Friday, March 15, 2019

For Whom the Door Revolves: Founder and Director of Multiple Biotechnology Companies Became Director of the NCI and Now Nominated to be Acting Commissioner of the FDA

Dr Scott Gottlieb, the first commissioner of the US Food and Drug Administration (FDA) appointed by President Trump, has announced his plans to depart.  At the time of his nomination, Dr Gottlieb's many conflicts of interest were well known (see this NY Times article, for example), as were his exceedingly friendly views of the pharmaceutical/ biotechnology industry (see this long ago post, for example).


President Trump's regime just announced a new acting commissioner, Dr Norman ("Ned") E Sharpless, another industry fan.


Founder and Director of Several Biotechnology Companies

G1 Therapeutics

As StatNews just reported, Sharpless "founded two biotech companies."  His fans cited as proof of the "breadth of his experience,"

the $105 million that G1 Therapeutics, a company Sharpless co-founded, raised in 2017 while developing the lung and breast cancer drug trilaciclib.

Apparently, his work in industry has made Dr Sharpless rich

According to public records, founding these companies may have paid off.  Sharpless reported selling more than 400,000 shares of G1 Therapeutics in October 2017 - which, at the time, were worth more than $9 million.


So far, I have seen no other recent reporting that goes into any detail about Dr Sharpless' connections to the pharmaceutical and biotechnology industry.  Nor did I see much reporting about these relationships from the time Dr Sharpless was appointed to head the National Cancer Institute in October, 2017, again by the Trump regime.

A little digging provided a bit more detail about his relationship to G1 Therapeutics.Crunchbase revealed that Dr Sharpless was a Co-Founder of G1 Therapeutics, a member of its Scientific Advisory Board, and a member of its board of directors.  A  press release from the UNC Lineberger Comprehensive Cancer Center did gush a bit about his ability to raise capital for G1 Therapeutics in May, 2017, a few months before he was appointed to head the NCI.

G1 Therapeutics, Inc., a clinical-stage oncology company in Research Triangle Park with ties to the University of North Carolina Lineberger Comprehensive Cancer Center, has raised approximately $108.6 million in an initial public offering of its stock. The company began trading on the NASDAQ Global Market under the ticker symbol 'GTHX' on May 17.

Furthermore,

Founded in 2008 with support from KickStart Venture Services, a UNC-Chapel Hill program that works to turn University research into new companies, G1 is developing novel therapeutics based on discoveries made by UNC Lineberger Director Norman E. Sharpless, MD, and Kwok-Kin Wong, MD, PhD, then at Dana-Farber Cancer Institute and now at the Perlmutter Cancer Center, NYU Langone Medical Center. The early research that led to the formation of G1 was supported by the University Cancer Research Fund.

'Congratulations to Dr. Sharpless and the entire G1 Therapeutics team for achieving this major milestone, making an impressive market debut and accelerating important advances in cancer therapies,' said Judith Cone, Vice Chancellor for Innovation, Entrepreneurship and Economic Development at UNC-Chapel Hill.

It was an advance in raising capital, although the eventual clinical value of the venture may not yet be clear.  Trilaciclib is apparently still under development and has not been yet subject to big randomized clinical trials.

Sapere Bio


StatNews also reported,

The second company that Sharpless-directed science helped spawn is Sapere Bio, also based in North Carolina

which is

developing a diagnostic text to measure a patient's 'molecular age.'
whatever that may be, and whatever use it may turn out to have, or not.


There is not much more information about Dr Sharpless' relationship with Sapere Bio.  In February, 2019, the WRAL Tech Wire stated,

Physician Norman 'Ned' Sharpless and Natalia Mitin, Ph.D., founded Sapere Bio in 2013. It was originally called HealthSpan Diagnostics, a reference to the period in your life when you’re healthy. The company grew out of the research of Sharpless, who at the time was director of the Lineberger Cancer Center at the University of North Carolina at Chapel Hill.

Apparently, by the time this article was written, he was "no longer involved" with the company.


Consulting and Other Financial Relationships

Further web searching revealed that Dr Sharpless had to disclose other financial relationships with health care corporations in the past.  In 2017, he was one of multiple authors on a paper in The Oncologist (Patel NM et al. Enhancing next-generation sequencing-guided cancer care through cognitive computing. Oncologist 2017; 22: 1-7.)

Norman E. Sharpless: G1 Therapeutics, Unity Biotechnology, HealthSpan Diagnostics (C/A, IP,SAB, OI), Pfizer (H)

Where

(C/A) Consulting/advisory relationship; (RF) Research funding; (E) Employment; (ET) Expert testimony; (H) Honoraria received; (OI) Ownership interests; (IP) Intellectual property rights/ inventor/patent holder; (SAB) Scientific advisory board

The ProPublica Trump Town database also stated that Dr Sharpless was a former consultant to Unity Biotechnology and that

Compensation to be an advisor to Unity is solely through an option to purchase up to 50,000 shares of their stock. Roughly half of these options are unvested.
I cannot find anything more about Dr Sharpless' relationship to Unity Biotechnology, which is apparently yet another start-up biotechnology corporation with drugs in the development pipeline.
 
Again, it appears that Dr Sharpless may have ended these relationships when he became NCI director.  A disclosure in December, 2018, for a talk he gave at the American Society of Hematology included

Sharpless: Pfizer(relationship ended): Honoraria; G1 Therapeutics (relationship ended): Membership on an entity's Board of Directors or advisory committees; G1 Therapeutics (divested): Equity Ownership; Healthspan Diagnostics (relationship ended): Membership on an entity's Board of Directors or advisory committees; Healthspan Diagnostics (divested): Equity Ownership; Unity Biotechnology (divested): Equity Ownership; Unity Biotechnology (relationship ended): Membership on an entity's Board of Directors or advisory committees; Unity Biotechnology (relinquished)


Summary

Dr Norman "Ned" E Sharpless is clearly an experienced academic physician, and hence is a welcome contrast with the many ill-informed ideologues lacking any experience or expertise in biomedical research, medicine, health care or public health recently appointed to important US government health care related positions (for the most recent example, look here).

However, while he held a major academic leadership position, Dr Sharpless had multiple important conflicts of interest, including founding and serving on the boards of directors of several for-profit biotechnology companies, as well as having other financial relationships with health care corporations.  He apparently had already become rich via these relationships before he became director of the US National Cancer Institute (NCI), although he apparently ended the relationships when he assumed the directorship.  As the head of the NCI, he was in a position to have some influence over US health care research policy affecting the pharmaceutical and biotechnology industry.  Hence his appointment to that position was an example of the revolving door.



Now about one and one-half year later, his position as acting commissioner of the FDA will give him much more influence over pharma and biotech.  This appointment is an even more strking example of the revolving door.

Both examples seem to have so far gotten lost in the continuing chaos generated by the Trump regime.

Yet, as we have said until blue in the face, and most recently less than a month ago...

The revolving door is a species of conflict of interest. Worse, some experts have suggested that the revolving door is in fact corruption.  As we noted here, the experts from the distinguished European anti-corruption group U4 wrote,




The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door from industry to the Trump regime once again suggests how the revolving door may enable certain of those with private vested interests to have disproportionate influence on how the government works.  The country is increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism. The latest cohort of revolving door transits suggests that regulatory capture is likely to become much worse in the near future.

Remember to ask: cui bono? Who benefits? The net results are that big health care corporations increasingly control the governmental regulatory and policy apparatus.  This will doubtless first benefit the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people, due to detriment of patients' and the public's health, the pocketbooks of tax-payers, and the values and ideals of health care professionals.  

 The continuing egregiousness of the revolving door in health care shows how health care leadership can play mutually beneficial games, regardless of the their effects on patients' and the public's health.  Once again, true health care reform would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.



Thursday, March 07, 2019

Another Missing Link Discovered: 1969 IRS Rule Change Allowed US Hospitals to Discriminate Among Patients Based on Ability to Pay

Prelude: the Suits in the Elevator

Another long night on call of my interniship was over.  Having managed to wolf down breakfast and brush my teeth, disheveled and in unwashed scrubs I stumbled into the elevator on my way to the wards.  In it were some of well-groomed people in nice suits.  They looked at me with wrinkled noses, oozing disdain.  I wondered who they were: pharmaceutical representatives?  Somewhat troubled, I disembarked the elevator and went to work, just another house-staff cog in the teaching hospital patient care machine.  The suits went up to the management floor.  Later I would learn they were top hospital executives....

