Drugs: A Good Reason To Fly To Thailand More Often

I love Thailand. I’ve been going there for 4 decades and have explored every part of the country— from Chiang Rai and the Golden Triangle, through Mae Hong Son, Chaing Mai, Udon Thani, down through Hua Hin, Ko Samui (back when there were no hotels, no phone service and no airport), Surat Thani, Phuket and Yala. And, of course Bangkok. They call it the Land of Smiles and the Thai people are the biggest asset the country has, of course. The food is great too. And I usually get off the plane and head right for Health Land for a 2 and a half hour massage. But now I have a new reason to visit Thailand— drugs.

After cancer treatment I was left with several side effects that have to be treated. Insurance pays for some. For example, I need albuterol to spray into my lungs twice a day. The co-pay is between $70 and $80. In Thailand it’s $6. Yeah, six. All the drugs I take are like that. The worst though is an experimental drug my doctor has me on, locosamide (VIMPAT). My doctor is an award-winning cancer doctor and, in the midst of her research and award winning, she saved my life. When I felt my ability to walk was being threatened by a severe case of peripheral neuropathy caused by one of the chemo drugs, we tried lots of standard stuff that didn’t work. She then prescribed the VIMPAT. The good news is that it’s working. The bad news is that Humana, the insurance company, refuses to pay. The worse news is that it costs $3,000 a month. In Thailand the VIMPAT only costs $600 a month. The savings pays for a vacation!

My own story made me recall a feature David Sirota wrote last summer, although I live in California, not Connecticut, Why Are Drug Prices Going Up? Democratic Power Players Help Pharmaceutical Industry In Connecticut Battle. His set-up should sound familiar to anyone who pays attention to this kind of thing at all: “Wide majorities of voters want public officials to reduce American medicine prices, which are the highest in the world and have become a key driver of skyrocketing healthcare costs. And yet as politicians including Donald Trump and Bernie Sanders have continued to call for a crackdown, corporate power players have successfully blocked even minimal reforms— with the help, at times, of industry-connected Democrats, whose party portrays itself as a consumer-defending critic of the healthcare industry.”

Democrats control the state legislature and the governor’s mansion in Connecticut but the Democratic Party  there is at least partially controlled by the insurance industry. “The clash between populist outrage at rising drug prices and the industry’s political clout in Hartford,” wrote Sirota, “illustrates why seemingly straightforward consumer protection measures still face steep odds.” Keep in mind when you read this that Governor Daniel Malloy is the most hated governor in America.

Fresh off a presidential campaign that saw both parties’ candidates promising to make prescription medicine more affordable, Connecticut lawmakers in January introduced legislation to bring more transparency to drug prices. The bill, which mirrors similar initiatives in other states, also aims to stop insurance companies from effectively forcing their policyholders to pay more for medicine than it actually costs— a lucrative scheme that critics say allows insurers and their affiliated pharmaceutical benefit managers to pocket the difference.

Despite the pharmaceutical industry’s opposition, the Connecticut legislation initially seemed headed for approval: It was sponsored by the Senate Democratic and Republican leaders and was backed by high-profile officials like the Democratic state comptroller.

But a few weeks ago, bill proponents say, Connecticut’s insurance commissioner Katharine Wade pressed for changes that would weaken the penalties in the legislation and leave enforcement of its provisions to the healthcare industry itself.

Democratic Gov. Dannel Malloy, who appointed Wade, came to her defense. “We must take much greater care in considering the impact our actions have on Connecticut insurers,” he said. House Majority Leader Matt Ritter, a Democrat, suggested lawmakers were not sufficiently listening to insurers— and then sponsored an amendment to implement Wade’s proposals. He also backed an amendment to strip out a separate provision in the bill designed to compel insurers to more explicitly disclose all their fees to policyholders.

Much of the pushback was framed as an effort to preserve the roughly 58,000 insurance industry jobs in Connecticut at a moment when Aetna is threatening to move its headquarters out of the state. However, left unmentioned was a web of familial and financial links between the Democratic officials floating changes to  the bill and the industries with a potential financial interest in the legislative outcome.

- Wade is a former vice president of Cigna— the insurance behemoth that runs its own pharmacy benefit manager (PBM) and that is facing a class action lawsuit in Connecticut over its role in an alleged drug price-gouging scheme. As Wade’s department regulates Cigna and its PBM, her husband is an in-house Cigna attorney and her father-in-law, James Wade, is a partner in a law firm working for the PBM, OptumRX, named as a defendant in the Connecticut price-gouging suit. That same law firm lobbies for Cigna and for the health insurance industry’s trade association in the state.

- Ritter’s father, a former Connecticut House Speaker, runs the government relations division of Brown Rudnick— a law and lobbying firm that represents drug manufacturer Boehringer Ingelheim and the Healthcare Distribution Alliance. The latter describes itself as “the national organization representing primary pharmaceutical distributors.”

