action Network’s first CEO and is still the chairman of the organization’s board of directors.

Brian Walsh — the former political director for the National Republican Congressional Committee who helped Republicans win control of the U.S. House of Representatives in 2010 — served as the president of the American Action Network between 2011 and 2015.

The group’s current executive director is Corry Bliss, who managed Ohio Republican Sen. Rob Portman’s successful re-election campaign in 2016.  

Americans for Tax Reform

Originally founded in July 1985 to promote President Ronald Reagan’s proposal for tax reform, Americans for Tax Reform remains a powerful lobbying organization today that also frequently spends money in elections to aid Republican candidates. The group’s founder and president is Grover Norquist, a conservative activist who once boasted that his goal was to get government 'down to the size where we can drown it in the bathtub.'

In 1994, Norquist was one of the co-authors of the 'Contract with America,' the campaign platform that helped the GOP win control of the U.S. House of Representatives for the first time in more than forty years and helped elevate Rep. Newt Gingrich (R-GA), another co-author, to the position of Speaker of the House.

Americans for Tax Reform’s primary advocacy tool is its 'Taxpayer Protection Pledge,' which asks politicians at the local, state and national level to “make a written commitment to oppose any and all tax increases.”

The third group, to which only one donor gave only $5K, was identified with Democratic / left-wing causes.

Patriot Majority USA

Patriot Majority USA, a 501(c)(4) 'social welfare' organization that often spends money in elections to aid Democratic candidates, was founded in March 2011 by political consultant Craig Varoga, a Democrat with strong ties to former Senate Majority Leader Harry Reid (D-NV). To wit: Varoga led an independent group that helped Reid win his contentious re-election race in 2010.

The fourth organization, the one to which most of the health care corporate donors gave the most money, is in a class of its own.  The Issue One description of it was

US Chamber of Commerce

the U.S. Chamber of Commerce ranks as one of the nation’s largest and most powerful lobbying groups, with an ornate headquarters in Washington, D.C., just a block from the White House.

A trade association organized under Section 501(c)(6) of the tax code, the U.S. Chamber of Commerce mostly endorses Republican candidates, although it occasionally supports business-friendly Democrats. The group says it represents more than 3 million businesses across the country and has a membership of approximately 300,000.

The USCC has received much - probably unwanted - publicity about its efforts to help President Trump's controversial nomination of Brett Kavanaugh to the Supreme Court.  An October 4, 2018, article in the Intercept included:

Business groups with interests before the U.S. Supreme Court have orchestrated a multifaceted campaign to pressure the Senate to swiftly confirm Judge Brett Kavanaugh to the nation’s highest court. The advocacy reaches across the influence economy of Washington, D.C., with the largest corporate lobbying groups and billionaires working in concert with Republican operatives to elevate Kavanaugh to a lifetime posting atop the judiciary.

Few businesses, however, have stamped their names on the effort. Most major corporations and wealthy donors are instead using 501(c) nonprofit groups that do not require donor transparency to air upward of $15 million in reported advertising spending in order to convince the public to support Kavanaugh’s nomination. Other conservative groups contributing to the ad war have not disclosed how much they are spending, likely bringing the total much higher.

Among the groups publicly campaigning for Kavanaugh to be confirmed are the giants of pro-business lobbying — organizations like the U.S. Chamber of Commerce and the Koch brothers-funded Americans for Prosperity. Lesser-known, business-funded political groups, such as the Republican Attorneys General Association, are also spearheading campaigns.

The article also said this specifically about the US Chamber of Commerce

The powerful lobby announced in August that it would mobilize support for Kavanaugh, claiming it would score support for Kavanaugh as a 'key vote' in evaluating members of Congress. The Chamber spends tens of millions of dollars every election cycle against lawmakers who cross them on major votes.

One wonders whether patients or health care professionals who must deal with large health care corporations have any idea that these companies are promoting partisian causes, mostly right-wing/ Republican/ pro-Trump causes?  One wonders whether the employees and small stockholders of these corporations likewise have any idea about this?