Introduction: the Rise of Health Care Dysfunction

Despite some protestations to the contrary (e.g., here), the US health care system has been plagued by dysfunction.  According to a recent Commonwealth Fund study, the US was ranked 11 out of 11 in health care quality, but 1 out of 11 in costs.  Traditionally, health care reform has targeted ongoing problems in the cost, accessibility and quality of health care, but reform efforts have yielded little improvement.  (For example, recently the Accessible Care Act seems to have improved access, but hardly addressed cost or quality.)

In the early 2000s, before we started Health Care Renewal,  we encountered lots of disgruntled health care professionals who thought that health care was going off the rails, but had no idea what to do about it.  Some crude qualitative interviews, and a lot of delving into news stories about health care dysfunction suggested a number of factors that seemed to enable increasing dysfunction, but were not much discussed.  They included threats to the integrity of the clinical data base, including manipulation and suppression of clinical research; deceptive marketing; distortion of health care regulation and policy making; bad leadership and governance; concentration of power, abandonment of health care as a calling, perverse incentives putting money ahead of patient care, teaching, and research; the cult of leadership; managerialism; impunity enabling corruption; and taboos preventing honest discussion. (Look here for details.)

As a medical student, I was idealistic, thinking it was all about taking care of patients in a humane way, based on science. Was I just completely naive?  Others, however, have described health care in the US from the end of World War II into the 1960s as underfunded, but earnest in pursuit of the mission.  It was also a very human affair, not based in large organizations and big business.  Physicians practiced as individuals or in small groups.  Hospitals were local, community-based charitable organizations or teaching hospitals tied to single medical schools.  Insurance was largely provided by regional non-profit organizations or the government. 

We seem to have stumbled down a dark path since those days. Now everything revolves around huge hospital systems and for-profit corporations.  Physicians are now largely corporate employees.  It is all about money.  And we have the most most expensive health care system in world.  How did we get from there to here?

Early on, many of the people we met seemed to insist that it was all inevitable.  Some changes admittedly were not too hard to explain.  For example, after government started providing insurance to the elderly and poor, and research spending ramped up, costs rose, and in the Nixon administration the government outsourced cost control to commercial managed care.  By the 1980s, as Ludmerer wrote in Time to Heal (p 365), under pressure from managed care:

The field of hospital administration became more tightly affiliated with programs of business administration, and hospital administrators increasingly held M.B.A. degrees.  The new hospital administrators assuemed business titles (president or chief executive officer rather than superintendent or director), demanded and received corporate levels of compensation, and retained hordes of management consultants....


Now I could recognize those suits in the elevator.

However, the roots of the huge changes that happened in the US from the end of World War II to now were frequently unexplained.  Why could not business oriented management still put patients first? Why were the new managers so ill-informed, ignorant of or even hostile to the health care mission, self-interested, conflicted or even corrupt? Why did regulation of health care seem so big, yet so ineffectual?  Why were the prices of some goods and services so far beyond any value that they could have provided?  Etc, etc, etc.

Since the early 2000s, we have learned more about the historyof health care dysfunction, and also stumbled upon some missing links that added to the explanation. 

For example, we have discussed:
- how market fundamentalist lawyers challenged the power of medical associations to enforce medical ethics, allowing the commercialization of medical practice (look here)
- how government failure to enforce the responsible corporate officer doctrine allowed the impunity of health care corporate management (look here)
- how an obscure AMA committee (Resource Based Relative Value Scale Update Committee, or RUC) took control of the government process for setting physician payments, hugely favoring payments for procedures and invasive treatments.

This week, we found another missing link.



An Obscure IRS Rule that Allowed Hospitals to Discriminate Among Patients According to Ability to Pay

On March 5, StatNews published a commentary by Patrick Masseo entitled "IRS Rule Changes Helped Create a Payment-Focused Hospital System."  It noted

Often overlooked are small regulatory changes, such as adjustments to Internal Revenue Service codes over the past 70 years, that have allowed hospital care to evolve from a charitable mission into a profit-driven industry.

The historical background is

In 1956, as hospitals were evolving into centers for medical interventions, the Internal Revenue Service issued Revenue Ruling 56-185, which applied solely to hospitals. This ruling was the first to allow hospitals to qualify for federal tax exemptions if they fulfilled qualifications related to providing health care. That represented a deviation from the previous requirement of affiliation with a religious institution or fulfilling another charitable purpose.

Revenue Ruling 56-185 established four criteria that a hospital must fulfill to qualify for 501(c)(3) tax-exempt status:

- be organized as a nonprofit charitable organization for the purpose of operating a hospital for the care of the sick

- be operated to the extent of its financial ability for those not able to pay for the services rendered and not exclusively for those who are able and expected to pay

- not restrict the use of its facilities to a particular group of physicians and surgeons, such as a medical partnership or association

- net earnings must not benefit directly or indirectly any private stakeholder or individual

Through criteria 2 of Revenue Ruling 56-185, the IRS — not the legislative, executive, or judicial branches of government — mandated that tax-exempt hospitals must provide care to patients who were unable to pay without an expectation of payment.

 However, for reasons that remain unclear,

  
In 1969, the IRS issued Revenue Ruling 69-545, which updated the federal tax exemption requirements for hospitals. This ambiguous ruling, written as a case example rather than a defined list, included a subtle change of language that permitted tax-exempt hospitals to restrict access to care depending on a person’s ability to pay. For many individuals, that meant their health insurance status. According to Revenue Ruling 69-545, a hospital that operates as described as follows (emphasis added) would qualify:

The hospital operates a full time emergency room and no one requiring emergency care is denied treatment. The hospital otherwise ordinarily limits admissions to those who can pay the cost of their hospitalization, either themselves, or through private health insurance, or with the aid of public programs such as Medicare. Patients who cannot meet the financial requirements for admission are ordinarily referred to another hospital in the community that does serve indigent patients.

This language is a subtle yet monumental contradiction of the IRS’s original 1956 guidance, which stated that a 501(c)(3) hospital 'must not, however, refuse to accept patients in need of hospital care who cannot pay for services.'

Revenue Ruling 69-545 was neither an act of Congress nor a flashy executive order, yet it laid the foundation for the U.S. health care system to become driven by payment, a privilege of the rich and a necessity continually out of reach for the poor.

There was almost no public discussion of its change and its implications

The year after this ruling appeared, The Tax Lawyer, a publication of the American Bar Association, described the 1969 rule change as 'representing a shift by the [Internal Revenue] Service from requiring the admission of a substantial number of charitable cases in order to qualify for exempt status.'

A 1971 paper written by Marilyn G. Rose for the Catholic University Law Review correctly forecast the implications of this new ruling. 'Most importantly, this tax policy [Revenue Ruling 69-545] operates as unwise health policy by perpetuating and enlarging the gulf between the health care available to the rich and that available to the poor,' Rose wrote.

Beyond those publications, I found little evidence of journalistic coverage of the 1969 rule change. Only a handful of academic papers on it were published between the 1970s and the 1990s.

New IRS rulings have not substantially changed the effects of the 1969 ruling.  Since 1969, but especially in the last 30 years, we have seen increasing evidence of hospital leaders' hostility to the traditional mission that put patient care ahead of all else, including revenue generation.  Instead, even in non-profit institutions, leaders have appeared to adopt the shareholder value dogma propogated by business schools, putting revenue ahead of all else (look here).  Of course, as revenue goes up, hospital management has been able to command even greater compensation.  When revenue generation is the main goal, perverse incentives drive ignorance, conflicts of interest, even crime and corruption.

And yet it took 50 years to discover this missing link.

And it raises further questions.  Who was responsible for the 1969 regulatory change?  What was the motivation for it?  Why did it attract so little attention at the time?  Why did nobody really notice it for 50 years?
 
Discussion

Those who are ignorant of history... are unlikely to be able to fully challenge its effects.

As we learn more about the hidden history that explains where we are today, a bigger meta-question is why there has been so little curiosity about the roots of our current health care (and broader political economic) dysfunction, at least until now.

When people do not look to answer questions, it  may be that they fear what they will find.  

While we try to push for all the reforms that are so badly neeed, we are handicapped by our ignorance about how our current troubles came to be.  We must vigorously seek reform while simultaneously vigorously investigating why the world went wrong. 