- Malloy is the chairman of the Democratic Governors Association, which raised more than $6 million from donors in the health insurance and drug industries during the 2016 election cycle, according to data compiled by the Center for Responsive Politics. Malloy was reelected chairman of the group in December— and days later the DGA received $100,000 from UnitedHealth, whose PBM is a defendant in the same Connecticut class action suit over drug prices. With insurance money flowing into the DGA— which directly supported Malloy’s own election campaigns— the Democratic governor has pressed for insurance industry tax cuts, pushed state subsidies for Cigna, and blocked the creation of a publicly run health insurance option.

Katharine Wade, Malloy and Optum did not respond to IBT questions. A spokesman for Ritter said the majority leader “has not been involved in negotiating this bill or the amendments,” despite the fact the amendment, which was eventually dropped, that sought to add Wade’s language back into the bill had his name on it.

James Wade said in an emailed statement, “I have had nothing to do with this case. My appearance was filed merely to accommodate an out of district attorney to enable him to be admitted pro hac vice in this district. Other than that I have not participated in the case.”

Cigna declined to comment. Malloy and Wade have previously said that, despite their attempts to change the bill, they support the larger aims of the legislation.

That assertion has not satisfied lawmakers pushing the bill. Noting that Wade faced a state ethics probe last year over her regulatory involvement in Cigna’s proposed merger with Anthem, Democratic and Republican senate leaders criticized her work on the new prescription drug bill.

“Since you are the chief public officer charged with regulating health insurers, reviewing their financials, and approving their rates in a manner consistent with both the letter and intent of the law and the public interest, we would have expected you to support legislation that improves public transparency regarding drug prices, protects consumers from secret price gouging and prevents the off book accumulation of what is essentially premium revenue,” state Sens. Martin Looney (D) and Len Fasano (R) wrote in a May letter. “Please accept this letter as an expression of our concern regarding your attempt to influence pending legislation in which Cigna, your former employer and your husband's current employer, has a direct financial interest. We believe we have been down this path before and we fear we are heading in that direction yet again.”

America spends more on healthcare per capita than any other industrialized nation— and ever-pricier prescription drugs have fueled that trend. Spending on medicine has in recent years increased more than the overall rate of health spending— and drug expenditures now comprises roughly 17 percent of all healthcare costs, according to a recent study by Harvard University researchers Aaron Kesselheim, Jerry Avorn and Ameet Sarapatwari.

Much of the outrage about high medicine prices has been aimed at pharmaceutical manufacturers— especially after drugmakers’ headline-grabbing price spikes for EpiPens and emergency therapies to combat lead poisoning. Connecticut’s legislative fight, by contrast, spotlights the labyrinthine system of intermediaries between drug manufacturers and American consumers. In the middle of that maze of doctors offices and pharmacies are PBMs, which administer the drug benefits promised by insurers to their policyholders.

When they were first conceived in the 1960s, PBMs held out the promise of using their power to negotiate price discounts, and in recent years, three companies— OptumRX, Caremark CVS, Express Scripts— have accumulated control of the vast majority of the market. That consolidation in the $250-billion-a-year market has not coincided with lower drug prices for consumers. Instead, spending on prescription medication spiked 20 percent between 2013 and 2015, according to Harvard researchers. This year, drug prices for Americans under age 65 are expected to rise nearly 12 percent, almost five times the expected growth in wages for 2017.

In October, lawyers representing Cigna policyholders brought a class action case against the insurer, asserting that, through its deal with OptumRX, the company had illegally conspired to inflate the drug prices charged to thousands of its policyholders.

Cigna, the complaint alleged, either independently or in conjunction with a PBM, required pharmacies to jack up the prices of their prescription drugs— sometimes to more than the full price of the drug. After the patients would pay the inflated fee, usually for generic medicines, the pharmacy would funnel the difference between the drug’s original price and its newly-elevated price, also referred to as the “clawback” or “spread,” to either the insurer or the PBM, according to the suit.

The suit also alleged that the pharmacies were contractually prohibited from alerting patients of the practice or directing them to lower-priced options. In a February report, Bloomberg obtained contracts prohibiting pharmacists from publicly criticizing the PBMs or recommending less expensive ways to purchase the drugs, such as paying the pharmacy directly out of pocket.

The system, lawyers argue, is a violation of the promise that a policyholder’s payment is a shared “copay” between the consumer and the insurer— and that the consumer will never have to pay more than insurers are paying a pharmacy for the covered medication.

“PBMs can serve a helpful role in managing drug insurance, and copays can be a useful strategy when applied to expensive drugs with similarly effective lower-cost alternatives that are assigned lower copays,” Harvard’s Kesselheim told IBT. “But when copays are high and there are literally no other alternatives, then patients have a problem.”

The clawback practice is far from uncommon, according to a June 2016 survey of 640 pharmacists, conducted by the National Community Pharmacists Association. Only 16 percent of respondents said PBMs imposed clawbacks fewer than 10 times per month. More than a third said the practice occurred more than 50 times on a monthly basis, and nearly half said it happened between 10 and 50 times over the same period. A full 87 percent said the clawbacks “significantly affect their pharmacy's ability to provide patient care and remain in business.”

