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Propositioning for drugs


Most of the propositions on the California ballot for tomorrow make my eyes glaze over. But I nonetheless wanted to discuss two of those propositions.

Prop. 78, if passed, will create a prescription-drug discount program for relatively low-income Californians who aren't covered by other discount or insurance or state-funded programs.

Prop. 79, if passed, will also create a prescription-drug discount program, with many of the same attributes.

Supporters of each proposition are opposed to the other. If they both pass, whichever one gets the largest number of votes will go into effect.

The differences between the two seem relatively slight on the surface, at least to this uninformed observer. The income cap for 79 is higher (so 79 provides discounts to more people, including some who might not be generally considered low-income). Prop. 78 excludes some people who've had other coverage anytime in the preceding three months (so some people might be unable to afford drugs for three months after, say, losing a job with health insurance). Prop. 78 charges participants $15/year; 79 charges $10/year. Prop. 79 makes it "a civil violation for a drug maker to engage in profiteering from the sale of drugs." And then there are obscure but apparently major differences in how the discounts/rebates are negotiated.

Like I said, eye-glazing-over stuff. But here's the thing:

I've received at least four automated/prerecorded phone calls in the past week urging me to vote yes on 78 and no on 79.

Each of them starts with a just plain ol' person introducing themselves. John Kehoe, Policy Director of the California Senior Advocate League. Kathy West, calling for the Epilepsy Foundation of San Diego County. Linda Halderman, surgeon in Fresno County.

(I'm sure that none of those people would have taken any drug company money in return for their endorsement, no, certainly not.) [Added 12 July 2006: Dr. Halderman has pointed out, quite rightly, that I should not have implied that she or these others took money from the drug companies; I had and have no reason to think that any of these specific people took such money. Please see the comments below for more details and a non-broken link to the LA Times article about people who did take money.]

Each of the callers goes on to say a completely unscripted impromptu little speech that I'm sure they just made up on the spot because they were so carried away with enthusiasm. If 78 passes, they tell us, "doctors will be able to choose which medicines to prescribe." (Indirectly suggesting that doctors currently can't do that.) Patients will get up to 40% discounts on medicine. Under 79, on the other hand, "bureaucrats in Sacramento" will be able to deny patients the drugs their doctors prescribe. (Damn those bureaucrats! I bet they're sitting there in Sacramento right now trying to figure out the best way to deny me the medications my selfless doctors want to prescribe for me.)

And then at the end of the little speech, a woman says, at about double normal speaking speed, that this message was paid for by Californians for Affordable Prescriptions and sponsored by Pharmaceutical Research and Manufacturers of America, with funding provided by Johnson & Johnson; Merck & Co., Inc.; Pfizer, Inc.; GlaxoSmithKline; and other companies. She also mentions their website, though it would have been impossible for me to understand the URL if I hadn't seen the term "Cal Rx" in the voter info pamphlet.

So these calls made me a little suspicious. What is it about prop. 78 that makes the pharmaceutical companies so eager for me to vote for it?

The arguments pro and con in the ballot pamphlet provide a little more info.

The pro-78 argument says that it's related to an existing program and is "an improved version of a successful program already operating in Ohio." It has bipartisan support and offers extensive discounts. The people who signed the pro-78 argument are all RNs; one is the COO of a hospice, another is a pediatric oncology nurse at the UC Davis Medical Center. Among the signers of the rebuttal-to-anti-78 argument is the Senior VP of the Epilepsy Foundation of San Diego County. Nobody could impugn those folks' credentials, and this time I'm not being sarcastic.

The anti-78 argument, on the other hand, says that 78 was "bankrolled with tens of millions of dollars from the prescription drug lobby to block Prop. 79, a real discount solution put forward by consumer, health, and senior groups." They add: "Newspapers report that just one contribution from GlaxoSmithKline for $8.5 million could be 'the largest ever from a corporation to a California campaign.' Drug companies donated $50 million to Prop. 78 by mid-July, on track to run what could be the most expensive initiative campaign in California history. Jan Faiks, VP with PhRMA, the industry's lobbying arm, told the Los Angeles Times 'the industry would spend "whatever it takes" to defeat [Prop. 79].'" (Emphasis theirs.) The anti-78 people say 78 relies on the drug companies voluntarily lowering prices, which drug companies aren't likely to do. They add that the discounts offered under 78 "could be anywhere from 15 to 40 percent--significantly less than Prop. 79's discounts." And they note that there's a provision in the law that says that if not enough drug companies decide to participate, the program will be cancelled. Oh, and speaking of unimpeachable credentials: one of the anti-78 signers is the president of the League of Women Voters of California; another is the executive director of Breast Cancer Action; another is an RN, the president of the United Nurses Association of California.

The pro-79 people talk about pretty much the same stuff as the anti-78 people. They have a website, too. (Both the pro-78 and pro-79 websites feature photos of cute little kids, of course.) Another notable credential on the pro-79 side: the president of the AIDS Healthcare Foundation.

(That pro-79 website, btw, includes an LA Times article about a flyer the pro-78 people sent out, featuring photos of various black legislators next to calls to vote for 78. Funny thing: many of those legislators actually oppose 78; their photos were used in this flyer without their knowledge or permission.)

