Pegaspargase – an example of how we don’t control drug costs

Under Medicare Part B, America’s seniors are entitled to drugs administered in the hospital, but they are responsible for 20% of the cost. That sounds reasonable, and Medicare officials say they carefully scrutinize drugs before approval.

But I have yet to discover a list of unapproved drugs. It appears that if the FDA says it can be sold, Medicare pays for it at list price. For a $50 drug, this seems reasonable. You would pay $10, and Medicare would pay $40 if administered in a hospital..

Not all drugs are priced equally, and paying for some – even at 20% – could be a financial disaster.

For example, Pegaspargase is a biologic that treats leukemia. It’s on the World Health Organization’s List of Essential Medicines. The course of recommended treatment is two vials every 14 days for up to six months.

Each vial costs Medicare $17,566. Since negotiation of drug prices is not allowed, the 26 vials needed for six months cost Medicare $228,358. That’s also the price for an uninsured senior or younger patient. (Medicare B and D are optional, extra-cost additions to original Medicare.)

Your co-pay under Medicare B for Pegaspargase would be $45,671. And that’s not all, because other drugs – anthracycline, vincristine, and prednisone – are often prescribed at the same time.

The Medicare Payment Advisory Commission said that physician-administered biologics accounted for two-thirds of spending and all 10 of the highest-expenditure drugs in Medicare Part B in 2017.

Biologic exclusivity in the United States is currently 12 years, and nations we are negotiating with are far less generous – eight years for China and Canada, and five years in Mexico. Recently, the GOP pushed for 10 years in current trade deals for foreign countries, but backed down to gain Democrat support to pass recent budget deal. The U.S. continues to guarantee 12 years.

If you don’t have $45,671 to co-pay for this required drug, a trip to India might be in order. Total price of 26 vials there is $5,460 –  a savings of some $40,000, and that’s not just co-pay, it’s the total price..

While India’s $210 a vial (versus $17,566 here) is the cheapest in the world, Great Britain’s National Health Service pays only $980 a vial, a savings of $16,500 vs. their liberated colony.

While elites of both political parties here have complained that Medicare is too generous to seniors – an insane accusation – they have done nothing to curb payments, including this example of $228,358 for one drug for one patient.

Drug lobbies have lawmakers addicted to campaign contributions, exotic trips, campaign funding and perhaps, even briefcases stuffed with cash, or offshore accounts. Big money is behind Big Pharma, and that includes the hedge funds, who finance drug development and mergers, as well as our willfully blind media, grown fat and complicit from billions of dollars in drug ads.

Young couple (drive two Ferraris and own a $700,000 home) charged $21 for 3-day hospital stay. Average senior pays $1,364.

The corporate exec was sincere when he explained to me why he didn’t pay most of his workers a wage higher than $14.25 an hour:

That rate keeps them under $30,000, and that’s about the cutoff for Medicaid and many other public assistance programs for a family of three.  Without Medicaid they would have to pay for health insurance and that isn’t cheap.

A raise to $31,000 can leads to a disaster for a family:

This year, the average (health insurance) annual premiums are $7,188 for single coverage and $20,576 for family coverage. The average premium for single coverage increased by 4% since 2018 and the average premium for family coverage increased by 5%. The average family premium has increased 54% since 2009 and 22% since 2014. – Kaiser Family Foundation (KFF).

Ferrari plus nearly free healthcare!

Even if your company offers a health plan, getting a raise can still be very bad news. In those plans, some $11,000 in annual premiums on average are paid by a family, and the remaining $9,500 by employers.

The much-touted $15 minimum wage (equals equals $31,200 a year) means no Medicaid for your family. That leaves you only eligible for private or company insurance that reduces your pay $2.50 an hour minimum and up to $10 an hour maximum.

No wonder that 75 million Americans are on Medicaid today, compared to just 50 million in 2010.

It is especially attractive, because if you work “under the table”, or have a business that “reports” low income, you can get Medicaid regardless of huge real estate investments or even owning multiple mansions, thanks to changes enacted by the Affordable Care Act.