The survey buttressed the lawsuits’ allegations that pharmacists were prevented by “gag clause” rules from telling patients about the alleged scheme or lower-cost alternatives— even if the patient asked. Nearly a fifth of the pharmacists who participated in the study reported “gag clauses” preventing them from telling patients about cheaper options more than 50 times a month, and 39 percent said it happened between 10 and 50 times.Those cheaper options mainly included paying out of pocket— meaning patients paid more for their drugs using their insurance than if they had simply paid the cost of the drug without involving their insurance provider.

“It's really not insurance, is it?” Randal Johnson, the president and CEO of the Louisiana Independent Pharmacies Association, told New Orleans TV station Fox 8 of the alleged Cigna and UnitedHealthcare schemes. “I mean, what is that if you go in and they're negotiating a price for you, and it's actually costing you more to acquire the drug with your insurance than you could if you walked in off the street and you didn't have insurance?”

While the PBMs allegedly extracted the spreads from the pharmacies, it’s unclear whether the insurers or their PBMs are pocketing the difference between what they’re allegedly pushing the pharmacies to charge and the drugs’ wholesale prices.

“We don’t really know what happens to the money. That’s where the lack of transparency makes everything very confusing,” John Norton, the communications director of the National Community Pharmacists Association, told IBT.

“I could break into Fort Knox easier than being informed by the PBMs or insurers the portion of the clawback amount retained by either the insurers or the PBMs,” said Susan Hayes, a founder of and principal at the consulting firm Pharmacy Outcomes Specialists. But unless sponsoring companies— usually very large ones— are contracting directly with their PBMs, in which case the PBM keeps all of the clawback, the insurer and the PBM are probably splitting that spread, she said.

With polls showing that most Americans want lawmakers to move aggressively to lower drug prices, legislators have intensified their scrutiny of insurers and PBMs.

Sens. John McCain (R-AZ) and Tammy Baldwin (D-WI) introduced bipartisan legislation in May to bring transparency to prescription drug pricing. But with the pharmaceutical industry’s lobbying muscle in Washington and huge campaign donations to both national parties, consumer advocates are trying to take the fight local.

“The pharmaceutical industry has spent literally $80 million lobbying in the first quarter this year. They have two lobbyists for every member of Congress in D.C.,” Ben Wakana, executive director of the newly formed Patients for Affordable Drugs, told IBT. “State capitols can provide an opening where people are a little more open-minded because they have not been bought out by pharma.”

Nearly 80 bills have been introduced in 30 states to tackle prescription drug costs, according to the National Academy For State Health Policy (NASHP). Almost all of these bills seek to bring more transparency to the pricing of pharmaceutical drugs.

In Connecticut, the legislation prohibiting both clawbacks and the “gag” contract restrictions came at a particularly sensitive time for the industry— it was introduced just as the drug-price lawsuits against Cigna and OptumRX began moving forward in the state.

During the initial hearings, consumer and physician groups argued that the bill represented an important step in shedding more light on opaque drug pricing policies.

“Pharmacists, like physicians cannot negotiate terms of their contracts with insurers,” said a coalition of medical societies in a statement to lawmakers. “Many physicians believe that if these clawbacks were outlawed and patients were given the information and allowed to choose the cheaper option they would have more disposable income for other medications and other needs.”

The pharmaceutical industry countered by arguing that the current system helps consumers.

“Any provisions that would call for manufacturers to publicly justify the price of certain therapies by detailing the input costs to develop and market them can interfere with the market-based ecosystem that works to bring down prescription drug costs through robust private-sector negotiations,” testified Patrick Plues of the Biotechnology Innovation Organization, a drug industry trade association.

State records do not reflect the insurers publicly lobbying on the legislation, and it is unclear how much insurers are directly receiving from clawbacks. Still, the bill’s sponsors suggested the opposition has been fueled by the industry.

“We naively assumed the health insurance industry would support these common sense reforms designed to save their policyholder's money,” Looney and Fasano wrote in May. “However, we now realize that many insurers have formed their own separate but related PBM businesses which engage in this very same practice...it is clear that the goal of insurer affiliated PBMs is to generate off book revenue that is not subject to regulatory review or public accounting.”

Among the biggest players in the legislation has been Wade, who was Cigna’s top lobbyist from 1992 to 2013. According to Looney and Fasano, Wade “proposed language that would essentially limit the enforcement of the anti-gag and anti-clawback provisions and cede that enforcement to the health insurers and PBMs themselves”— a proposal the lawmakers called the “fox guarding the hen house.” In an interview, Looney told IBT: “I think the pharmacology groups, the manufacturers, are actually for the bill— they’ve been quite helpful. The PBMs and the insurers tend not to be as supportive. The insurers actually own some of the PBMs... I think their interests were being represented by the language the insurance department was suggesting to add to the bill.” A spokesperson for Wade told the Hatford Courant that the senators “omitted an important part” of the language that Wade had proposed be added to the bill. Wade’s office did not respond to repeated IBT requests for comment and for the full language that Wade wanted added to the bill. Malloy defended his insurance commissioner, saying in a statement that “to accuse the commissioner of 'interjecting' herself into an open legislative process by offering appropriate language is ridiculous on its face. It's especially ridiculous given that our administration has been consistently supportive of the underlying bill concept— to imply otherwise is disingenuous at best, and a lie-by-omission at worst.