Summary and Discussion

This is now the fourth time we have discussed the role of dark money in health care.  In 2012 we discussed a case of "dark money" being used to conceal sources of support for particular health policy and political positions.  Earlier this year,  we discussed the case of huge pharmacy chain CVS,which proclaims its "social responsibility," and its policy of only making charitable contributions to improve "health and healthcare nationwide."  Yet CVS was donating to America First Policies, a supposed non-profit group devoted to promoting the partisan agenda of President Trump, including "repealing and replacing Obamacare," and immigration policies such as building the "wall" and deporting  "illegal immigrants." (Note that these CVS dark money contributions were separate from those discussed above.)  Ten days ago we discussed how the pharmaceutical trade organization, PhRMA, and some large drug companies donated money to a dark money organization to combat a state initiative to limit pharmaceutical prices, but also to the American Action Network (see above) to "repeal and replace" the Affordable Care Act (ACA, "Obamacare") despite their previous support for and then current neutrality on the ACA.

Now it appears that health care corporations often donate large amounts to dark money organizations, and as best as we can tell now, nearly all the donations and all the money go to organizations that support right-wing/ Republican/ and now pro-Trump causes.  Many of these causes seem to openly conflict with the corporations' promises of social responsibility.  The slanting of these efforts towards one end of the political spectrum, one party, and now the current president suggest that these corporations may have partisan agendas.

Note that without the various ongoing investigative efforts mainly inspired by the actions of the Trump administration, we would have little idea that this was going on.

I hope that such investigations continue.

Furthermore, the increasing knowledge of these corporate actions raises a big question: cui bono? who benefits?

It is obvious why a pharmaceutical company, for example, might want to defeat legislation that would lower its prices.

It is not obvious why it would want to consistenly support actions by one party, or by people at one end of the political spectrum.

The obvious hypothesis is that these donations, which must be orchestrated by top corporate management, and which are not disclosed to employees or smaller corporate shareholders, are likely made to support the top managers' self interest.

Thus not only is more investigation needed, at the very least, "public" corporations ought to fully disclose all donations made to outside groups with political agendas.  This should be demanded by at least the corporations' employees and shareholders, but also by patients, health care professionals, and the public at large.

Meanwhile we are left with the suspicion that top health care corporate management is increasingly merging with the current administration in one giant corporatist entity which is not in the interests of health care, much less government by the people, of the people, and for the people. 


Musical interlude: "On the Dark Side," Eddie and the Cruisers

Friday, October 05, 2018

New York Times Remembers Dr Bernard Carroll, the "Conscience of Psychiatry"

We at Health Care Renewal miss Dr Bernard Carroll, who we were proud to count among our bloggers.

The New York Times just published a kind obituary, which called him "the conscience of psychiatry."

It opened:

Dr. Bernard J. Carroll, whose studies of severe depression gave psychiatry the closest thing it has to a 'blood test' for a mental disorder, and who later became one of the field’s most relentless critics, helping to expose pervasive corruption in academic research, died on Sept. 10 at his home in Carmel, Calif. He was 77.

It described how he started his "second career":

He and a lifelong friend, Dr. Robert Rubin, a professor of psychiatry at the University of California, Los Angeles, dissected psychiatric studies as they appeared, flagging sloppy work and sniffing out conflicts of interest. They then broadcast their findings to former colleagues and allies through various email lists, often taking their findings to the news media.

'He never stopped; he was up at all hours,' said Dr. Allen Frances, a former Duke colleague. 'I mean, I’m an early riser. I’d get up and there’d be a bunch of emails from Barney.'

In the 2000s, Dr. Carroll and Dr. Rubin worked with Paul Thacker, then a staffer for Senator Charles Grassley of Iowa, to help expose huge undeclared payments to top academic researchers at Harvard, Emory University and other institutions. He knew very well how this world operates; he had consulted widely with drug makers himself.

Dr. Carroll concluded that the psychiatric drug literature had become so polluted as to be virtually meaningless; he called most drug trials “infomercials.”

'We weren’t after anyone, nor did we care how much money people were making — we were concerned about how corrupt the science had become,' Dr. Rubin said in a phone interview. 'The tragedy in all this was that the corrupt science was affecting countless people’s lives.'

Dr. Carroll’s work ethic and vast connections helped convert many younger researchers to his cause; they now view the published psychiatric science with his skeptical eye.

'He was the conscience of psychiatry,' Dr. Frances said, 'and he spawned a generation of future consciences along the way.'