Someone could own a home worth $850,000, a Lamborghini, a second vehicle, hundreds of acres of farmland, and still technically be eligible for Medicaid. These Americans would be considered wealthy by any standards, but by sheltering their net worth under the current tax laws, they would be legally eligible for Medicaid. – KFF

The only folks who can’t take advantage of the goodies in Medicaid (and still own terrific assets) are all 47 million seniors on Medicare. The elderly face a unique “assets test.” That’s just for seniors, and there are no exceptions for the elderly.

The insane rule is that you can’t have more than $2,300 in the bank, other savings, etc. The government can even investigate you to learn whether you made large gifts from prior savings to your children during the past 60 months.

The usual reason that seniors want Medicaid is to pay for nursing home care. Medicare pays nothing, but Medicaid covers it all. About 40% of nursing home residents are on Medicaid.

America’s nursing homes charge more than $85,000 annually at list price and that’s what you’ll pay until you are dirt poor and qualify for Medicaid. Insurance companies and Medicaid cut special deals and pay nowhere near that amount.

Some friends have suggested that Medicaid and Medicare are about the same thing.

Let me count some of the ways they are starkly different:

  1. Annual premiums: Medicaid is $0. Medicare is minimum $3,468 a year for a couple. High earners pay as much as $5,700 each.
  2. Inpatient hospital care:  Medicaid co-pay is $3 for each day in the hospital, up to $21 for the entire stay. Medicare co-pay for even one day is $1,364, and if you re-enter the hospital after 60 days, each time another $1,364 is due. For Medicare hospital days 61-90: an added $341 co-pay each day, and days 91 and beyond: another $682 each day. After 60 days beyond the 90 lifetime limit, Medicare pays nothing and you are responsible for all hospital bills.
  3. Short Procedure Unit: Medicaid co-pay is $3 for Surgical Center (ASC) visits. Medicare co-pay is 20% of the charges, no matter how high the cost. Some common procedures may be billed in excess of $10,000 list price.
  4. Brand name drugs: Medicaid co-pay is $3 for each prescription or refill. Medicare requires monthly co-pays up to $100 or more per prescription, depending on the drug. For example, Xarelto co-pay is about $1,200 annually. Medicare pays for all additional drugs only if an individual spends more than $6,350 a year out-of-pocket.
  5. Outpatient x-rays:  Medicaid co-pay is $1 for the total  service (not for each x-ray). Medicare co-pay is 20%. X-rays generally cost $260 to $460 each. Some are more than $1,000 list price.
  6. Physician visits: Medicaid co-pay is $0. Medicare co-pay is 20%.
  7. Chiropractor visits: Medicaid co-pay is $1 for each visit. Medicare will only cover chiropractic care as a treatment for a condition called spinal subluxation. Co-pay is 20%.
  8. Emergency services: Medicaid pays everything. Medicare co-pay is 20% of all charges, plus set fees for procedures and supplies. Average ER visit is $775.
  9. Blood and blood products: Medicaid pays everything. Medicare minimum co-pay is 20% of all charges.
  10. Drugs: Medicaid pays all costs for high blood pressure, cancer, diabetes, asthma, epilepsy, heart disease, psychosis, HIV/AIDS, glaucoma, depression, and anxiety drugs, as well as anti-Parkinson agents, anti-manic agents, anti-convulsants, anti-neoplastic agents, oral contraceptives, test strips, lancets, meters, and needles. Medicare co-pay is 20%
  11. Dental visits: Medicaid pays everything. Medicare pays nothing.
  12. Skilled Nursing Facility: Medicaid pays everything. Medicare co-pay is $0 for days 1-20; $175 for days 21 to 100; and you pay everything for days 101 and beyond.
  13. Nursing Home Care: Medicaid co-pay is $0. Medicare pays nothing for long-term care.

If all that doesn’t disturb you, consider the stupidity of the current political promise to enshrine Medicare for All, a program with fatal flaws that date back to its inception in 1965.

Medicaid for Everyone has a more logical beneficial foundation, and maybe this time it could include the old, the sick, those soon to die, and not just the young and sometimes quite wealthy.

Army-Navy Game gesture enraged “Where’s Waldo” watchers, even though Anti Defamation League once called it a mere hoax

Your mission: find the “utterly dangerous” circle okay sign in the Army-Navy crowd

The Army and Navy academies are looking into whether circle-hand symbols by cadets and midshipmen at a football game on Saturday were related to hate groups. Some three “signals” were spotted.