" Malloy’s statement chastised the senators for their “unnecessary and antagonistic approach toward Connecticut’s insurance industry.” The governor repeated that critique Friday, saying the senate had “turned a deaf ear on the insurance industry” when lawmakers passed a bill that would require insurers to provide additional health benefits for women, children and adolescents and expand contraception benefits.

“They are a very, very powerful lobby here in the state,” Ellen Andrews, executive director of the Connecticut Health Policy Project, told IBT about the insurance industry.

“Honestly, this is a very small thing. If a drug costs $5 why should we be overpaying? Pushback from the administration speaks to how powerful the insurance industry is here.”

Despite Malloy and Wade’s pressure, Connecticut’s senate unanimously passed the drug pricing bill— but the bill’s fate in the House remains uncertain in the waning hours of the legislative session. [Subsequnetly the bill passed in the House.] Ritter, the Democratic Majority Leader, along with the Democratic chairs of the Public Health and Insurance and Real Estate Committees, drafted an amendment containing nearly the exact same language that Wade sought to add into the bill. A later amendment ultimately scrapped the language.

When it comes to health insurance issues, Ritter told reporters that lawmakers should be “careful what they propose.”

“Even if it’s a concept and you want to get a public hearing, be careful. That’s a very important industry to the state of Connecticut,” Ritter said.

But while the bill could be watered down, it is also possible that time to pass it will simply run out. The session ends Wednesday, and it is unclear if the Democratic leadership will bring the bill to the floor for a vote before then, despite the bill’s unanimous passage in the Senate.

Republican Rep. Fred Camillo, a co-sponsor of the legislation, told IBT that although Connecticut politics has changed and “bills that normally would have flew through years ago are not,” he hoped the anti-clawback bill would reach the floor of the House.

“It certainly has a lot of support. We’re hoping it gets called,” he said.

…Matthew Katz, the executive vice president and CEO of the Connecticut State Medical Society, a physicians’ group and a state-level entity of the American Medical Association, said the class action lawsuit’s allegations against Optum should “at least” warrant some sort of review by the state’s health insurance department. But he raised concerns about the familial connections of Wade, the insurance commissioner.

“The wisest thing would be for her to recuse herself if there was an ongoing investigation in this matter. If there is an investigation, she should step back, as there’d be at least a perception of a conflict of interest,” he told IBT.

“There’s a lack of transparency that could rise to the level of deception,” he said. “What seems to be happening here is the patients are getting the short end of the stick.”

Your Captured Government at Work: Conn. Gov. Malloy Met With Cigna and Anthem CEOs During Merger Review

by Gaius Publius

Cigna and Anthem are health insurance giants that want to merge. Cigna is Connecticut-based (the "C" in Cigna stands for "Connecticut") and pulls in over $1.6 billion in revenue. Its 2012 total assets topped $50 billion.

Anthem, Inc. used to be known as Wellpoint, and if you click the link, you'll see that it too is a player. Anthem pulls in over $2 billion annually and its 2012 assets also topped $50 billion. Both companies truly are giants in the health insurance industry. Connecticut is an insurance state, so as you can imagine, the industry controls most politicians (because, "jobs," about which see below.)

Dan Malloy is governor of Connecticut, current chair of the Democratic Governors' Association (DGA) and former co-chair of the Democratic Convention in Philadelphia. Malloy is a mixed bag as governor, supporting some reasonably advanced progressive policies (for example, marijuana reform, opposition to capital punishment) and some not-so-progressive policies ("shared sacrifice" and "union concessions" during budget negotiations).

Malloy also has ethics issues, especially involving the insurance industry:

Connecticut’s Ethics Board is debating whether to launch an investigation into Malloy’s administration. Under Malloy’s watch, one of the largest health insurance mergers in United States history—a $48 billion deal—could potentially increase premiums and reduce health care coverage for 53 million people across the country.

According to the Norwich Bulletin, “When the deal between Connecticut-based Cigna and Anthem Blue Cross Blue Shield was being negotiated in early 2015, Malloy appointed Katharine Wade as the state insurance commissioner. Wade, a former lobbyist for Cigna with a handful of family ties to the company and a firm that lobbies for it, appointed a deputy and an agency counsel who had worked for Cigna.”

Did I mention Malloy was also co-chair of the Democratic Convention in Philadelphia. You don't get to run an operation like that if you're not deeply in favor with those who really run all operations like that — in this case, the money-soaked mainstream of the modern Democratic Party.

The Cigna-Anthem Merger

In 2015 Anthem announced it wanted to acquire Cigna:

In June 2015, U.S. health insurer Anthem Inc. announced an offer to acquire Cigna for more than $47 billion in cash and stock.^[13] Anthem confirmed it had reached a deal to buy Cigna on July 24, 2015.^[14] On 21 July 2016 the US Justice Department filed an antitrust suit to block the proposed merger.^[15]

Part of the problem the Justice Department has with this merger — it will combine the number 2 and number 5 insurance providers — is that Humana and Aetna also want to merge, in a deal that will combine the number 3 and number 4 providers as well. (And for good measure, there are some stories that United Health may have been interested in Aetna.) No good, for consumers, can come from any of this.