Sunday, March 03, 2019

Don't Know Much About Health Care and Public Health: Politicans' and Pundits' Unjustified Statements About Causation, Benefits and Risks



A major focus of Health Care Renewal has been problems in leadership and governance of health care organizations, which we believe became major causes of health care dysfunction. We have discussed how leadership is often ill-informed.  More and more people leading non-profit, for-profit and government health care organizations have had no training or experience in actually caring for patients, or in biomedical, clinical or public health research. Instead, people trained in business management have largely supplanted health care professionals as leaders of health care organizations.  This is part of a societal wave of "managerialism."  Most organizations are now run by such generic managers, rather than people familiar with the particulars of the organizations' work.  Obviously health care and health policy decisions made by ill-informed people are likely to have detrimental effects on patients' and the public's health.

Through 2016, our examples of ill-informed leadership in health care tended to be executives of hospital systems (e..g.,in 2014, here, on the mishandling of a patient with Ebola in a hospital system led by generic managers; and in 2013, here, on a luxurious hospital led by a former hotel executive).  Others were top executives of pharmaceutical corporations (e.g., in 2011, here, on previous Pfizer CEOs).

However, since 2016, when we all seem to have stumbled into an alternative universe, most of the examples we have found of ill-informed health care leadership have come from politicians, government officials, and pundits.  Cases have lately been coming thick and fast, so here is our latest round-up, in chronological order by date of publication.


Kentucky Governor Matt Bevins (R) Stated that Television Shows About Zombies Cause Mass Shootings

In November, 2018, the Washington Post reported,

Kentucky Gov. Matt Bevin (R) has been forthright about what he believes are the root causes of mass shootings. A few months ago, he blamed gun violence on children’s access to smartphones, video games and psychotropic drugs.

Most recently, he blamed society’s obsession with a specific genre of violent entertainment.

'Seriously, what’s the most important topic that seems to be in every cable television network for example? Television shows are all about what? Zombies,' he said in an interview Tuesday with conservative Kentucky radio host Leland Conway.

Mass shootings point to deep cultural problems, Bevin said, particularly in a society that consumes daily doses of violence through the media. He acknowledged tying zombie shows to gun violence might be perceived as 'trite and simplistic.' But, he argued, American culture is 'inundated by the worst things that celebrate death,' including the forms of entertainment young people consume.

Needless to say, he cited no evidence, and I am aware of no good evidence that television shows about zombies cause people to stage mass shootings.

Governor Bevin, according to Wikipedia, had a career in finance and business management, and has no background in health care or public health.

Tennessee Republican Representative Elect Dr Mark E Green Stated Concern that Autism is Caused by Vaccine Preservatives

In December, 2018, the Tennessean reported,

'Let me say this about autism,' Green said. 'I have committed to people in my community, up in Montgomery County, to stand on the CDC’s desk and get the real data on vaccines. Because there is some concern that the rise in autism is the result of the preservatives that are in our vaccines.'

'As a physician, I can make that argument and I can look at it academically and make the argument against the CDC, if they really want to engage me on it,' Green said.

While it is very hard to disprove the hypothesis that vaccines or their preservatives cause autism, the CDC and the American Academy of Pediatrics have stated that there is no good evidence that they cause it.  Interestingly, the Tennessee Department of Public Health quickly made a similar statement to refute Representative Green's concern (look here).

Rep Green is definitely a physician, apparently in emergency medicine.  Whether he has had any training in evidence-based health care is unknown.

Kentucky Governor Matt Bevin (R) Implied that Exposure to Severe Cold Weather is Harmless

On January 29, 2019, the Louisville Courier-Journal reported,

Gov. Matt Bevin prodded Kentucky school districts to toughen up in the face of dangerously frigid winds that are blowing through the region.

Speaking on 840 WHAS radio Tuesday, host Terry Meiners reminded Bevin that he would be up late tonight with his children because of classes being canceled on Wednesday.

'Now we cancel school for cold, I mean —  Bevin said.

'It's deep freeze; this is serious business,' Meiners responded.

'Come on, now,' Bevin said. 'There's no ice going with it or any snow. What happens to America. We're getting soft, Terry, we're getting soft.'

The upcoming weather forecasts for that time were:

Arctic air from the polar vortex has gripped the country, causing several school districts in the Louisville area — including Jefferson County Public Schools and Catholic schools — to be closed Wednesday as temperatures are expected to dip to a low of 5 degrees.

With the wind chill on Wednesday morning, forecasters say that it could feel as cold as minus 10 or 20 degrees in parts of Louisville.

Note that school children may have to be exposed to such conditions for considerable time when they are walking to or waiting at school bus stops.  The hazards for frostbite and hypothermia increase as wind chill gets worse.  Wind chill near minus 25 degrees (F) can cause frostbite in 30 minutes per the National Weather Service (look here).

We discussed Gov Bevin's lack of health care and public health background above.

Arizona State Legislators Considering Declaring Pornography a Public Health Crisis

According to the Arizona Republic, on February 7, 2019,

Citing concerns about the proliferation of erotic images online and their 'toxic' effect on behavior, Arizona lawmakers are pushing to declare pornography a public health crisis.

State Rep. Michelle Udall, R-Mesa, introduced a measure that declares the crisis and states porn 'perpetuates a sexually toxic environment that damages all areas of our society.'

'Like the tobacco industry, the pornography industry has created a public health crisis,' Udall told lawmakers.

There is no good evidence that pornography is a serious public health problem.  As the Republic noted,

There are numerous conflicting studies about the affects of pornography viewership. Some studies document negative affects on relationships and addictive behavior.

But other researchers say there isn't evidence to show porn is addictive in the same way as alcohol or tobacco, though the perception of addiction can lead to psychological distress.

In some countries, instances of sexual assault declined after porn was legalized, leading some to hypothesize that it provides a safe outlet for sexual expression.

Note that a number of other state legislators have made similar claims, as we discussed here.

Fox News Pundit Pete Hegseth Stated that "Germs are Not a Real Thing," and that Handwashing is Unnecessary

On February 11, 2019, per the Miami Herald, Mr Hegseth stated,

'As I told you my 2019 resolution is to say things on air that I say off air ... I don’t think I’ve washed my hands for 10 years,' Hegseth said, inexplicably.

Then,

'Really, I don’t really wash my hands ever,' Hegseth continued.

'I inoculate myself. Germs are not a real thing. I can’t see them. Therefore they’re not real,' Hegseth insisted.

'So you’re becoming immune to all the bacteria,' Bila replied.

'Exactly,' said Hegseth. 'I can’t get sick.'

If germs are not real, how can one be immune to them? Setting aside this apparent self-contradiction, the germ theory of disease was considered already well established by the early 20th century.

Hegseth is a Fox News pundit with no background in health care or public health, according to Wikipedia.

Darla Shine, Wife of White House Communications Director, Stated that Having Measles Prevents Cancer

On February 15, 2019, the Washington Post reported,

Darla Shine, the outspoken wife of White House communications director Bill Shine, has been tweeting about childhood diseases, claiming that illnesses such as measles, mumps and chickenpox 'keep you healthy & fight cancer.'
According to the Daily Beast, she also tweeted:

Here is a study from Scientists at Mayo Clinic who were interviewed by CNN and they say they have clinical studies that #Measles Virus kills #Cancer
However, the Washington Post article noted,

Len Lichtenfeld, interim medical director of the American Cancer Society, told The Washington Post on Thursday there is no evidence that contracting measles makes a person healthier later in life or helps prevent cancer.

In addition, Lichtenfeld said, 'It’s easy to forget the disease burden that came with measles when we were young.'

'It is a real illness with real consequences,' he said. 'Fortunately, for most people, those consequences were not serious, but it is an infection, and it can cause life-threatening events. It can cause pneumonia, and it can cause meningitis. Fortunately, those complications are rare but do occur — and children did die as a result of measles infections.'
And, as the Daily Beast noted, the study to which Ms Shine referred used a modified measles virus that was engineered to reduce its disase causing ability, and so the study was not likely applicable to the native version of the virus.

It is hard to find biographical information on Darla Shine, but there are some reports that she was a television producer, and no indication she has a health care or public health background.  (I included her in this post because I thought her position put her in a position to be a pundit, but one could debate that.)

Texas State Representative Bill Zedler (R) Implied that Antibiotics are an Effective Treatment for Measles, and Hence Measle Vaccination is Unneeded

On February 26, 2019, the Texas Observer reported,

Texas state Representative Bill Zedler doesn’t understand the fuss over the resurgence of infectious diseases. 'When I grew up, I had a lot of these illnesses,' he said, listing measles, mumps and chickenpox.

