Insulin and It's Discontents

NPR this morning ran a story on insulin pricing. Costs for patients have tripled over the past 10 years.
Of course, costs for all patients have not tripled, only costs in the United States and only for those patients who don't have some sharp advocate at a work HR dept or in a union to watch out for them.


The insulin story as it ran on Morning Edition was one of "human interest" sob stories about sympathetic people who are struggling to pay the $600 monthly for a medication they cannot live without. In some cases, the costs were $30,000 annually, for reasons which were unclear.

As heart rending as these stories may be, they are the "easy" story, the low hanging fruit for today's media--all you have to do is send out a reporter with a microphone and interview people taking insulin.


But the real stories here are not as easy to uncover:
1. Why are insulins so expensive?
2. Why are some insulins $600 a month and others $25 a month?
3. What are the decision drivers for the big Pharma companies, whose executives in their glass windowed corner offices are pricing these products?
4. Who are the "good guys" in this story, from the point of view of John Q. Public?


So there is a story here about journalism failing to do its job.
There is also  the story about how the commercialization of medicine drives costs without benefits.
There is the story about the failure of government, with some notable exceptions, to meaningfully address this scandal.
And there is the Trumpsky story: He has randomly tweeted the way he does, about drug prices, but then, as always, lost interest.

Insulin was discovered in Toronto by Banting and Best in 1921-1922,  one of the most important triumphs of 20th century science and medicine. (Who knew? Every school child learns about generals and Presidents: Can your kids tell you what Banting and Best did?)


From the time of its discovery, new insulins have been developed, new delivery systems have been invented but, truth be told, these are all just nibbling around the edges--insulin therapy has not progressed much since it was first discovered. Oh, it's been refined, but still you inject it, and wait for it to start working and when it stops, you give some more.


In the United States, there are only 2 companies which make the standard, basic insulins: Eli Lilly and Novo Nordisk. There are other companies which make "newer" insulins, which they claim are significantly better than the old ones, but which in fact, are not; they are only more expensive, not better.
All insulin, in the end, is the same when it arrives at the insulin receptor at the cell and fits into that receptor like a key fitting into a lock, where it opens the door to the cell and allows sugar, which is hanging out in the blood doing nobody any good, to be sucked inside the cell where it is used to generate energy.


All insulins, or almost all, are now packaged into more convenient, souped up delivery systems called "pens" or in insulin pumps. But it's the same insulin, just a different vehicle. The old insulins (N and R) are like the Chevy with the standard shift; the new insulins range from the Mercedes (insulin pump) to the BMW (insuln pens) with prices to match. The "new" insulins with different structures and huge price tags are really no different than the old insulins, although their manufacturers and marketers will shriek with indignation to deny that.


If you go for fancy delivery systems, you pay the premium for all that engineering, glass and plastic. A very large premium.


And yet, oddly, in some places, like the Commonwealth of Massachusetts, if you are on Mass Health (Medicaid), you can get the pens and the latest versions of insulin at no cost or very low cost.

How much does it cost to manufacture insulin? Professor Google says about $72 per patient per year. Presumably this is for the standard, basic insulins (NPH and Regular.) The drug companies which make the newer insulins (Novolog, Humalog, Lantus, Basilar etc) will argue there were research costs in developing these, but this would only justify their costs if they were somehow superior to the old, standard, basic insulins.


Just remember: all insulin looks the same to the insulin receptors on the cells. The only real difference among any of the insulin is in their different "kinetics" i.e., how fast or how slowly they begin working and how long they last. But in the end, all insulins are the same; we are just arguing about convenience and price.


If the government took over manufacture of insulin, the prices for the patients, for the American citizens, would drop from $30,000 a year (in some cases) to $75 a year.


Consider who would benefit and consider who would be hurt by this outcome.
You will understand the answer to the "why" question of why we have this current state of affairs insulin pricing.

"The People" and their Representatives

My father would respond to my diatribes about the structural problem with a representative democracy: I maintained the majority of people were too lame to actually know what they wanted or what was best for them.


"Oh," he said, "They may not know how to get what they want, but they know what they want, at least in general terms."