David Sirota at IBT (my emphasis throughout):

Citing unnamed sources, Bloomberg and Reuters both reported that Justice Department officials are positioned to file lawsuits to halt Anthem’s multibillion-dollar acquisition of Cigna, as well as a separate merger between Aetna and Humana. The mergers would create the largest private health insurance companies in American history, and reduce the total number of major insurers to just three — a situation that groups representing physicians and consumers said could raise premiums and limit medical care for tens of millions of consumers across the country. The companies have argued that the mergers would create cost-saving efficiencies that would benefit their customers.

So faced with Justice Department opposition, the Cigna-Anthem merger is under multistate national review. Who's leading that review? The Connecticut insurance commissioner and a Malloy appointee:

Connecticut Insurance Commissioner Katharine Wade, a former Cigna lobbyist [runs the] agency ... leading the national multistate review of the transaction.

Turns out Malloy not only seemed to favor the merger — by appointing a Cigna lobbyist as his state's insurance commissioner while the merger was being negotiated. He also personally met with Cigna and Anthem execs during the same time.

Sirota again:

Money In Politics: Connecticut Gov. Malloy Met With Cigna And Anthem CEOs During Merger Review

Facing criticism over his decision to appoint a former Cigna lobbyist to a position regulating Cigna's controversial merger, Connecticut Governor Dan Malloy has sought to distance himself from the merger review. The regulator in question, Katharine Wade, has said she followed all applicable conflict-of-interest rules. But newly unearthed documents detail Malloy's meetings with company officials and with Wade — and also raise new questions about Wade's financial connections to Cigna.

The emails were released to International Business Times in response to a series of open records requests amid a state ethics probe that has helped throw the colossal Cigna-Anthem deal into turmoil. Connecticut has been leading the multistate regulatory review of the deal, which physicians and consumer groups say could raise healthcare premiums for up to 53 million Americans across the country....

One set of documents shows that the governor met with Anthem CEO Joseph Swedish on August 28, 2015. That was two days after Anthem and Cigna executives met with Wade’s agency specifically about Connecticut’s merger review, and the same day Anthem donated $25,000 to the Democratic Governors Association, which backed Malloy’s closely contested election campaigns. At the time, Malloy was already gearing up to lead the DGA in 2016.

Emails previously obtained by IBT show that Malloy spoke with [Anthem CEO Joseph] Swedish and Cigna CEO David Cordani the night before the merger was announced. They also show that Malloy’s top economic development official told Cordani the governor’s administration would help Cigna if the company pursued the merger. Calendar items just obtained by IBT show Malloy later met with Cordani in the governor’s office in June of 2016 — three days after Connecticut Common Cause called for the ethics probe of Wade over her ties to Cigna.

The $25,000 that Anthem donated to the DGA wasn't the only money that changed hands.

While pushing the merger, Swedish and Cordani’s companies have in the 2016 election cycle delivered more than $1.1 million to the DGA, which Malloy now chairs. In fact, Anthem is now the single largest donor to the Malloy-run organization. Documents previously obtained by IBT show that under Malloy, the group has promised donors access to governors' policy meetings in exchange for large contributions.

There's much more at the link. Do you wonder why the nation is on the verge of revolt? I certainly don't.

When the Rich Say "Jobs" They Mean "Profit"

A side note. Why is Malloy doing this? Sirota again:

Asked whether Malloy discussed the merger with the CEOs, Malloy spokesperson Chris McClure told IBT in a written statement: “Governor Malloy fights for each and every job, and he believes in cultivating quality relationships with our employers — which our residents expect of us.

"Jobs" is a magic word; it erases (or obscures) all sins. But it also does more than that. "Jobs" is a tell — it tells the truth if you perform a simple substitution. Noam Chomsky:

In contemporary Newspeak, the word “jobs” means “profits”...

When the rich or their agents say "jobs," they always mean "profits." Perform that substitution yourself and everything they say will make sense. For example:

Protests Erupt in San Juan as President Obama Forms Unelected Control Board to Run Puerto Rico

... "I came to see the PROMESA conference that’s going on. I’ve actually made a great sacrifice to come here. I’m not—I’m not rich. I’ve worked hard, and I’ve made—I’ve made a choice in my life to move away from my family to come here to try and create jobs, to invest in Puerto Rico."

Of course the "unelected control board" about creating profit, even if the speaker doesn't recognize it. Just watch. PROMESA will turn out to exist to protect hedge fund investors, even those who bought PR bonds at pennies on the dollar, and their profit. That's why it's unelected, like Michigan's emergency managers.

Or an old favorite:

[President] Clinton, while signing the NAFTA bill, stated that "NAFTA means jobs. American jobs, and good-paying American jobs"...

NAFTA was always about outsourcing jobs and sweetening the profit pie. We know the kind of local jobs NAFTA created; people who sell these things for example.