Then,

'They want to say people are dying of measles. Yeah, in third-world countries they’re dying of measles,' Zedler said, shaking his head. 'Today, with antibiotics and that kind of stuff, they’re not dying in America.' Zedler says he’s adamantly in favor of 'freedom of conscience' and against mandatory vaccination. 'This is not the Soviet Union, you know.'

Measles is caused by a virus, not a bacteria.  Antibiotics have no effect on it.  People rarely die of measles in America, mainly because until recently, due to vaccination, very few people were afflicted with measles anymore.

According to Wikipedia, Zedler's highest degree is an MBA, although according to his state legislative webpage, he worked as a manager for various health care related businesses, and currently serves on the Public Health Committee.

Arizona State Representative Kelly Townshend (R) Asserted Vaccines Cause Many Serious Adverse Effects, Based on a Single Personal Anecdote

On March 1, 2019, the Washington Post reported,

Republican State Rep. Kelly Townsend, a five-term state representative who is no stranger to making controversial and befuddling statements on social media, took to Facebook on Thursday to bemoan that Arizona was 'prepared to give up our liberty, the very sovereignty of our body, because of measles.'

Why? Because doing so would be “Communist.”

'I read yesterday that the idea is being floated that if not enough people get vaccinated, then we are going to force them to,' Townsend wrote on Thursday morning. 'The idea that we force someone to give up their liberty for the sake of the collective is not based on American values but rather, Communist.'

Ah, those Communists are at it again.


Why did Rep Townsend feel so strongly about vaccines?  She actually "acknowledges the voluminous studies supporting the need for and safety of vaccines," however

Townsend says her opposition is rooted in her experience. The legislator’s 22-year-old daughter has significant medical problems that she blames on a vaccine she received when she was 10 months old. She says no scientific evidence will convince her otherwise.

'My entire life has been a struggle, and it’s been nothing compared to my daughter’s struggle, and it’s been due to the shots she got at 10 months old,' she said. 'You can have 10 years’ worth of daily articles saying vaccines do no harm and I won’t believe it because it happened to us.'

As we noted above, there is good evidence that measles causes important morbidity to a significant number of people afflicted, and that the vaccine is effective in preventing measles.  While no vaccine is perfectly safe, there is no good evidence that the measles vaccine is particularly dangerous.

Rep Townsend's case is apparently built upon a single anecdote, that her child got some unspecified disease soon after a vaccination.  This is a classic case of anecdotal reasoning, and is logically fallacious.  She appears unaware that two events happening in sequence can often be unrelated.  Suppose her daughter ate chocolate ice cream before she got sick.  Would Rep Townsend be pushing to outlaw chocolate ice cream?

Oddly enough, Rep Townsend reportedly has a masters degree in infant-family practice from Arizona State, which was designed to prepare her "to work in prevention and intervention programs, serving families with infants, toddlers and preschool-age children."


Summary

We are seeing increasing numbers of cases of spectacularly ill-informed statements made by people in positions to influence political decisions affecting health care and public health.

It would be too much to expect that health care policy debates would be rigorously evidence-based.  It does seem to me that in the past political leaders at least made some attempt to consult with health care professionals or academics before taking on complex health care issues.  However, lately they seem to be happy to loudly express views devoid of fact justification or sometimes rationality.

We have proposed that ill-informed leadership of health care organizations is often the result of "managerialism."  We have discussed this doctrine, promoted in business schools that people trained in management should lead every type of human organization and endeavor.  Management by people from the disciplines most relevant to the mission and nature of particular organizations should be eschewed.  So managers, not physicians or other health care professionals, should lead health care organizations.  Following that theme, managers, or those like them, rather than health care professionals and health policy experts should lead health policy. 

However, the increasing numbers of spectacularly ignorant utterances made by political figures and newly appointed leaders of government health care organiations cry out for other explanations.  One may be the increasing influence of propaganda and disinformation in the health care space.  Another may be a trend toward anti-intellectualism or what has recently been termed "The Death of Expertise" (see this New York Times review of a book with that title.)  And the extreme relativism of post-modernism, which we also discussed in the context of the current debate on health care reform, could be another.

Facts, however, are stubborn things. Physiologic processes, and pathogenic organisms do not listen to assertions about the existence of "alternative facts."  Evidence is evidence, no matter whether it offends politicians, religious leaders, or corporate executives.  Basing legislation and political decision-making on the sorts of alternative thinking displayed in the cases above could lead in real life to adverse consequences for the sick, injured and vulnerable.  True health care reform requires clear thinking and the input of people who actually know something about health care.


Friday, February 22, 2019

The Revolving Door Spins Again: the Now Constant Coziness Between the Health Care Industry and US Government

Just because Washington DC is now crazy town does not mean the revolving door has stopped spinning.  We have been dutifully accumulating cases, so it is time to present our latest update.



I will divide this into two sections 1) the incoming revolving door, through which come people from the health care industry to enter US government positions in which they may influence health care regulation or policy relevant to their former positions; and 2) the outgoing revolving door, through which go people from US government positions in which they influenced health care regulation or policy to industry positions which were relevant to the scope of their government work.  In each section, we will list cases chronologically according to when they were made public.

Incoming Revolving Door Transitions

James Parker from Multiple Positions in For-Profit Health Insurance Companies to Director of DHHS Office of Health Reform

This was reported in Health Leaders Media in April, 2018:

Parker's profile on LinkedIn says he worked for Anthem from 1995 through 2004, serving more than four years as president of Anthem Blue Cross and Blue Shield of Maine.

Parker then worked about five years for WellPoint after it was acquired by Anthem, serving as president of federal employee benefits, then president of federal government solutions, then chief of staff to President and CEO Angela Braly.

Parker spent more than three years as an independent healthcare consultant before landing his job as president and CEO of provider-sponsored IU Health Plans in 2012. Last year, he was named president and CEO of MDwise, an Indianapolis-based Medicaid managed care organization.

Note that current Secretary of DHHS Alex Azar, who came to his job from a top management position in pharmaceutical giant Eli Lilly, rationalized Parker's appointment thus:

His knowledge and expertise will be vital to our work at HHS to ensure that Americans have access to insurance that meets their needs,
Funny, he did not seem at all worried about putting a long term leader of for-profit health insurance companies in charge of ... health care (but operationally largely health insurance) reform.

Andrew Smith from a Legal Firm for which he Represented Numerous Large Health Care Corporations to Head of Federal Trade Commission Consumer Protection Bureau

This was summarized in The Hill in December, 2018:

The top consumer protection official at the Federal Trade Commission (FTC) is barred from handling cases involving more than 100 different companies due to conflicts of interest from his prior work as a private sector attorney, according to documents obtained by the consumer group, Public Citizen.

Andrew Smith, who was tapped as the chief of the FTC’s Consumer Protection Bureau in May, listed 120 conflicts on a financial disclosure form that Public Citizen released on Thursday.

The Hill's reporting emphasized Smith's representation of financial and technology firms, but he also represented a number of big health care corporations, based on the disclosure form that Public Citizen obtained via a freedom of information act (FOIA) request.

These included Bioverativ (a Sanofi subsidiary), Cardinal Health, GlaxoSmithKline, and the Pharmaceutical Research and Manufacturers of America (PhRMA).

Lisa Gilbert, Public Citizen Vice President of Legislative Affairs, was quoted:

Even in an administration full of unprecedented conflicts of interests, Mr. Smith’s conflicts stand out from the pack

An article in GizModo noted

Senator Elizabeth Warren was another staunch critic of Smith’s hire who in May said the agency’s decision was 'outrageous' and added that the FTC 'should pick someone with a track record of protecting consumers, not companies that cheat people.'

Dr Amy Abernethy from Chief Medical Officer for Roche Subsidiary Flatiron Health to Principal Deputy Commissioner of the FDA

Per Matthew Herper writing for Forbes in December, 2018:

The Food and Drug Administration has named Amy Abernethy, currently the chief medical officer at Flatiron Health, a unit of the drug giant Roche, to one of its highest positions. She will start in a few months.

Abernethy, an oncologist who is credited with helping Flatiron transform data collected from electronic medical records into information that might become acceptable to FDA regulators, will be the Principal Deputy Commissioner for Food and Drugs. This is the highest position at the FDA that is not a political appointment. It cuts across all areas of the agency’s remit, overseeing initiatives that cut across offices that oversee the regulation of drugs, medical devices, tobacco and food. Flatiron was purchased by Roche at a valuation of $2.1 billion earlier this year.