But yesterday, in my office, I was struck again by what's out there.
A woman whose bones were found to be thin and likely to fracture kept insisting this made no sense at all because she swallows four calcium pills a day. When I told her there is no evidence that oral calcium was effective in building bone density or strength or preventing fractures she said, "But I take my pills every day." It turned out she did not understand what "oral" meant, as in taking a pill by mouth.

And another woman who came in walking with a red and white cane: I asked her, "Do you have any vision at all?

She did not know what vision meant. And English is her native language. She also could not recall the name of the doctor who had operated on her brain aneurysm. It was "Chan." Not a complicated name. She was conversational, and would have struck nobody, from ordinary conversation as being demented. She is a lovely grandmother to her grandchildren. She just never got much of an education.
She does not watch "The PBS News Hour." She watches Fox.

As Ben Franklin emerged from the Constitutional Convention in Philadelphia, a woman asked him, "What kind of a government have you given us, Doctor Franklin?"
And he replied, "A Republic, madam. If you can keep it."


Watching Nancy Pelosi's investiture on CSPAN was one of those experiences when hope was ascendant over experience. Our hope is so high, but there among the House CSPAN panned over Jim Jordan chewing his gum like cud and Ted Yoho and Louie Gohmert, who really do represent people who, in the immortal words of Stringer Bell, from the Wire, are simply "too ignorant to have the floor."

(This occurred when Stringer tried to run his meetings of hoppers and touts and street thugs by Roberts' Rules of Order and a young tout challenged his plan for becoming less confrontational and more business like and Bell cut him off and one of the other touts reminded him, "Stringer, Poot do have the floor." And Stringer Bell dismissed all that with, "This nigger too ignorant to have the floor.")

Guerra

And so we wonder, as the American Experiment goes forth, are our people simply too ignorant to have the floor?

The Fifth Risk: Why Government Is Necessary

Michael Lewis has in 219 pages outlined what is wrong with Trumpism.

Michael Lewis 

And what is Trumpism?  At it's essence is the conviction we do not need government except for two things: Military might and defending our borders.

What Lewis shows, by telling stories of various admirable people who chose to work in the federal government, is how important the daily workings of the federal government really are: The Department of Commerce, which is really the department of Data, which collects weather data and transforms it into weather predictions. The Department of Agriculture, which is really the Department of Rural Development and the Department of Science and Technology.

Part of the problem is the names of the various Departments are misleading. We know what Defense and State do, even though those, too are misnomers: These are really the Department of War and the Department of Foreign Affairs. But most of us do not know or understand what Commerce or Agriculture do.

Growing up in the Washington suburbs, I went to school with the kids of Congressmen--this was back when Congressmen, especially Senators, moved their families to Washington and lived there--but most of the parent of kids I went to high school with worked for agencies like Standards and Measurement or NOAA or the National Institutes of Health, or NASA.

They did things like figuring out how much stuff had to be in building materials so skyscrapers wouldn't collapse, or figuring out how to predict tornadoes in time to warn people to take cover. They were involved in collecting huge troves of data which allowed airplanes to fly, buildings and bridges to remain functional. They did all the work which was too expensive or unprofitable for private enterprise to be interested in doing but which made private enterprise profitable--like developing something called "the world wide web" and the internet. 

These are the people of what Trump's friends at Fox News call "the deep state." These are the men and women vilified by Steve Bannon:  All those nefarious civil servants who Trump wants to root out.

People like the folks at the Department of Agriculture who, with astonishing speed, developed a lab test for bird flu so only a few million chickens had to be culled rather than hundreds of millions, and who protect us from Mad Cow Disease getting into McDonald's burgers across the land, or Toni Fauci, who heads the institute at the NIH which oversaw the identification and treatment of HIV/AIDS.

Toni Fauci

But as Lewis demonstrates, the men President Trump has appointed to run these departments have either been actively hostile to the idea of what they might be doing-- without actually knowing--like Rick Perry who thought the Department of Energy was all about funding solar energy, killing "clean coal" and proving climate change was man made, and was clueless about it's more important mission, which is to track loose nukes (stolen nuclear war heads) to insure our own nuclear arsenal is maintained safely and to clean up vast areas contaminated by previous nuclear bomb building factories which currently are moving in subterranean drift toward the Columbia River.