And then there's the anti-79 argument, which adds a whole new twist. It's based on the idea that 79 "is so poorly written it will result in years of legal challenges and will never get approval by the federal government." The gist of their argument is: if passed, 79 will never take effect; therefore, you should vote for 78, which may not be better but at least it won't result in endless lawsuits. Oh, yes, and the anti-79 people also want to warn us that 79 would "let trial lawyers file thousands of frivolous lawsuits simply by claiming the price charged for the product is too much or that the manufacturer's profits are too high." Note the clever use of that maligning phrase "trial lawyers." Not just ordinary lawyers, who might be decent folk, but trial lawyers, whose evil deeds and rapacious ways are widely known. If this measure happens, those awful trial lawyers might attack our poor innocent pharmaceutical companies! Think of the children!

Okay, so I'm getting carried away. Really, I came out of this feeling slightly queasy about both of these propositions. I suspect that the anti-79 people are right that 79 isn't specific enough about some things and that it'll be tied up in litigation indefinitely; the anti-79ers also suggest that 79 is subject to Federal approval and that there's no way that'll happen. (I'm unclear on the details of this aspect.) And if 78 would actually work, well, 40% off of prescription drugs for the poorest Californians is nothing to sneeze at. And for that matter, I'm a little bit more in favor of drug companies than a lot of my friends are; sure, they can be pretty evil, but they're also developing some important drugs that help a lot of people. And I do respect several of the people who support 78.

But I'm pretty set on voting no on 78 just because I'm so annoyed at the pro-78 campaign's tactics. I'm not sure yet how I'll vote on 79.


Proposition 79 allows the state to ... pressure ... drug companies into participating in the discount scheme by threatening to (a) withhold medicare contracts and (b) public shame them, if they don't.

Proposition 78 is "entirely voluntary".

"(I’m sure that none of those people would have taken any drug company money in return for their endorsement, no, certainly not.)"

I don't know why the writer sarcastically implied that those of us who endorsed Prop 78 were paid for it. I am a surgeon who volunteered to support it because I saw it as a better choice for my patients than Prop 79, which would have interfered with my Medi-Cal patients' access to medications (it had a "carrot and stick" clause which jeopardized medications currently covered by Medi-Cal).

I didn't have anything to gain by publicly speaking and writing about Prop 78; in fact, I was attacked by people like the writer who assumed that the only reason a doctor advocates for their patients is for money. It was unfair of the writer to make that unsubstantiated allegation against those of us who spoke out for Prop 78; I wasn't offered payment, and I would not have accepted it if I had been.

Dr. Halderman:

I apologize for making the remark you quoted; I agree that I shouldn't have said that. I have no reason to think that you or either of the other two people I named took any money from the supporters of Prop. 78, and I'm sorry that I implied that you had.

I should add that my remark made a little bit more sense in the context of the page that it linked to, before that page was taken down. (The pro-79 website is now offline.) The page was a copy of a Los Angeles Times article titled "Drug Firms Gave Money to Some Who Endorsed Proposition 78," by Dan Morain, dated November 4, 2005. The link in my previous sentence is to another copy of the article, on another site. The article is no longer available for free from the LA Times website, but you can purchase it from their archives for $3.95.

The article starts out: "The nation's drug makers have given hundreds of thousands of dollars to political leaders and civil rights groups that have endorsed the industry's initiative on the Nov. 8 ballot." It goes on to mention (among several other examples) that "an emergency room physician in Los Angeles [...] received $30,000 as a consultant to the campaign." (I should add that the article also mentions at least one organization that was pro-78 without taking any drug-company money.)

So what I intended with my link was not to suggest that no doctor could possibly be in favor of 78 without being paid, but rather to point out that some people, including at least one doctor, had received substantial payments from the drug companies for their support of prop. 78. However, I was quite wrong to phrase things in a way that suggested that you specifically (and the others who called me) were also being paid for your support; there's nothing in that article to suggest that, and I should not have suggested it.

Nonetheless, the phone calls did turn me off from the pro-78 campaign. Regardless of how they came about, they gave me the impression that they were heavily scripted by the drug companies, full of vague phrases of the sort that are common in political advertisements. All of those calls may well have been honest, heartfelt, genuine endorsements from people who really cared, but none of them sounded that way to me, and the combination of all four (or more) of them gave me the very strong impression of astroturfing, of big companies trying to give the impression that there was a groundswell of grassroots approval.

Ironically enough, it would probably be possible for a good enough hired actor to make me really believe that they're an ordinary person giving an honest, heartfelt, genuine endorsement. I don't claim to be perfect, or even very good, at detecting when people are trying to fool me. But I have a very strong gut negative reaction when I think people are trying to fool me, even if they're not. So that's the context in which I wrote what I wrote. But that doesn't excuse my having made the particular comment about you and the others who called.

Anyway, I hope this provides an explanation, even though not an excuse, for my comments, and I apologize again for impugning your reputation and those of the other two people I mentioned. I've now added a note to the entry itself to point to these comments for clarification.