There are 4,389 Army cadets and 4,526 Navy Midshipmen. The odds any single one of them was involved is nearly one in 3,000. That’s about the same odds as being drafted into the NBA, or six times the odds of being born with 11 fingers or toes.

Despite those odds, the mass media thought it was a really big deal, pushing the military academies into classic defense mode and leading them to launch two official investigations.

G.F.B.D. is bad, skull and crossbones okay?

On Sunday the Army also announced it had stripped the motto from a team spirit flag.  Since the mid-1990s, the Army Black Knights football team at West Point has been using a flag with a skull and crossbones and a “G.F.B.D.” above the teeth, which stands for “God Forgives, Brothers Don’t,” the academy said.

The complaint was that the Aryan Brotherhood of Texas (ABT), a white supremacist prison gang, referred to one another as “brothers” and called their female associates “sisters.”

That conclusion didn’t agree with Anti-Defamation League (ADL) research. ABT doesn’t use a circle gesture.

ABT members frequently use single-hand hand signs with two fingers upraised and one finger upraised, separated by a non-raised finger. They may also use two-hand hand signs with one finger raised on one hand and two fingers raised on the other hand, ADL reported last year..

If the ABT connection sounds lame for areason, consider the circle signal’s actual history.

The circle hand gesture was a hoax campaign, started by members of the website 4chan – an anonymous discussion board that has been responsible for everything from the “I can haz cheeseburger” cat meme to the idea of Rickrolling. They have also produced a number of fakeries with white supremacist themes to trick largely credulous online audiences.

An anonymous 4channer announced “Operation O-KKK” in February 2017, telling other members that “we must flood Twitter and other social media websites…falsely claiming that the OK hand sign is a symbol of white supremacy.”

In September, last year, the ADL reported:

The 4channer provided a graphic showing how the letters WP (for “white power”) could be traced within an “OK” gesture. The originator and others also suggested useful hashtags to help spread the hoax, such as #PowerHandPrivilege and #NotOkay.

“Leftists have dug so deep down into their lunacy,” wrote the poster, “We must force [them] to dig more, until the rest of society ain’t going anywhere near that s***.”

Following the cues of the hoax’s originator, 4channers created fake e-mail and Twitter accounts and bombarded civil rights organizations, journalists, and others with messages furthering the “OK” hoax.

The original launch of “Operation O-KKK” sputtered after a few days, and it seemed that the hoax had run its course without spreading too far, but it picked up again in late April, 2018, and this time was far more successful in spreading across social media—and beyond, the ADL explained.

What happened to make an old gesture this year’s astronomical crime, punishable by investigations and accusation articles in the NY Times and elsewhere?

Enter the Southern Poverty Law Center (SPLC), which decided it didn’t like the gesture.

The SPLC surmised last year that white nationalists, neo-Nazis and Klansmen “have increasingly begun using the use of the symbol both to signal their presence to the like-minded, as well as to identify potentially sympathetic recruits among young trolling artists flashing it.”

This group has condemned everyone from Franklin Graham (son of Billy Graham) to the Family Research Council. Oddly, it doesn’t consider Antifa as terrorist, but despite a reputation as a very far-left advocacy group, popular media immediately reacts to SPLC’s messaging about the organizations or individuals it targets.

Touching the thumb and index finger to make a circle, with the remaining three fingers held outstretched, is a gesture that people around the world have made for centuries, mostly in positive contexts, according to the ADL explanation last year.:

It is used for several purposes in sign languages, and in yoga as a symbol to demonstrate inner perfection. It figures in an innocuous made-you-look game. Most of all, it has been commonly used for generations to signal “O.K.,” or all is well.

The Twitter reaction Sunday was brutal:

The gesture is also part of a juvenile prank popular in junior military ranks called the circle game.Image

Check out this video for a better explanation:

Although the ADL had thoroughly explained the gesture was a hoax and used for decades, even in sign language, when SPLC announced it was a “hate signal” this year, the ADL quickly turned on its heels and agreed.