Mr Herper did include this dry statement

That potential conflict of interest could be an issue for some outside the FDA.

Of course, the current FDA commissioner was rather blase about any conflict of interests Dr Abernethy might have:

In his memo to staff, Scott Gottlieb, the FDA commissioner, said that Abernethy’s ethics review is still pending. It will likely help that she is unlikely to own large amounts of stock in either Flatiron or Roche, because Roche paid for Flatiron in cash.

There was considerable discussion of  Dr Gottlieb's own conflicts of interest at the time of his appointment (see, for example, this article from the New York Times).  

Outgoing Revolving Door Transitions

Multiple High Ranking FDA Officials to Pharmaceutical Companies

This was reported in April, 2018 in the newsletter of the Regulatory Affairs Professional Society:

Twenty-year FDA veteran Badrul Chowdhury, most recently director of the Center for Drug Evaluation and Research’s (CDER) Division of Pulmonary, Allergy and Rheumatology Products, has taken a job this month as senior vice president at AstraZeneca.

FDA confirmed to Focus that Chowdury joined the agency in 1997 and left on 16 April. And Chowdury isn’t the only one to leave in recent months for an industry job, FDA said.

Sarah Pope Miksinski, former director of the Office of New Drug Products in FDA’s Office of Pharmaceutical Quality, left the agency in February, also for AstraZeneca. And last July, Geoffrey Kim, former director of FDA’s Division of Oncology Products moved to AstraZeneca to become its VP of oncology and head of oncology strategic combinations.

Meanwhile, Jean-Marc Guettier, former director of FDA’s Division of Metabolism and Endocrinology Products, left FDA in December 2017 for Sanofi, Niraj Mehta, former associate director for global regulatory policy at FDA moved over to Merck as a director in March 2018....
So where could former FDA officials get such well compensated, top positions outside the pharma industry?

Bruce Greenstein, Chief Technology Officer of DHHS to LHC Group (For-Profit Home Health Care Provider)

Reported in the Home Health Care News in May, 2018:

HHS CTO Bruce Greenstein will become LHC Group’s first chief innovation and technology officer in June, the home health, hospice and personal care services provider announced Tuesday.

Note that in 2017, we discussed how Greenstein had transited the incoming revolving door from a health care technology company to DHHS.

Once a revolving door transitioner, always a revolving door transitioner? 

Dr Tom Price, Former Secretary of DHHS to Jackson Healthcare

As reported in Health Leaders Media in January, 2019:

Tom Price, MD, the scandal-plagued former secretary for the Department of Health and Human Services, has been named to the advisory board of Jackson Healthcare.

A spokesperson for the Atlanta-based healthcare staffing firm said that the company is privately held and would not detail Price’s compensation.

It is interesting that Health Leaders Media inserted that phrase, "scandal-plagued," in such a prominent way.  Nonetheless, the leaders of Jackson Healthcare was effusive:

'Nobody has as profound an understanding of the national healthcare landscape as Dr. Price,' Richard L. Jackson, chairman and CEO of Jackson Healthcare, said in a media release. Tom has exhibited an unwavering commitment to preserving the patient-physician relationship. That mindset, along with his physician, business and policy experience, will make him an invaluable addition to our board.'

No scandals to see here, please move on. 

Courtney Price, Assistant Secretary for Legislative Affairs at DHHS to Cigna

In February, 2019, ProPublica published an article documenting the departure of 33 top  executive branch officials for lobbying positions.  These included:

Courtney Lawrence was a longtime aide for Reps. Bill Cassidy and Tom Price and a federal lobbyist for the insurance trade association America’s Health Insurance Plans before taking a job as assistant secretary for legislative affairs at Health and Human Services in March 2017, when Price briefly headed the agency. Lawrence stayed for 18 months before leaving in August 2018 for a director role at Cigna Corp., the health insurance conglomerate.

Lawrence registered as a lobbyist with Cigna in October. Her disclosure forms state that she was working on proposed changes to Medicare, the Affordable Care Act and prescription drug rebates. Federal lobbying disclosures show that Lawrence was one of several lobbyists to communicate with federal agencies and the White House, and not just members of Congress. In a statement, Cigna asserted that the lobbying disclosure — which was prepared by the company — is inaccurate. Cigna blamed a 'formatting issue.' The statement said Lawrence 'does not and will not lobby the Executive Branch.' The company said it would correct her lobbying disclosure form.
So where will she lobby instead?

Alex Campau, White House Health Policy Aide to Cozen O'Connor

ProPublica also briefly noted

Alex Campau, a White House health policy aide now running the health lobbying team at Cozen O’Connor

That should do it for now.

Summary

With so many crises appearing during the Trump regime, the issue of the revolving door seems to get lost in the fray.  However, the Trump regime has supercharged a chronic problem, especially in its proclivity to hire people direct from industry to regulate and set policy that affect their old employers.  As we have said again and again, that is three times in 2018,  

The revolving door is a species of conflict of interest. Worse, some experts have suggested that the revolving door is in fact corruption.  As we noted here, the experts from the distinguished European anti-corruption group U4 wrote,



The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy, especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door from industry to the Trump regime once again suggests how the revolving door may enable certain of those with private vested interests to have disproportionate influence on how the government works.  The country is increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism. The latest cohort of revolving door transits suggests that regulatory capture is likely to become much worse in the near future.

Remember to ask: cui bono? Who benefits? The net results are that big health care corporations increasingly control the governmental regulatory and policy apparatus.  This will doubtless first benefit the top leadership and owners/ stockholders (when applicable) of these organizations, who are sometimes the same people, due to detriment of patients' and the public's health, the pocketbooks of tax-payers, and the values and ideals of health care professionals.  

 The continuing egregiousness of the revolving door in health care shows how health care leadership can play mutually beneficial games, regardless of the their effects on patients' and the public's health.  Once again, true health care reform would cut the ties between government and corporate leaders and their cronies that have lead to government of, for and by corporate executives rather than the people at large.


Thursday, February 14, 2019

How Stupid Do They Think We Are? - Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo

In the early 21st century, the debate about health care reform in the US ramped up.  The result ultimately was the Patient Protection and Affordable Care Act (PPACA, ACA, "Obamacare"), which arguably improved access to health care, made some reforms in the regulation of health care insurance, but did not affect the fundamental reliance of the US on employer-paid, for-profit health care insurance to finance health care for many patients.  Nor did it really affect the issues we discuss on Health Care Renewal (look here for details).

After the tumultuous election of President Donald Trump, the debate started up again with his and his party's attempt to "repeal and replace" Obamacare.  Arguably, Obamacare ended up damaged but not repealed.  Once again, the issues we discuss on Health Care Renewal were ignored, including threats ot the integrity of the clinical evidence base, deceptive marketing, distortion of health care regulation and policy making, bad leadership and governance, concentration of power, abandonment of health care as a calling, perverse incentives, the cult of leadership, managerialism, impunity enabling corrupt leadership, and taboos, or the anechoic effect.  (Look here for a detailed discussion. )

It is time once again to discuss health care reform in the US.  Now the push is from the Democrats and the left, with the stated goals of making care more universal, and perhaps decreasing or even ending the role of for-profit commercial health care insurance companies.

It is no surprise that those who benefit the most from the current system (even as modified by Obamacare) are rushing to its defense. 

Dark Money to Defend Commercial Health Insurance

We already discussed  how large health care corporations, including pharmaceutical and biotechnology companies, have been using dark money to funnel money for distinctly partisan purposes, to defeat whom they perceive as too left-leaning politicians, almost all Democrats.  They seem to fear such politicians might promote health care reform efforts that would be based on "anti-free-market, anti-business ideology," that is efforts to decrease the role of commercial, for-profit health insurance in financing health care.

More recently, the focus has shifted to Democratic proposals for government run single-payer, or "Medicare for all" health insurance. In early January, 2019, the Hill reported

Thomas Donohue, the president and CEO of the Chamber of Commerce, on Thursday vowed to use all of the Chamber's resources to fight single-payer health care proposals.

'We also have to respond to calls for government-run, single-payer health care, because it just doesn't work,' Donohue said during his annual 'State of American Business' address.

The US Chamber of Commerce historically has had many executives of big health care corporations on its board.  We listed 10 such members in 2015.   It also historically has received financial support from some corporations.  We listed 17 in 2018.