It's cruel that they do this — dangle the reason (no good jobs) most Americans are close to revolt as a tease to protect the reason (even more excessive profit) those jobs went away in the first place. But there you have it. Your captured government at work.

GP
 

Martin Shkreli Isn't The Only Greedy Little Monster Driving Up The Price Of Medicine

More great investigative reporting from David Sirota at the International Business Times, this time on how proposed healthcare insurance mergers between Anthem-Cigna and Aetna-Humana will harm the public by reducing competition and raising costs for consumers. He reports how Kathleen Sebelius, "one of the key architects of President Obama’s Affordable Care Act is raising questions about the potential consequences of two giant healthcare insurance mergers that could affect millions of Americans now facing rising premiums." Sebelius is worried that going from 5 major insurance companies down to just 3 will impact the entire American population negatively.

The two mergers, which were announced in 2015, are now undergoing reviews by both federal and state regulators charged with making sure they do not restrict competition and hard consumers. Sebelius said that “part of the premise of the Affordable Care Act” was to engender the kind of competition that mergers can threaten.

“Creating a marketplace structure and encouraging additional companies to come into the market [was] certainly part of the overall strategy” of the Affordable Care Act, she said.

“Competition actually is a great price lever, and competition gives not only more choices to consumers but typically better prices to consumers.”

Executives for the companies have argued that the mergers will bring greater efficiencies and cost savings, ultimately benefiting consumers.

"It's going to increase choice, not decrease choice. It's going to increase affordability, not decrease affordability," said Cigna CEO David Cordani, who Bloomberg News says could reap a personal $58 million windfall if the deal goes through, depending on the personnel changes at the new company. That payout is second only to the $131 million that could be made by Aetna’s CEO Mark Bertolini, who told congressional lawmakers in September that a merger “will enable us to offer more consumers a broader choice of products and access to higher quality and more affordable health plan options.”

Sebelius is no stranger to the supercharged regulatory debates around healthcare mergers: as Kansas insurance commissioner in 2002, the Democrat blocked Anthem’s proposed acquisition of Kansas Blue Cross Blue Shield in what at the time was seen as a precedent-setting case . Back then, she said the transaction “would cost Kansas businesses, small employers and families millions of dollars.” Campaigning on the issue in her first successful bid for governor, she called Anthem “an aggressive, for-profit holding company whose primary objective is to beat its national competitors” -- which, she said, “may be fine for Anthem, but it's simply wrong for the health care and economic security of the people of Kansas.” (Anthem challenged her move in a lawsuit and won an initial victory, only to see it overturned by the state’s Supreme Court, which backed Sebelius).

Fourteen years later, Anthem has only grown bigger: It went on to merge with Wellpoint, and now stands to become the single largest health insurer in American history-- with 53 million customers-- if its acquisition of Cigna is approved. That proposed transaction was supported by the company’s shareholders, just as it was by Cigna’s shareholders-- and just as Aetna and Humana shareholders supported their separate merger.

Sebelius, however, said that shareholders and regulators face different questions when they consider approving mergers.

“Overwhelmingly the shareholders have signed off on this with all four companies, and so they clearly are confident that these mergers will produce more profitable insurance companies,” she said. “What the regulators want to know-- and it sort of gets flipped-- is what happens to consumers? Is this bad or good for consumers? And they are not necessarily the same answers.”

Following an IBT investigative report last week, consumer and ethics watchdog groups have criticized Connecticut Democratic Gov. Dan Malloy for appointing a former longtime Cigna lobbyist to the regulatory position now leading 26 states’ review of the Anthem-Cigna deal. Sebelius said that in general, questions about potential conflicts are “appropriate.”

“There’s always a concern about whether there is conflict or whether there are interests involved,” she said. “The connection with the specific company involved is maybe a little unusual, but it is not at all unusual to have a state regulator who actually has been deeply involved in the industry and it does bring a level of expertise. I think it is appropriate to ask, and I’m sure this question will be asked all along, are there any conflicts? Are consumers going to be adequately represented?”

She added that regardless of the controversy over the Malloy administration’s appointment, others in Connecticut such as U.S. Sen. Richard Blumenthal-- a former state Attorney General-- have in the past made sure that mergers get the scrutiny they need.

“I don’t think there are any shortage of people who will be engaged and involved in the Connecticut situation,” she said.

It sounds very similar to an argument over healthcare raging in Vladimir Putin's Russia, where his prime minister, Dmitry Medvedev, was caught on camera being confronted by angry pensioners demanding higher pensions to cover the increased costs of medicine and food. "There's no money, but take care," he told them cavalierly. In a similar exchange with the public, Putin told angry questioners about rising costs of medicine-- gargantuanly rising, like on a Shkreli level-- that he tries to steer clear of medicines "by leading a healthy lifestyle." If eating fresh fruits and vegetables and fish are part of that, it's also out of reach for increasing numbers of Russians as they watch the prices rising for food stables out of reach.