Oddly, the SPLC itself was almost agreeing with ADL’s stance last year, reporting on September 19:

So what does it mean when someone flashes the OK sign? In the end, it can mean almost anything, but primarily it’s one of three things:

  • It can be a harmless use of its traditional meaning that all’s well.
  • It can be an ironic attempt to troll liberals with a symbol chosen to “trigger” their inner “SJWs.”
  • It can be a surreptitious way of signaling your presence to other white supremacists.

Such uncertainty didn’t slow the headline writers at the New York Times on Sunday:

The Army and Naval academies said they were looking into
whether hand symbols by cadets and midshipmen at a
football game on Saturday were related to hate groups.

More Twitter reaction:

@SachaGilbert: These are officers in training and their conduct is unbecoming regardless of the minimizing excuses of “they’re just trolling the libs” or “it’s only the middle school game of Made You Look!” They know it’s offensive even if they eventually claim to disavow white supremacy.

@TenaciousEye: The ones doing it need to be expelled immediately.

@3ChicsPolitico: This was planned. And one flashed the white power sign after he touched the head of the Black cadet. This is what they think of him. Very disturbing and painful to the soul.

@NancyNoseYou: If the kid who did that is not punished and ousted, the Army has lost its way. But with a draft dodger in command, it’s no wonder it’s being poisoned and it’s dignity being stripped too. Join the club, regular Americans know the feeling.

@Brooksie458: I was one of eight children of a marine. If one of us did something like that then all of us were going to be disciplined. All of those who were amused by their buddies’ behavior need to find out what being part of team is about. That is not it.

@fishnbaja1: Simon Wiesenthal had to rely on old address books to hunt down nazis. Today, all he’d have to do is ask @ESPN for their football game footage. I feel sorry for our nation, and more immediately, for that brown skinned cadet.

@leslee105: Sad day for our country and whatever happened to good sportsmanship Especially from the man who is supposed to guide the freedom of our country

But no Twitter comment chain wouldn’t be complete without hate like the following:


And if you are wondering: Navy 31, Army 7.

America gives away our jobs and factories to China with a lopsided de minimis rule promoted by global businesses

Zach Mottl

Zach Mottl, chief alignment officer of Atlas Tool Works and a past chairman of the Technology and Manufacturing Association of Illinois, is a very unhappy American.

Four of his state’s members of the House of Representatives are trying to block the White House effort to lower the “express shipment” measure included in the de minimis rule. This regulation currently allows China to send us goods without any tariffs or customs duties, as long as the value is less than $800.

These anti-American politicians – tools of global businesses – oppose lowering this limit to $200: Cheri Bustos (D), Bradley Schneider (D), Danny Davis (D), Mike Quigley (D) and Never-Trumper Darin LaHood (R).

Mottl said the current deal with China is blatantly unfair:

China’s de minimis level is a mere $8. That means any American company shipping a product to China – valued at more than $8 – must pay a duty. But there’s no reciprocity; a Chinese good priced as high as $799 can enter the U.S. duty-free.

In 2016, Congress increased the de minimis limit from $200 to $800.

That opened the floodgates, allowing companies like Amazon to further incentivize imports, Mottl explained.

My manufacturing company, Atlas Tool Works, has been in operation in Illinois since 1918. We are a textbook example of the kind of domestic American company that has been surviving for years in the face of heavily subsidized imports. And our nearly 80 employees depend on Atlas for their jobs and livelihoods.

Mottl said the current system is being exploited and the $800 limit is being abused to allow a flood of goods entering the United States, often with much higher ticket prices than listed on import documents:

For example, 60 counterfeit Chicago Cubs jerseys were recently seized at O’Hare Airport. The jerseys were listed at a value of only $177. But a Customs official estimated the merchandise would have actually sold for $7,200.

Duties are only charged based on the value of the import. Popular items, such as designer sunglasses may sell here for $500 or more, but their actual price to import from China usually ranges between $7 and $15. That means 100 sunglasses would avoid any import duties ($700 declared), but would retail here for $500 X 100, or $50,000 total.

Also, Congress could better serve America’s manufacturers by passing the U.S.-Mexico-Canada Agreement (USMCA), Mottl said.