Then later in January, The Hill reported that a group called Partnership for America's Health Future started digital ads attacking "Medicare for All."  The Hill stated its

members include major industry players such as America’s Health Insurance Plans and the Pharmaceutical Research and Manufacturers of America
So here we have the leaders of big health care corporations funneling corporate money into propaganda campaigns to defeat government run single payer health insurance, an old policy idea that suddenly is looking politically credible.  Current US regulation and practice allows them to hide the exact amounts spent on such campaigns by processing them through dark money organizations.

Such stealth health policy advocacy is now not new.  What is surprising now is how some top leaders are willing to jump into the debate themselves, rather than just trying to manipulate public opinion through public relations/ propaganda proxies.  Here are some telling examples. in chronological order.

Quest Diagnostics CEO Attacks "Medicare-for-All" Using an Appeal to Authority, an Argument by Gibberish, the Non Sequitur Fallacy, (and an Incomplete Comparison) 

On January 24, 2019, Yahoo Finance reported

A top health care CEO is sounding the alarm on 'Medicare for All,' an idea gaining steam in political circles, including from newly-elected Rep. Alexandria Ocasio-Cortez (D-NY).

'Most people don’t understand the basics of health-care economics in the United States,' said Steve Rusckowski, chairman & CEO Quest Diagnostics (DGX), in an interview with Yahoo Finance editor-in-chief Andy Serwer at the World Economic Forum in Davos, Switzerland....

Mr Rusckowski implied that he knows a lot more about health care economics than most people, so most people should listen to him.  Thus, he began with an implied logical fallacy, the appeal to authority.

He then presented the justification for his argument.

'The majority of people get their health care from their employers, and the majority of healthcare costs are paid by employers and employees,' he said. 'If you look at the $3.5 trillion spent on healthcare costs, that portion is actually funding the Medicare and Medicaid programs throughout this country.'

The syntax was fractured, and so this was incoherent and confusing. In particular, it was not clear to what "this portion" referred.  $3.5 trillion? Health care costs paid by employers and employees?

The context of  his use of that phrase did not help.  Note that US total health spending was reported to be approximately $3.5 trillion in 2017 by the US Center for Medicare and Medicaid Services (CMS).  However, that was total health spending, not just the amount spent by Medicare and Medicaid.  Furthermore, Medicare and Medicaid are funded by sources other than employers and their employees.  While employers and employees pay tax on employee income to fund Medicare, general funds from the federal government, and from state governments funds Medicaid. Furthermore, many employers pay parts of their employees' private health insurance premiums, while the employees make up the difference in premiums. Self-employed people may may for their own insurance, etc, etc.


Mr Ruskcowski, not to put to fine a point on it, seemed to speaking gibberish, and would use this gibberish to justify his next point.  So in formal terms, he used the logical fallacy of an argument by gibberish.

When incomprehensible jargon or plain incoherent gibberish is used to give the appearance of a strong argument, in place of evidence or valid reasons to accept the argument.

In any case, Mr Rusckowski went on to argue that he

remained skeptical of a Medicare-for-all plan funded by corporations and employees. 'I don’t think [corporations and employees] can afford to provide that access as described.'
However, not only were his earlier statement gibberish, they were not clearly arguments in support of his contention that corporations and employees cannot "afford to provide that access as described."  So this appeared to be an example of the logical fallacy of the non-sequitur.

Mr Rusckowski's total compensation as CEO of Quest was over $10 million in 2017, as estimated by Bloomberg News.  So it is perhaps not surprising that is self-interest in preserving the status quo was strong enough to motivate him to jump into the debate.  One would think, however, that someone who managed to become a rich CEO of a medical diagnostic company could manage to be a bit more logical.

Anyway, he has some strange bed-fellows in this cause, including two billionaires who are not directly involved in health care corporations, but who have obviously benefited from the current economic status quo.

Michael Bloomberg and Howard Schultz Used the Incomplete Comparison Fallacy

Two billionaires provided striking examples of one logical fallacy. 

First, from the New York Times, January 29, 2019:

Mr. Bloomberg, the former New York City mayor who is considering a 2020 bid on a centrist Democratic platform, rejected the idea of 'Medicare for all,' which has been gaining traction among Democrats.

'I think you could never afford that. You’re talking about trillions of dollars,' Mr. Bloomberg said during a political swing in New Hampshire, which holds the nation’s first primary in 2020.

'I think you can have ‘Medicare for all’ for people that are uncovered,' he added, 'but to replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time.'

Second, from CNN on January 30, 2019:

'Why do you think Medicare-for-all, in your words, is not American?' CNN's Poppy Harlow asked Schultz on Tuesday.

'It's not that it's not American,' Schultz said. 'It's unaffordable.'

'What I believe is that every American has the right to affordable health care as a statement,' Schultz said, lauding the Affordable Care Act, otherwise known as Obamacare, as 'the right thing to do.'

He added, 'But now that we look back on it, the premiums have skyrocketed and we need to go back to the Affordable Care Act, refine it and fix it.'

He argued that the Democratic progressive platform of providing Medicare, free college education and jobs for everyone is costly and as 'false as President Trump telling the American people when he was running for president that the Mexicans were going to pay for the wall.'

So both billionaire Bloomberg and billionaire Schultz stated that Medicare-for-all would cost too much.  Yet neither addressed how much our current health care system costs.  However, as a subsequent op-ed in the Washington Post by Paul Waldman pointed out, it only makes sense to talk about affordability in the context of a comparison with a reasonable alternative, say, the current health care system:

there is one thing you absolutely, positively must do whenever you talk about the cost of a universal system — and that journalists almost never do when they’re asking questions. You have to compare what a universal system would cost to what we’re paying now.

there have been some recent attempts to estimate what it would cost to implement, for instance, the single-payer system that Sen. Bernie Sanders (I-Vt.) advocates; one widely cited study, from a source not favorably inclined toward government solutions to complex problems, came up with a figure of $32.6 trillion over 10 years.

That’s a lot of money. But you can’t understand what it means until you realize that last year we spent about $3.5 trillion on health care, and under current projections, if we keep the system as it is now, we’ll spend $50 trillion over the next decade.

Again, you can criticize any particular universal plan on any number of grounds. But if it costs less than $50 trillion over 10 years — which every universal plan does — you can’t say it’s 'unaffordable' or it would 'bankrupt' us, because the truth is just the opposite.

These are text-book examples of the fallacy of incomplete comparison.

By the way, buried amongst his use of gibberish and non-sequiturs, Quest Diagnostics CEO Rusckowski also opined that Medicare-for-all would be unaffordable without any reference to the costs of the status quo, and hence also provided an example of an incomplete comparison.

The Waldman op-ed noted

The fact that these two highly successful businessmen — whose understanding of investments, costs and benefits helped them become billionaires — can say something so completely mistaken and even idiotic is a tribute to the human capacity to take our ideological biases and convince ourselves that they’re not biases at all but are instead inescapable rationality.

Maybe.  However, it may also be a tribute to their arrogance bred by decades of public relations (which Bernays thought sounded better than "propaganda") and disinformation meant to soften up the minds of the public so that they will follow the lead of the rich and powerful.  

Schultz Also Added an Appeal to Tradition (or to Common Practice)

Also on January 29, the Washington Post reported that

Schultz referred to a town hall hosted Monday night by CNN in which Harris embraced a 'Medicare-for-all' single-payer health insurance system and said she would be willing to end private insurance to make it happen.

'That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

'That’s not correct. That’s not American,' Schultz said on CBS. 'What’s next? What industry are we going to abolish next? The coffee industry?'

Presumably, by saying "that's not American," Schultz means that is not what we have always done, that is not what has been traditional American practice, begging the question of whether that practice could be ill-advised.  Thus Schultz appeared to ladle on an appeal to common practice, otherwise known as an appeal to tradition

As an aside, the quote also suggests that Schultz's real concern is not with the affordability of Medicare-for-all, particularly in comparison with that of the current system, but with the financial health of the insurance industry.  But that is for another day....

Summary

So, to protect against the dread "Medicare for all," that is, proposals for a government single-payer health insurance system to replace our current practice of financing health care through large, mainly for-profit  insurance companies, we see an acceleration of public relations/ propaganda paid by undisclosed donors, that is, via dark money.  We also see prominent multi-millionaire and billionaire executives laying down a barrage of logical fallacies to support the status quo.


It is hard to believe that the defenders of the current system are not mostly self-interested.  That status quo has made some people very rich.  