Medicine sales have fallen for the first time in Russia since 2008: Analysts recorded a 10 percent drop in drug sales in the first quarter of this year. During a severe economic crisis, a growing number of Russians can no longer afford to buy medicine.

The figure is the latest indicator of falling living standards in Russia, and has alarmed some experts, who say that medicine is the last commodity for people to cut back on. Writing in Slon magazine, Yevgeny Gontmackher said more and more Russians are turning to home remedies to cure illnesses.

Russia's deteriorating health care system will also have long-term effects. Staff cuts in hospitals and growing pressure on doctors mean an increasing number of Russians, especially in remote regions, are losing access to free medicine.

...[Marina Krasilnikova, an economist at the Moscow-based Levada Center] says medicine sales show that life is about to become much harder for families with chronically ill family members and pensioners.

"The prices just keep soaring," says Irina Kuninskaya, a woman buying prescription drugs for her 78-year-old mother in a Moscow pharmacy. "With my mother's miserable pension and my income falling, we don't know how to feed the family anymore," she says.

The drugs Kuninskaya bought are foreign-made. She expressed hope that Russia would soon be able to produce affordable medicine of the same quality.

The Russian government has tried to boost self-sufficiency in drug production by limiting imports of foreign substances for pharmaceutical companies. Moscow introduced new laws last year forcing Russian companies to import less from European companies in a bid to increase the amount of Russian-made drugs on the market from 30 percent to 50 percent by 2020.

While there may be more domestically produced drugs in Russian pharmacies, many prices are, in fact, rising faster than those of imported medicine. According to a study by Moscow's Higher School of Economics, the price of Russian-made essential medicines rose by 28.9 percent in 2015, compared to just 4.9 percent for imported drugs. In that same year, prices for life-saving medicine, whose prices are regulated by the government, rose by as much as 32 percent.

The Kremlin has said it will crack down on pharmaceutical businesses not selling products at the regulated price. Starting this week, pharmacies not adhering to these rules could be shut down for up to 90 days.

But Russian pharmaceutical companies say they cannot compete in a foreign-dominated market. The crash of the ruble meant foreign substances used in drug production became more expensive, further straining Russian companies. During the call-in with Putin, the owner of a pharmaceutical company from Samara asked the Russian president to scrap government price restrictions. "We are forced to sell goods at the same price as six years ago," he said.

Pensioners are perhaps the group most affected by increasingly expensive medicine in Russia. This year, the government increased pensions by only 4 percent, set against double-digit inflation in food and medicine.

What would Putin-admirer Donald Trump say? Probably something derogatory about Pocahontas.

Why Dan Malloy Won Reelection And Mary Landrieu Will Lose Her Runoff... By A Lot

Animals smell fear-- and it emboldens them. Tuesday most Democrats did the right thing for America and humanity by voting against the Keystone XL Pipeline project. The calculus about how much more poison the earth could take wasn't on the minds of the fearful Democrats who crossed the aisle to vote with the Republicans and their Big Oil allies. Their calculus was about winning reelections (some, like Mark Warner for example, in 6 years) and political advantage back home and with campaign donors in return for failing to find the intestinal fortitude it would take to display some courage. In Wednesday's National Journal Josh Kraushaar plays up a Beltway interoperation of what happened as Obama dividing the Democratic Party.

President Obama's biggest problem over the next two years may not be coming from recalcitrant Republicans, but from members of his own party blanching at his activist agenda over the final two years of his presidency. While the midterm election results suggested widespread dissatisfaction with the president's policies, Obama nonetheless is planning to press forward on several polarizing decisions in his final two years. It could help advance his legacy, but come at the expense of the Democratic Party's long-term health.

Three of the administration's biggest agenda items-- threatening a veto of bipartisan legislation authorizing construction of the Keystone XL pipeline, reaching a nuclear deal with Iran, and issuing an executive order legalizing millions of illegal immigrants-- divide Democrats, and unite Republicans. If the president moves forward with all of them, it would aggravate fissures in an increasingly-divided Democratic Party. And it would put Hillary Clinton, his party's expected 2016 standard-bearer, in an uncomfortable position even before she announces her candidacy. She's already avoided taking stances, if not outright rejecting the direction Obama is heading during his final two years in office.

The dirty secret in Washington is that while Obama (rightly) blamed Republicans for holding positions to the right of the American electorate, the president is pursuing policies that are equally as far to the left.

You can get very rich living inside the graft and corruption-greased Beltway. Money flows everywhere. It isn't worth it. "Approving construction of the long-delayed Keystone XL pipeline may not be the most consequential legislation," he continued, "but it is symbolic of the lengths the administration has gone to avoid a postelection bipartisan accomplishment. Embattled Sen. Mary Landrieu, on the ballot next month in a Louisiana Senate runoff, has been furiously lobbying colleagues to approve the pipeline, and won support from 14 Democrats in an unsuccessful vote Tuesday. A new USA Today poll of adults, conducted last week, found strong support for it-- 60 percent backing construction of the Keystone pipeline, with only 25 percent opposed. This month, the Pew Research Center found even 44 percent of Democrats supporting it, with 46 percent opposed. When Republicans take control of the Senate in January, it's expected to pass with at least 63 votes." Sad... but that's what happens when people move to Washington.