He worked until the end, Sylvia Carroll said, finishing a last paper and, as ever, expanding his electronic presence. His email lists were active; he had started tweeting (he was terrible at it, Dr. Frances said); and he contributed to various blogs, including Margaret Soltan’s 'University Diaries,' for which he sometimes wrote limericks under the name Adam, like this one:

And then we have just across campus

The medical guys playing scampers.

They’ve learned to beguile,

To increase their cash pile

Once grant funds are safe in their clampers.

— Adam.

Dr Carroll was  was with us at Health Care Renewal since 2005, contributing insightful, pithy, provocative and important posts.  He also authored some of our most widely read posts.  Most viewed was: JAMA Jumps the Shark.   His most recent post was Corruption of Clinical Trials Report: A Proposal.   All his posts can be found here. We all miss him.

Sunday, September 30, 2018

Pharma's Dark Money: Touting Corporate Responsibility and Non-Partisanship, But Using Dark Money to Promote Self-Serving Policies and Partisan Causes

Health Care Corporations Promote Their Social Responsibility

The US health care system's extreme dsyfnctionality is now a cliche.  So it's no wonder that everyone seems to want to make things better.  Big health care corporations in particular tout their socially responsible ideas for health care reform.

For example, PhRMA, the trade organization for drug and biotechnology firms, describes its mission thus:

PhRMA is committed to advancing public policies in the United States and around the world that support innovative medical research, yield progress for patients today and provide hope for the treatments and cures of tomorrow.

Amgen states simply its mission is "to serve patients."

Biogen published a "Corporate Citizenship Report" which included

our commitment [is] to positively impact our communities, to inspire the next generation of scientists, to solve social and environmental challenges and to create a diverse and inclusive workforce that thrives professionally and personally.

Giant pharmaceutical/ biotechnology/ device company Johnson & Johnson has its famous "credo" which starts with

We believe our first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use our products and services.


We are responsible to the communities in which we live and work and to the world community as well. We must be good citizens – support good works and charities and bear our fair share of taxes. We must encourage civic improvements and better health and education.

With all that positivity supporting better health care, one would think that health care dysfunction should be soon gone. But maybe under all this talk about corporate responsibility lies something darker.

An Early Case of Dark Money in Health Care

Back in 2012 we discussed a case of "dark money" being used to conceal sources of support for particular health policy and political positions.  The case was of the Center for Protection of Patient Rights, an obscure group whose mission was to "protect the rights of patients to choose and use medical care providers."  The CPPR financed the US Health Freedom Coalition, led by Dr Eric Novack, which received nearly its entire budget — $1.7 million — from the center to help pass a state ballot measure that aimed to block President Obama's healthcare overhaul.  The Center ultimately transferred $55 million to Republican candidates in the 2010 election.  Its money came from the equally obscure Americans for Job Security, and was conveyed by groups such as the American Future Fund. The people who gave the money to the Americans for Job Security remained unknown, save for one wealthy Alaskan "landowner."  

Do Health Care Corporations Put Their Money Where Their Mouths Are?

This year, we discussed the case of huge pharmacy chain CVS,which proclaims its "social responsibility," and its policy of only making charitable contributions to improve "health and healthcare nationwide."  Yet CVS was donating to America First Policies, a supposed non-profit group devoted to promoting the partisan agenda of President Trump, including "repealing and replacing Obamacare," and immigration policies such as building the "wall" and deporting  "illegal immigrants."  America First Policies appears to be yet another dark money organization.  CVS only decided to stop contributing when journalists revealed that America First Policies staffer had made flagrantly racist and pro-Nazi comments.

This suggested that it is possible that health care corporations which promote themselves as socially responsible and non-partisan may actually be secretly promoting political agendas that might shock some of their consumers and/or patients, employees, and health care professionals who must deal with them. 

We have  now found some more cases that reinforce this suspicion, showing how pharmaceutical and biotechnology companies have funneled funds through more "dark money" organizations to support policies that do not fit so well with the image they want to convey.

The PhRMA Backed Dark Money Campaign Against an Ohio Initiative to Control Drug Pricing

In August, 2017, the International Business Times revealed how the pharmaceutical/ biotchnology industry had set out to defeat a 2017 Ohio initiative meant to hold down drug prices without revealing who was funding it.

PhRMA had already succesfully defeated a similar initiative in California in 2016.  However, industry support for this campaign, while obscure, was not a secret. 

