Tuesday, May 08, 2018

More Dander Rising: Ditto to Dr. Poses

Let me second the emotion now recently and repeatedly voiced by Dr. Poses in these pages. It's getting real hard to separate the health policy and malfeasance fecaliths from the general Washington Scheißsturm raining down on all of us. We feel pretty much buffeted non-stop, like (whomp!) badminton shuttlecocks in the corruption game the prevaricator-in-chief seems happily to carry on forever. Or at least until some better angels out there in America rise up to put an end to it. Because it's pretty obvious the party hacks clearly aren't going to. They're way too busy (padre you're fired! padre you're unfired!) doing other important stuff. And avoiding the wrath (why invite trouble?) of the prevaricator-in-chief.

Maybe tweets are effective covering fire. Maybe it's not a kakistocracy we live in so much as a tweetocracy.

In fact it's also getting pretty easy to find the links between the micro- and the macro-misdeeds in today's kakistocracy. I want to talk about two of those today. Both stem from recent months' events in the game of musical chairs at two of the most cost- and problem-ridden departments overseen by our executive branch. Of course, as the reader likely already surmised, these are the two health-related departments: HHS and veterans' affairs. Dr. Poses has in fact just posted on the latter, given the zany events in the previously barely-known White House Medical Unit.

(In fact, in discussing what happens with the current administration Dr. P has hit upon an essential mechanism linking the macro- and the micro-elements: the posse of inbound revolving door plants whom the White House directs to these departments. In situations where some guy with expertise for a job may show questionable judgment in comporting himself--yes we're always talking about men these days--all too soon, as a result of these inbound hacks, he's offed by those appointed to "help" him. Which makes for great press (?) but poor government. But since when is anything like good government even the point? Hacks make hay while the sun shines. They're out to satisfy their rich donors like the Kochs and Mercers. Some get to stay in place if they're somnolent enough. I mean you, Carson. Others, including folks who're not hacks, for example Dr. David Shulkin at the VA, are out on their tushies before press or good-government critics get to prove much of anything.)

Let's take these two agencies in turn.

The VA. First there was David Shulkin. I've written about him before (e.g. here and here), as has Dr. Poses. Not much more to say here about the guy who came in with good intentions, inaugurated some important positive changes in information technology and elsewhere in a badly-battered organization, then made what might at worst be characterized as some slightly sloppy mistakes in his record-keeping and travel-planning while on official business.

Then the jackals swooped. Out he went. Next up: Ronny Jackson, ER doctor, erstwhile head of the White House Medical Unit and Navy frat-boy par excellence. Ronny was to be Shulkin's replacement, until his boss rewarded his sucking up with a now-standard distancing maneuver. Which might be described as "stir up a fuss, you go under the bus." Jackson, AKA "Dr. Feelgood" (ibid. and here), will never be VA Secretary now, or get his second admiral's star. (Or whatever it is that admirals get.) His unit's curiously isolated place in the hierarchy allowed him allegedly to abuse his reports, but at the same time seemingly left him, his boss, and anyone who's supposed to vet cabinet-level appointees, blind-sided about what it takes to run a large health care organization. Oh, wait, they actually started with someone who had what it takes. But none of this is any longer about good government or effectiveness or expertise. It's about ideology, or ideology as refracted through donors' eyes.

Ideology and narcissism.

And Jackson's boss, as his latest hapless subaltern edges closer to the undercarriage of the bus, says "[t]hey’re trying to destroy a man," Ronny's such a good guy--just look what he said about my health, my hands are clean, it's all fake fake fake. Fake news. Actually, classic gaslighting. Now the boss is going after Ronny's tormentor, Montana Sen. Jon Tester. But my friends in Montana tell me Tester's not got so much to worry about. Montanans are a cussedly independent lot. They don't take too kindly to these bad-mouthing bad boys from out of the swamp over there in Dee-Cee.

So who's next in the cavalcade of stars for the truly humongous VA bureaucracy and its leadership?