The pending deal contains helpful enforcement mechanisms and also directs Canada and Mexico to raise their current de minimis levels.

Matching America’s de minimis levels to those of our trading partners could help to ensure a more level playing field.

Meanwhile, Bustos, LaHood, Schneider, Davis, and Quigley have written to U.S. Trade Representative Robert Lighthizer, explaining that they “strongly oppose any effort … to lower the $800 de minimis threshold” in the U.S.

Their stance is purely pro-business, benefiting huge corporations like Amazon and Walmart, who can use multiple small purchases to avoid the duties our goods face in China. This is not the historic stance of the Democrat Party, which has long supported workers and consumers over retailers and wholesalers.

As Mottl explained:

These representatives are essentially arguing for a lopsided policy that enables Amazon — one of the world’s most profitable companies — to keep importing subsidized, low-cost goods from China at absolutely no cost.

This is doubly egregious considering that Amazon paid zero federal and state taxes in 2018 on more than $11 billion in profits.

Bike supplier and retailer offers similar warning on de minimis rule

de minimis rates in various countries

Congress forces USPS to subsidize mailers in China and gouge Americans nearly six times as much to send the same package

Billions of dollars of goods are imported from China into the United States every week, and very little is exported to that communist monolith from small businesses in our country.

Most of our exports are from giants like: Boeing selling planes, Wall Street hawking financial services, or Hollywood offering pablum movies censored by the Chinese dictator-for-life and his all-seeing minions.

Is our huge trade deficit because entrepreneurs in China are just born smarter, work harder or are more thrifty, patient and all-seeing?

The answer is none of the above.

As usual, the problem is an always supplicant Congress, embracing big business, promoting their monopoly at the expense of the little guy or gal.

Most of us have seen pictures of cargo ships filled with China’s products unloading into our West Coast ports. Shipping containers are relatively inexpensive and cost just as much sailing from China to the U.S., as from the U.S. to China.

A small business can’t afford to fill shipping containers.

Instead, American exporters mail packages, and that’s where folks here get screwed by their own government as well as by China’s import duties and taxes.

Pretend you have a one-pound book worth $30 to mail in China to a customer in the United States. Using their mail, your package will arrive in about seven days at a cost of $7.31.

Suppose the book is damaged? You can mail it back to the sender and get a refund.

However, that means you have to pay the USPS postage – $46.71. If you are not in a hurry you can save money and it will be delivered in about seven weeks at a cost of $24.06 on a slow boat to China.

It’s not fair trade when one party is charged $46.71 and the other gets subsidized to only pay $7.31.

In 2011, Congress ordered the the U.S. Postal Service to make special agreements with the national postal carriers of China and Hong Kong to allow tracking-enabled packages not exceeding 36” or weighing more than 4.4 pounds to be sent to the U.S. at bargain basement rates. This shipping option – the ePacket – has rates so low that it’s cheaper to ship small parcels from China to an American city than it is to mail that same parcel within our country.

USPS subsequently extended the same deal to South Korea and Singapore. The plan was to increase imports into our country and help Asian countries at our expense.

Unlike the United States, China subsidizes its postal system so costs are minimal in that country. At the same time, USPS is subsidizing mail from China to keep prices low for our Far East competitor.

If the huge disparity in mailing costs doesn’t make Americans noncompetitive in the Chinese marketplace, consider the impact of taxes and fees levied by each government.

Let’s compare the approximate cost of shipping a one-pound box of gold-plated jewelry to each country.

Shipping from China to the United States
Item cost : $300
Shipment cost : $8
Total amount: $308

Shipping from United States to China
Item cost : $300
Shipment cost : $46
Customs duty rate @35% = $121
Vat rate @17% = $59
Total amount: $525

A first step in lowering costs for America’s small businesses is to reduce the rate we pay to mail to China and raise the rate we charge them to deliver here. The current imbalance of $8 to $46 to mail the same package is almost 6 to 1 – an unbelievable gift to Chinese exporters.

This change alone will help small business compete, plus impact the nearly $4 billion in so-called “loses” that will be incurred this year by the post office.

Next week: We examine the De Minimis import value threshold, and how some slimy members of Congress want it to continue benefiting China’s exporters and restricting American business.