PhRMA set up ... Californians Against the Misleading Rx Ballot Measure, which raised over $111 million for its campaign against a California initiative that ... would have blocked that state from paying higher drug prices than those negotiated by the Veterans Affairs Department. The trade group set up a political action committee in California to which pharma companies donated directly — so PhRMA had to disclose these donors. Merck, Pfizer and Johnson & Johnson gave over $9 million each; Amgen gave $7.6 million; and 19 other drug companies gave $1 million or more. The PhRMA-run committee spent nearly all of the millions it raised, and the measure failed to pass, with 53 percent of voters shooting it down. All donors except for Genentech and Gilead Sciences are PhRMA members, and only a handful of companies out of more than 30 total corporate donors are headquartered in California.

Somehow, with all the news coming out about the 2016 US elections, this generated little interest.  However, in Ohio in 2017, PhRMA was able to do something similar while keeping the corporate sources of the money hidden.  Their target was:

Issue 2, the Ohio Drug Price Relief Act — a citizen-initiated ballot measure designed to prevent state agencies, including the state Department of Medicaid, from purchasing drugs at rates any higher than the lowest amount paid by the federal Department of Veterans Affairs, which negotiates with drug companies and saves between 20 and 24 percent on drug costs.

This time:

Pharmaceutical Research and Manufacturers of America (PhRMA), the biggest trade organization in the U.S. representing major drug companies, created a political action committee on May 1 called Ohioans Against the Deceptive Rx Ballot Issue. On the same day, PhRMA also founded a limited liability corporation of the same name and registered at the same address; under normal circumstances, it would not be required to disclose its donors. Campaign finance reports document only one donor to the ballot measure committee: the linked LLC.

So contributions from corporate donors to the LLC to financeed the political action committee were concealed.  So,

'Certainly, setting up an LLC to launder drug company money into fighting the ballot measure looks like an effort to evade Ohio's transparency and disclosure laws,' Brendan Fischer, director of federal and Federal Election Commission reform at the nonpartisan Campaign Legal Center, told International Business Times in an email.


The Campaign Legal Center contends that hiding donors this way at the federal level violates the Federal Elections Campaign Act, which prohibits 'straw donors.'

There were only two flies in the ointment.  Two companies did disclose donations to the LLC:

According to the Columbus Dispatch, California-based Amgen gave $6.3 million from 2016 through June 2017, and Biogen, headquartered in Massachusetts, gave $1.5 million last year. This accounts for roughly half of the $15.8 million total that PhRMA’s LLC raised in just May and June to fight Issue 2.
Who donated the rest, amounting to some $58 million, remains unknown.  And the effort to defeat Issue 2 was succesful, as reported by in November, 2017.

Issue 2 also now holds the distinction of being the most expensive ballot issue in state history, with more than $74 million raised over the course of three years, topping the $64.4 million spent on Issue 6 in 2008, which sought permission for a casino in Wilmington, Ohio. Issue 6 also failed at the ballot.

Big Pharma accounted for more than $58 million of the total raised.


Because the drug companies passed the money through a limited liability company created with the intention of funneling cash to the opposition campaign, it's currently impossible to tell which companies actively spent money combating the initiative in Ohio.

A proponent of Issue 2 charged:

'The onslaught, the bombardment of television advertising that was misleading, lying and negative led to tremendous confusion,' he said.

Uncertainty from the public about the effects of the bill coupled with the ugliness of the campaign likely led to Issue 2's defeat. Voters were often confused and felt both sides were of zero help in explaining the issue.

And by August 25, 2018, the Columbus Dispatch reported that all legal compaints against the PhRMA dark money campaign were dismissed.

Think of the campaign to defeat Issue 2 as a proof of the concept that health care corporations can finance campaigns against policy measures using dark money organizations to hide their support.

But no one would be surprised to find out that pharmaceutical companies were against a policy measure that would restrict the prices they charge.  Our next case shows how the dark money ruse can be used by corporations to support partisan policies that conflict with their proclaimed social responsibility and non-partisan nature.  