One name being bruited about is that of Jeff Miller, a lobbyist who once as a congressman chaired the House Committee on Veterans' Affairs. But according to Newsweek, Miller's real claim to fame is his work lobbying for insider trading hedge funder and Very Happy Guy Steven A. Cohen. Turns out Cohen is a major funder for the privatized health care that Shulkin quite rightly opposed. (See ibid. in Newsweek, and here.) Super-tight in with this crowd are also the Koch Brothers, the Daddies Warbuck for Concerned Veterans for America. CVA is another remarkable organization. It's lofty aims "to preserve the freedom & prosperity we & our families fought & sacrificed to defend" (where'd they find this copywriter?) include notable projects such as "VA Fail."  "VA Fail" is a "tracker" you can actually subscribe to so you can follow each and every one of this department's "missteps, mismanagement and misguidance." This is an obvious set-up to do away with an essential and in many ways still-vital branch of government. One that really needs help to change some dysfunctional internal systems, but still really helps people at reasonable cost compared to the fragmented private systems.

Right now I'm a long, long way from Washington. I'm in a place where government is equally corrupt and dufus-like. But at least the people are nice to each other and hip to their government's misdeeds. Still, it seems these democracies are having a really hard time right about now. Many citizens of the First World have lost faith in their voters' ability to impact the bizarre bull-in-china-shop behaviors of their leaders. Truth is, veterans want an effective and separate VA health system. I know, I worked there for a lot of years. The K-Stone Cops want to give them anything but.

Profit motive über alles. An awful lot of  members of "the Base" are veterans. Will they notice this scam?

Health and Human Services. First there was Tom Price, who was soon out of that job because a minor corruption scandal far eclipsed by his own entirely legal but misguided antics. Antics that while perfectly legal were perfectly dangerous, attempts to make good on campaign promises to sunder HHS and the Affordable Care Act. While Secretary, Georgia orthopedist and anti-Medicare activist Price approached the ACA the way he had most issues once arrived in Congress: undermine, undermine, undermine.

Look at him now. While Secretary, the Post tells us, he was all
"The individual mandate is one of those things that is actually driving up the cost for the American people in terms of coverage” ... on ABC’s “This Week” last summer. So, what we’re trying to do is make it so that Obamacare is no longer harming the patients of this land — no longer driving up costs, no longer making it so that they’ve got coverage but no care.”

But in a preternatural paroxysm of honesty just a week ago, on May Day, Price goes and tells a health conference just the opposite. It was the Congress that knew that the lack of the mandate would drive up the cost of insurance. But ideology and the donors said do it, so with his help they did it anyway. Along with any number of other measures to try and deep-six Obamacare. Of course they failed in spite of themselves--Obamacare is hanging in there. But it's no thanks to the guy whose job it was to make it work. He did everything he could to make it not work. (After his talk, of course, Price tried to walk back some of these views.)

Following Price, we now have a drug company executive, Alex Azar. He's actually done a few good things in his short time over at HHS. I've known a lot of drug company executives, as well as a lot of right wing doctors. The former are often a lot less ideological and a lot more practical than the latter. In a conversation this week with one of the most successful members of the former group, I find when it comes to activities questioned by the political left, e.g. lobbying, the response is remarkably forthright and lacking in hysterical right wing cant. "We need to sell our product" is the message. On which more in a minute.

Right wing doctors who go into politics have all sorts of extra axes to grind. So Azar sort of had a head start on Price.

Thus the focus now shifts at least for the moment from insurance to drug prices, one of the bugabears both of Azar and his boss Donald Trump. At this year's World Health Congress, Azar teed up the trial balloon that floated around the campaign and still bears watching. Azar stated that "President Trump wants to go 'much further' to attack high drug prices," according to many sources including CNBC's Angelica LaVito. But what does this mean? Drug companies have recently upped their spending on both lobbying and campaign giving. This has caused heavy breathing in health policy circles--see here for example--but in my opinion it's mostly chump change. A doubling from spending in the low six figures to the mid six figures for activities that impact government drug-price awareness is, to me, just budget dust for drug companies, and not the driver of change so much as keeping up with the Joneses.

The Big Nut is Medicare and active direct bargaining to get prices down. Will Azar be able to do the in-sell that gets his boss to come out swinging with the biggest weapon he has? The drug companies, when they spend the big bucks, are really playing a different game. There are so many players in the pharmaceutical sales-and-distribution space, most notably the separately powerful PBM (pharmacy benefits management) companies, that everyone's pushing on a wet noodle. The one really reliable weapon Azar and company have, if they're willing to use it, is Medicare spending. This one will be truly fascinating to watch. It will say a lot about whether the President wants truly to drain the swamp and hence really please those in his Base who need affordable meds. Or just refill that swamp in order to please the hacks with whom he's now surrounded himself.

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