It is also hard to believe they are stupid.  However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

In 2011, we wrote,

Wendell Potter, author of Deadly Spin, has provided a chilling picture of health care corporate disinformation campaigns and the tactics used therein.

In particular,

Mr Potter recounted how deceptive PR campaigns subverted the health care reform plans of US President Bill Clinton, reduced the impact of Michael Moore's movie, 'Sicko,' and helped to remodel the recent health care reform bill to reduce its threat to commercial health insurers.  He further noted how PR distracted public attention from the growing faults of a health care system based on commercial health insurance, and how practical and legal safeguards against abuses by insurance companies were eroded.

Furthermore, Mr Potter

described 'charm offensives;' the deliberate creation of distractions, including the planting of memes for short-term goals that went on to have long-term adverse effects; fear mongering; the use of front groups, including 'astroturf,' (faux disease advocacy and/or grass roots organizations), public policy advocacy groups, and tame (and conflicted) scientific/professional groups; and intelligence gathering.  He provided some practical advice for detecting such tactics. For example, be very suspicious of policy advocacy by groups with no apparent address or an address identical to that of a PR firm, or with anonymous leaders and/or anonymous financial backing.

Now it is 2019, once again health care reform is in the air, and once again the defenders of the status quo are hard at work.  Now, they are even wealthier than they were 10 years ago, and have even more sophisticated tools, like social media and its hacks, at their disposal.  Still, however, their arguments are ultimately built on sand.

As I did in 2011, it makes sense to quote Wendell Potter

onslaught drastically weakened health-care reform and how it plays an insidious and often invisible role in our political process anywhere that corporate profits are at stake, from climate change to defense policy.
[Potter, Huffington Post]
So,
The onslaughts of spin will not stop, the distortions will not diminish, and the spin will not slow down. To the contrary, spin begets spin, as the successes of corporate PR functionaries increase the revenues of their employers, further funding their employers' efforts to create a more hospitable climate for their business interests. Americans are thus being faced with increasingly subtle but effective assaults on their beliefs and perceptions. Their best defense right now is to understand and to recognize the sophisticated tactics of the spinners trying to manipulate them.

Most important is a singular mandate: Be skeptical.
[Potter, Huffington Post]

I still hope that summarizing some of Mr Potter's amazing points will help us all to be much more skeptical.

You heard it here first.

ADDENDUM (22 February, 2019) - This post was re-posted on Naked Capitalism.  See the comments section for a quite interesting discusison. 



Wednesday, January 30, 2019

Watching the Detectives: Logical Fallacies and Unsubstantiated Claims to Denigrate Investigations of Leaders' Conflicts of Interest and Alleged Corruption

Introduction: Logical Fallacies and Unsubstantiated Claims in Defense of Conflicts of Interest in Health Care

We have long been concerned about deceptive marketing to sell health care products, and deceptive public relations to push policy positions favorable to health care organizations' leaders.  Deceptive marketing and public relations may morph into stealth marketing and stealth advocacy, and then  outright propaganda and disinformation.

At the same time, we have long been concerned about how leaders have become unaccountable for the conflicts of interest generated and outright criminal and corrupt behaviors by their organizations.  They have thus exhibted impunity.

These concerns have sometimes merged.  We have occasionally written posts about how prominent figures in health care, thought leaders, or as health care marketers like to call them, key opinion leaders with impressive credentials, have used questionable data and logical fallacies to defend their and other health care leaders' conflicts of interest.  For example, most recently, in 2015, I discussed a commenary in the prestigious New England Journal of Medicine defending conflicts of interest affecting health care academics.  At the time, I wrote:

It was more surprising, given the reach of this journal, that these articles featured a catalog of logical fallacies in support of their arguments.  We have noted that logical fallacies have been a stock in trade of those who actively defend laissez faire policies about conflicts of interest, and other kinds of interactions among health professionals and industry.  However, I would not have believed that the New England Journal of Medicine would go along with this sort of thing.

The logical fallacies I cited were burden of proof, appeal to authority, ad hominem, appeal to pity, and the straw man fallacy.

I concluded with:

The series of articles about conflicts of interest that just appeared in the New England Journal, while ostensibly scholarly, published by the journal's "national correspondent" in the Medicine and Society section, appear to be polemical.  They deployed a substantial number of logical fallacies to make the point that medicine and society have gotten too tough on conflicts of interest.  They are notably short on logical, dispassionate discussion of the evidence.  Thus, they seem more like posts on a very opinionated blog site rather than commentaries in a scholarly medical journal.

I had written similarly in 2012 on logical fallacies employed in a report by the European Society of Cardiology defending, again, conflicts of interest, and again on logical fallacies employed by the new Chancellor of UCSF in the Wall Street Journal, again to defend conflicts of interest affecting academic medicine.

Now, in 2019, we stil see academics with impressive credentials making arguments in national media based on poor data and logical fallacies, but now to defend the highest leaders of our country from charges of conflicts of interest and corruption.

Victor Davis Hanson's Nationally Syndicated Challenge to the Postulated Over-Investigation of the Trump Administration


Here is one recent, vivid, widely published example.  An op-ed appeared in my local newspaper, the Providence Journal, an abbreviated version of a commentary by Victor Davis Hanson which appeared in the National Review, and was syndicated to numerous other right-wing or conservative publications, such as RealClear Politics, TownHall, and in syndication to multiple news media.  Per the ProJo version, Hanson professes to be "a classicist and historian at the Hoover Institution, at Stanford University."  His official Hoover Institute biograpshy states "Victor Davis Hanson is the Martin and Illie Anderson Senior Fellow at the Hoover Institution; his focus is classics and military history."  It claims he has received multiple awards, and has hundreds of publications.  Thus Hanson claims to be a public intellectual, not a polemicist, and may well fit the definition of a thought leader.

Hanson's main point was that President Donald Trump was being unfairly investigated.  He started with quoting the famous question, "who will watch the watchers," and then goes on to suggest that Trump's watchers (auditors, investigators) need to be reined in, implying that it was unreasonable that the Trump administration " has become the most investigated, the most audited, and the most closely examined presidency in history."

I my humble opinion, in support of his contention, Hanson offered arguments were often illogical, and lacked any substantiating evidence.  Therefore, his piece appeared to be propaganda.   Let me first list some of its illogic.

Hanson's Logical Fallacies


Logical Fallacy: Affirming the Consequent

Hanson's main assertion was:

Given President Trump’s unconventional background, his wheeler-dealer past, and the hatred he incurs from the left, few ever give him the benefit of the doubt.

The paradoxical result is that his tenure in just two years has become the most investigated, the most audited, and the most closely examined presidency in history.

Note that the superlative claims, that is those about the "most investigated," "audited," and "closely examined" presidency, are not substantiated.  These are the essence of  Hanson's argument is that Trump has been scrutinized for (morally) bad reasons, e.g., "hatred from the left."  Hanson is arguing this based on the truth of the result, that his presidency is the most scrutinized.  Yet even if it is, that does not prove the reasons were "hatred from the left," etc.  Thus, this is an example of the logical fallacy of affirming the consequent, presenting an argument in an if p, then q format, but then stating that if q is true, p must have true as well. 


Another example of this fallacy was a little way down the page:

his most frequent accusers — the media — have set themselves up as the country’s moral paragon. Journalists now see themselves as social-justice warriors who are immune from the scrutiny to which they subject others.

The result of such self-righteous moral exemption has led to journalism’s nadir, with an unprecedented lack of public confidence in the media. 'Fake news' now abounds, from CNN to BuzzFeed.

The argument here is a caustive one: if journalists are "immune" "social-justice warriors, then the result is "journalism's nadir," and "fake news."

Again, even if it is true that journalism is at its nadir, that does not mean Hanson's postulated cause, journalists as immune social-justice warriors, is true.  However, Hanson's argument, that the investigations are unreasonable, and the auditors need to be audited, arises from his claim that the original auditors, the journalists, are "immune from scrutiny" and need to be reined in.  Again, he states if p, then q, but then argues that because q, then p.

Logical Fallacy: Hasty Generalization

Trying strengthen his case that journalism as at a "nadir," with "fake news" abounding, Hanson then cited the case of a recent BuzzFeed article:

Recently, BuzzFeed (which first published the unsubstantiated Steele dossier) alleged that there was proof that Trump had ordered his erstwhile lawyer, convicted felon Michael Cohen, to lie.

Furthermore,

the BuzzFeed yarn drew a rare rebuke from Special Counsel Robert Mueller’s team, which disputed the veracity of the story.