The PhRMA Backed Dark Money Campaign to "Repeal and Replace" the Affordable Care Act (ACA)

Investigative journalism from Kaiser Health News appeared in the New York Times and the Washington Post in late July, 2018 showing how PhRMA again used dark money, but this time to advocate for "repealing and replacing" the Affordable Care Act (known informally as "Obamacare"), which PhRMA had previously supported, and about which it was then ostensibly neutral.  The article began,

In 2010, before the Affordable Care Act was passed by Congress, the pharmaceutical industry’s top lobbying group was a very public supporter of the measure. It even helped fund a multimillion-dollar TV ad campaign backing passage of the law.

But last year, when Republicans mounted an aggressive effort to repeal the law, the group made a point of staying outside the fray. 'We’ve not taken a position,' Stephen Ubl, head of the organization, the Pharmaceutical Research and Manufacturers of America, known as PhRMA, said in an interview in March 2017.

This was deceptive.

That stance, however, was at odds with its financial support of another group, the American Action Network, which was heavily involved in the effort to repeal the act, often referred to as Obamacare. The network spent an estimated $10 million on an ad campaign designed to build voter support for its elimination.

'Urge him to repeal and replace the Affordable Care Act now,' one ad running in early 2017 advised viewers to tell their congressman. That and similar material (including robocalls) paid for by the American Action Network ran numerous times last year in 75 congressional districts.

PhRMA was one of AAN’s biggest donors the previous year, giving it $6.1 million, federal regulatory filings show. And PhRMA had a substantial interest in the outcome of the repeal efforts. Among other actions, the Republican-backed health bill would have eliminated a fee the companies pay the federal government, one estimated at $28 billion over a decade.

But there was no way the public could have known at the time about PhRMA’s support of the network or the identity of other deep-pocketed financiers behind the group.

The KHN report went on to explain how this works

Unlike groups receiving its funds, PhRMA and similar nonprofits must report the grants in their own Internal Revenue Service filings. But the disclosures don’t occur until months or sometimes more than a year after the donation.

The conservative-leaning AAN has become one of the most prominent nonprofits for routing what is known as dark money — difficult-to-trace funds behind TV ads, phone calls, grass-roots organizing and other investments used to influence politics. Such groups have thrived since the Supreme Court’s Citizens United decision in 2010, which loosened rules for corporate political spending, and amid what critics say is nonexistent policing of remaining rules by the I.R.S.

Generally speaking, dark-money groups are politically active organizations, often nonprofit, that, under I.R.S. regulations, are not required to disclose the identities of their donors.

Such groups are often chartered under Section 501(c)(4) of the tax law, which grants a tax exemption to 'social welfare organizations.' For those seeking to influence politics but stay in the background, 501(c)(4) designations offer two big advantages: tax exemption and no requirement to disclose donors.
The AAN seems to be an obviously partisan, right-wing, pro-Republican group.

PhRMA’s $6.1 million, unrestricted donation to AAN was its single-biggest grant in 2016, dwarfing its $130,000 contribution to the same group the year before. Closely associated with House Republicans — AAN has a former Republican senator and two former Republican House members on its board — the group backed the failed G.O.P. health bill intended to replace the Affordable Care Act. It also supported the successful Tax Cuts and Jobs Act of 2017, which reduced corporate taxes by hundreds of billions of dollars over a decade.

So far in this election cycle, AAN has given more than $19 million to the Congressional Leadership Fund, a Republican super PAC with which it shares an address and staff, according to the Center for Responsive Politics. The fund recently ran ads opposing Democratic candidates in high-profile special congressional elections in Georgia and Pennsylvania.

In fact, PhRMA made a variety of contributions to dark money groups associated with right-wing and/or Republican party backed causes, while it presumably maintained a non-partisan public stance.

PhRMA gave nearly $10 million in 2016 to politically active groups, including AAN, that do not have to disclose donors, its most recent filing with the I.R.S. shows. By contrast, PhRMA and its political action committee made only about $1 million in political donations in 2015 and 2016 that were disclosed to regulators and reported by the Center for Responsive Politics.

PhRMA’s 2016 political activities included support for the Republican National Convention. Rather than directly support the Cleveland convention, which several companies pulled out of after it became clear that Mr. Trump was going to be the nominee, PhRMA routed $150,000 through limited liability companies with names like Convention Services 2016 and Friends of the House 2016.

Like 501(c)(4)s, LLCs do not have to disclose their donors. PhRMA’s support was revealed in I.R.S. filings more than a year later. (Donations by PhRMA and other groups to Friends of the House, which financed a luxury lounge for convention dignitaries, were first reported by the Center for Public Integrity last fall.)