Dan Malloy is the governor of Connecticut, far enough from the Beltway to dispense with a very different kind of a advice to his fellow Democrats-- in the words of David Freedlander: grow a pair. Early polling data on Malloy's reelection race this year was not, to put it mildly, auspicious. He was down or tied in almost every poll-- in several by as much as 7 points. That didn't turn him into a DINO or make him quake in his boots.

In his first term, Dan Malloy enacted a hugely ambitious progressive agenda. This fall, he ran on that record-- and won. Now he’s got some advice for his dejected fellow Democrats.

When Dan Malloy was elected governor of Connecticut in 2010, he was the first Democrat to win an open race in the Nutmeg State since 1980. It would have been reasonable to expect, then, something of a cautious approach, one wary of shifting political winds in an otherwise reliably blue state.

Instead, Malloy enacted one of the most ambitiously liberal agendas of any governor in the nation, from higher taxes on the wealthy to a higher minimum wage, guaranteed paid sick leave for workers, protections for gays and immigrants, strict new gun-control laws, looser marijuana-possession laws, allowing the unionization of daycare workers, and outlawing the death penalty.

The result? A 25,000-vote victory out of more than a million cast in Malloy’s reelection bid against Tom Foley.

Now, having barely survived in a race that was not conceded, Malloy has some advice for his fellow Democrats. But first he wants to clear up a few things.

“‘Barely?’ Let’s stop with the barely. 6,400 [votes], that was the barely,” he said in an interview, referring to his even squeakier 2010 race, which he won by half a percentage point against Foley. “Twenty-five thousand-- that was a landslide!”

If his fellow Ds want similar results in the wake of a bloodbath of an election that was the 2014 midterms, Malloy says: “They can’t run as Republicans. Democrats can’t run away from what they have done. If there is a message out there, it is that we failed to embrace our successes because we thought that it would remind people that we are Democrats. Well, guess what? I am a Democrat. And I ran as a Democrat.”

Too many Democrats, in the face of national headwinds, ran as Republican-lite, Malloy said. And now many of those Democrats are heading home after long careers in public life, with some losing easily winnable races.

“What I think happened is people underestimated the ability of the voting public to put things in context,” he said. “If you are going to have a contest and it is going to be about who is the grayest, then Democrats lose. But the world is more black and white than it is gray, and if you fail to point that out, then don’t be surprised that you lost.”

In Connecticut, Malloy was saddled with underwater approval ratings since his first year in office, when he instituted the largest tax increase in state history. As the campaign season heated up, his opponent hammered away on the issue. Malloy was unconcerned, he says.

“I always felt that when we got to a serious contest in October, we would be OK as long as we stayed true to our principles and talked about what we accomplished,” he said. “Tom Foley wanted it put out that there we raised taxes. And he talked about it month after month after month after month. But once people started to pay attention, I pointed out what we did with the money, which was lower the crime rate, increase graduation rates, invest in infrastructure, create a Housing Department, create an Energy Department, create a Department of Aging. We did all of these things. It was the right policy, and ultimately people came around.”

Democrats elsewhere, he says, were scared of making contrasts, of owning up to their record and saying, “This is why we did what we did.”

“You didn’t point out the difference between who you are and who the other people are,” he said. “Because the other people are the people who drove the economy into the ditch. The other people are the people who want to make the rich richer and, quite frankly, if that makes the poor poorer, that is OK with them. And if you don’t point that out, don’t be shocked that people get confused.”

During the campaign, Malloy didn’t just embrace his record and his party. He did what only a few Democrats were willing to do: Embrace Barack Obama. The president headlined a rally in Bridgeport in the days before the election, at a time when other candidates, like Alison Lundergan Grimes of Kentucky, wouldn’t even cop to voting for Obama in his reelection bid.

“I was never going to run away from the president,” Malloy said. “It was not even in consideration. I support the president. I think the president has been right. I mean, look at the numbers, look at the job growth, sustained job growth-- the greatest in American history. The. Greatest. In. American. History. Why didn’t people run on that? So you know that a bunch of political people say, ‘Well, it is not deep enough, and some people are hurting.’ OK, but talk to the people who have benefited. That is a better way of doing it than the other way.”

Yesterday, in a letter to his supporters, Congressional Progressive Caucus co-Chairman Raul Grijalva (D-AZ), who was reelected handily, 55.6-44.4%, took a similar line. "There’s no one single reason why we lost two weeks ago," he wrote. "The pollsters and the pundits all have a million reasons. But, here’s what I know. When Democrats articulate our values, we win. When we try to be Republican-lite, we lose. In 2008 and 2012, we ran as Democrats. We talked about our values-– peace, justice and equality for all. We won. This year, Democrats across the nation joined the attacks against our party and our values. What happened? We lost. Big. So, where do we go from here? We build. We build a stronger Progressive Caucus in the Congress. We empower the grassroots. We push progressive legislation. And, we deliver real results. Then, we’ll prove to all our voters who stayed home that we really are on their side."