That was one case, one anecdote.  Hanson did not cite any other examples of faulty journalism in his commenatry.  So this appears to be a version of the logical fallacy of hasty generalization, also known as an argument from small numbers, or anecdotal reasoning.  Citing an anecdote of a particular pheonomenon means that the phoenomenon is possible, but obviously does not mean that the pheonomenon is common, or important.

Again, Hanson made his argument that the investigations of Trump by law enforcement are alos excessive,


The Department of Justice and the FBI are supposed to be our preeminent guardians of justice. But former director James Comey, former deputy director Andrew McCabe, former general counsel James Baker, and several other top FBI officials have either resigned, retired, or been fired — and some may soon be facing indictments themselves.

Setting aside whether resignations, retirements, or even firingsd under these circumstance indicate excessive zeal or criminal behaviore, and whether Hanson's speculation about indictments are valid, he cited only a few cases to imply that investigation of Trump has been excessive.  So this is another case of reasoning from a small number of anecdotes, thus hasty generalization.

Base Rate Fallacy

Hanson went on to embellish his descriptions of the alleged misbehavior by a few Department of Justice personnel.  In particular, he noted

On 245 occasions in sworn testimony before Congress, Comey answered that he either did not know the answers to questions or could not remember the details of events. Had any private citizen tried such stonewalling in an investigation, he or she would likely end up in jail.

He here was no longer citing one or a few anecdotes.  245 occasions seem to be a lot.  However, Hanson's citation of it omits mentioning the numerator.  Setting aside again the notion that people may go to jail for responding to questions under oath by claiming faulty memory or lack of knowledge, Hanson failed to state either how many questions Comey was asked  Without knowing this, one cannot tell whether the Comey's behavior was frequent or rare.  Thus, Hanson's implication that Comey committed some sort of crime, and that doing so discredits his investigation of Trump, was based on the base rate fallacy.  He focused on the number of times an event occurred, while ignoring how many times it did not.

 Logical Fallacy: Incomplete Comparison

Consider again the two sentences written by Hanson above.  Not only did Hanson not establish the rate Hanson claimed faulty memory or ignorance, he did not address how often "private citizens" make such claims.  Thus, even if we knew the rate of Comey made these claims, we do not know the rate private citizens do so.  This thus appears to be an example of the logical fallacy of incomplete comparison, described as "an incomplete assertion that cannot possibly be refuted. This is popular in advertising."   


Hanson's Unsubstantiated Claims of Fact

I found the following relevant examples of claims about frequency or prevalence without any supporting data.

Half the country apparently believes Trump cannot be trusted.

everything he says and does is the object of pushback, opposition, and audit.

'Fake news' now abounds,

I found the following relevant examples of claims about causation without substantiation.

The sexual-abuse crises within the contemporary Catholic Church arose from the de facto exemptions from the law given to priests.

Too many assumed that men of faith were exempt from prosecution because as holy men they would be the last to violate the trust of minors


I found the following relevant unsubstantiated claims about peoples' intent or state of mind.

They all apparently believed that their loud liberal credentials gave them immunity from being held accountable for their harassment.

They apparently assumed that as supposed victims, they could not be viewed as being sympathetic to victimizers.

Journalists now see themselves as social-justice warriors who are immune from the scrutiny to which they subject others.

Weissmann apparently didn’t mind that the dossier was used by his colleagues to deceive the Foreign Intelligence Surveillance Court into granting a warrant to spy on an American citizen.

Credible Allegations of Trump's and Cronies' Conflicts of Interest and Corruption

While spinning his web of logical fallacies and unsubstantiated claims, Hanson ignored the rationale for the multitude of investigations of President Trump and associates.  In fact, there is voluminous documentation of evidence suggesting he has numerous conflicts of interest and he and his regime are corrupt.  We summarized some of the most recent data here, in October, 2018.  As I said then, up to October, 2018...

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.

In October, we summarized the lengthy Tracking Corruption and Conflicts of Interest in the Trump Administration. It broke down Trump and cronies' behavior into the following four categories: 1) US government payments to the Trump Organization; 2) use of the power of the presidency to promote Trump brands; 3)    U.S. government regulatory and policy decisions that benefit the business interests of the Trump family and senior advisors; and 4) private and foreign interests seeking to influence the Trump administration through dealings with Trump businesses.  The lists of specific instances in each category go on for pages, and have grown since October through weekly updates.

Most recently, Citizens for Responsibility and Ethics in Washington (CREW) published a report that listed the following concerning Trump's first two years in office:

CREW has identified 12 foreign governments that have made payments to Trump properties during his first two years in office, each of which is likely a violation of the Constitution’s foreign emoluments clause....

Instead of pushing back on President Trump’s refusal to divest from his business, allies in Congress have embraced the arrangement. 53 U.S. senators and representatives made more than 90 visits to Trump properties during his second year in office, up from 47 visits by 36 members the prior year, and similarly, at least 33 state-level government officials visited Trump properties, likely resulting in taxpayer funds going into Trump’s coffers.

More than 150 political committees, including campaigns and party committees, have spent nearly $5 million at Trump businesses since he became president. In Trump’s second year in office, CREW tracked 33 political events held at Trump properties—13 of which Trump himself attended, meeting and speaking with wealthy donors.

Special interests held at least 20 events at Trump properties during the president’s second year in office. Since Trump took office, at least 13 special interest groups have lobbied the White House, some for the first time, around the same time they patronized a Trump property, suggesting that making large payments to Trump’s businesses is viewed as a way to stay in his administration’s good graces.

Over the past year, President Trump made 118 visits to properties he still profits from in office, bringing his two-year total to 281 visits. CREW also identified 119 federal officials and employees who visited Trump properties over the past year, up from 70 the prior year.
In addition to making frequent visits to his properties, President Trump and other White House staff have promoted Trump businesses on at least 87 occasions. Trump himself mentioned or referred to his company 68 times during his second year in office, more than double the 33 times he did so the prior year.

Paying members at Trump’s resorts and clubs have received benefits beyond getting occasional face time with the President. Four Mar-a-Lago members have been considered for ambassadorships since his election, and three other members—with no federal government experience—acted as unelected, non-Senate-confirmed shadow officials in Trump’s Veterans Administration.
As an aside, in response to Hanson's claim that few have ever given Trump "benefit of a doubt," we discussed here all the credible allegations of misbehavior by Trump prior to his presidency that were investigated minimally, if at all, and which never led to any serious consequences for him.  Trump had been accused of lying to investigators about his Mafia connections; accepting kickbacks; violating fiduciary duties and at least two instances of fraud; failing to disclose he was under grand jury investigation in a casino license application; and perjury.  Also, his casino was found to have committed numerous violations of state regulations, and violating regulations regarding money laundering, but Trump paid no personal penalties.

Hanson ignored all that. 

Discussion

So here is one example, one anecdote, showing, in my humble opinion, an extreme case of illogical, unsupported argumentation in defense of our current president against multiple credible allegations of conflicts of interest and corruption.  These allegations should concern anyone who cares about conflicts of interest and corruption in health care, because the presidency sets the tone for the whole country, and up to now, the executive branch of the US government provided the most and best resources for preventing and challenging conflicts of interest in health care.  Obviously, these allegations should also concern anyone who cares about the state or representative democracy in the US.

This case is notable because of the academic credentials of the person whose argumentation was so illogical and unsubstantiated.  Someone with such a prestigious academic position ought to know better, I think.

The case was also notable for how this widely published article seems to have inspired no criticism to date.  Of course, note that analyzing a short article filled with logical fallacies and unsubantiated claims likely takes much longer than writing said article.  Furthermore, note that the criticism takes much more space than the article itself.  This makes it hard to do criticism that is likely to be noticed much or have much effect.


So in conclusion let me take something I wrote about bad arguments in support of conflicts of interest in medicine in 2015, and edit it for a 2019 audience [additions in brackets]

it is most disappointing that conflicts of interest are now being uncritically and illogically publicly defended by people in positions to exert so much influence on health care [and the greater political economy, and all of society].


Then

True ... reform requires such substantive reform of the financial arrangements among corporations  ... and others who make decisions about patients' or the public's health [and about the health of the political economy and the greater society].  To decide how to accomplish such reform, we need a better discussion informed by logic and evidence, sans logical fallacies. Those who lead health care [the political economy, and the greater society] ought to be able to participate in this discussion under these conditions.


Musical Interlude

To lighten things up a bit, here is a 1978 video of Elvis Costello live performing Watching the Detectives