PhRMA’s surge in donations to AAN coincides with the arrival of Mr. Ubl, who took over as president and chief executive in 2015 and has longstanding ties to Norm Coleman, a former United States senator from Minnesota who is now the network’s chairman. Mr. Ubl once ran the lobby for manufacturers of knee implants, heart stents and other medical devices, one of which, Medtronic, is based in Minneapolis.


PhRMA’s 2016 dark-money contributions included $150,000 to Americans for Prosperity, a conservative group associated with the billionaires Charles and David Koch. Their group has already signaled it will be active in November’s elections, running attack ads against Senator Jon Tester, a vulnerable Montana Democrat, for not supporting a repeal of the Affordable Care Act.

PhRMA also gave $50,000 to Americans for Tax Reform, run by the conservative anti-tax activist Grover Norquist.

In contrast, PhRMA gave lesser amounts to groups identified as centrist or left-leaning.

Mostly smaller amounts went to centrist and liberal groups. Center Forward, which claims to seek bipartisan, common ground on drug policy and other issues, received $300,000 directly from PhRMA and another $179,000 from a PhRMA-backed group called the Campaign for Medical Discovery, according to tax filings.

And the groups to which they donated were also pursuing narrower issues that supported the industry's economic interests, not broadly partisan (and in this case, prro-Democratic) issues. For example,

Center Forward worked to preserve a tax credit for researching rare-disease medicines known as orphan drugs. PhRMA took a similar stance, encouraging Congress “to maintain incentives” for rare-disease drugs.

The KHN article noted that there is evidence that individaul pharmaceutical companies hide their political advocacy, possibly mainly their advocacy of right-wing and/or Republican backed causes, in similar ways.

Johnson & Johnson gave $35,000 that year to the Republican Main Street Partnership, a 501(c)(4) that describes itself as a coalition of lawmakers committed to 'conservative, pragmatic government,' the C.P.A. data shows.

But the center’s research also shows that many pharmaceutical companies don’t disclose donations made to 501(c)(4) organizations, nor are they legally required to do so.

Corporations 'could dump millions into one of these (c)(4)s and nobody would ever know where it came from,' said Steven Billet, a former AT&T lobbyist who teaches political action committee management at George Washington University.

Summary and Discussion

So in three cases, health care corporations, and/or their trade associations, made significant financial contributions to dark money organizations, thus avoiding reporting of such fund transfers.  In two cases, these fund transfers went to organizations with clearly partisan, right-wing, pro-Republican and/or pro-Trump agendas.  Yet the corporations and their trade association had publicly committed themselves to social responsibility, putting patients and health care ahead of all other concerns, and had never advertised themselves as partisan, explicitly politically conservative, and/or Republican.

This is a new dimension of stealth health policy advocacy or stealth lobbying.  Most of the previous, at least pre-2016 campaign, examples we had found of these involved corporations promoting measures that would improve their revenue (and consequently their top managements' pay).  They did not involve explicitly siding with a single political party or political philosophy.

Patients, consumers, health care professionals, and the public at large might not be pleased but would probably not be too suprised that health care corporations and their management pursue financial self-interest, but prefer doing so without much publicity.  However, I suspect most people would be unpleanatly shocked to find out that well-known health care corporations have been actively siding with a single political party and that party's ostensible political philosophy, but keeping that support very quiet.

Since such dark money support is by definition secret, who knows how many health care organizations have been doing this?

As an aside, I wonder if this hidden support from large corporations has pushed one political party to more extreme actions despite such actions' popular disfavor?  But that is for more politically attuned people to ponder.

In any case, as we have said again and again,...

There are myriad ways corporate and political insiders push health policy agendas because of self-interest, regardless of their effects on patients' and the public's health.  Health policy in the US has become an insiders' game.  Unless it is redirected to reflect patients' and the public's health, facilitated by the knowledge of unbiased clinical and policy experts rather than corporate public relations, expect our efforts at health care reform to just increase health care dysfunction. 

Physicians, public health advocates, whatever unbiased health policy experts remain must educate the public about how health policy has been turned into a corporate sandbox.  We must try to somehow activate the public to call for health care policy of the people, by the people, and for the people.