Rick Perry

Wilbur Ross, who heads Commerce, thought the business of Commerce was business and tariffs and had no idea it is actually the main data collection center of the federal government, which does the census, tracks water temperatures, weather patterns and most of the data on the planet's natural phenomenon which control fisheries, airplane and ship travel, and when he was told about these other, more important functions said he was not interested in any of that.

Wilbur Ross

And there is Barry Myers, who founded a commercial weather prediction company which predicted a tornado would hit a town in Oklahoma but informed only his subscribers so the rest of the population of that town was struck without warning, whose company, Accu Weather, functions completely dependent on weather data collected by the federal government's National Weather Service (part of NOAA) but who considers the government a competitor and sought to become Secretary of Commerce so he could strip the Weather Service of its capacity to offer its services to any company but his own. 

Barry Meyers

All of this is the devil in the details. 
We think we know the venality and avarice and sheer depravity of Trump and those who sail with him from the Trump tweets and from CNN, but the details of these banal creeps who have swarmed in to eat out our government from the inside is only apparent when you dig into it with someone like Lewis. 

Reading Daniel Patrick Moynihan in 2018

Daniel Patrick Moynihan was a Democratic United States Senator from New York, an academic, an ambassador to the United Nations, but he is best remembered as an adviser to Richard Nixon.

Like many academics, he seemed happiest when he didn't have to do anything to accomplish change but could simply write a paper and watch the person or people in power execute his advice.

Nixon, like Trump, was not a deep thinker, a policy wonk.  
It is said there are 3 types of Congressmen: pot hole fillers, politicians, policy wonks, which is to say people who do constituent services, people who only care about getting re elected and people who like the idea of manipulating rules and systems to achieve big goals. 

This applies to Presidents as well. Nixon and Trump clearly had no real interest in anything but staying in power and getting re elected. 

So, it is natural that the President would put in place some people to tell him what to think and what to do.

In 1968 Moynihan was writing memos about the problem of global warming and CO2 emissions and burning fossil fuels.

He also wrote the famous memo, promptly leaked to the press, about "benign neglect" in the case of racial relations. What he actually was saying is there had already been too much said about race, that it began and ended every discussion and enough already!

Reading his memos to Nixon one sees the gauche pandering to a damaged ego, a friendly therapist who knows he is dealing with a fragile psyche he is being careful to bring along.

But the big take home is how very much more volatile and tumultuous the 1960's and 1970's were than what we have now with the Trumpling. American soldiers were coming home in body bags, or limbless, and were murdering Vietnamese villagers, women and babies at Mylai; demonstrations  were drawing hundreds of thousands; National Guardsmen murdered 4 students on a college campus; large parts of the inner cities were being burned down; white racist Southerners were murdering white Freedom Riders and black people; women were still not advancing in the workplace.

Compared to all that, the Trumpling is merely a malodorous cloud of gas emanating from the hind parts of a dyspeptic and flatulent nation.

B.S. "Big Sissy" Trump

Mad Dog has been trying to come up with a moniker for the Trumpling, in an effort to respond to his joyous playground practice of hitting his targets with mud pies like, "Adam Schitt" and "Little Marco" and "Pocahontas" and "Low Energy Jeb," and "Da Nang Dick Blumenthal."

Oh, we've all heard "When they go low, we go high."

And we've heard the advice you can't out Trump Trump.
But the fact is, you do not stand up to bullies by smiling in a superior adult way.

But the fact is, there is a certain potency in these jibes. He really does identify the most vulnerable thing about a person and goes for that.  Elizabeth Warren, that Waspy blue eyed blonde, claiming to be a Native American on an Harvard application, Richard Blumenthal caught in the lie of claiming to have seen combat in Viet Nam-- those speak to real flaws, disqualifying flaws of character because they are grounded in truth, however distorted or over played. 

So what is the undeniable vulnerability in Mr. Trump?


Joe Biden roused some spirit among dispirited Democrats by saying he'd take Trump out in the alley and beat the shit out of him, but Biden faded from the scene.

After Nancy Pelosi walked out of the White House, she joined fellow Democrats back on Capital Hill and she reportedly said, 
“It’s like a manhood thing with him — as if manhood can be associated with him,” Pelosi deadpanned. “This wall thing.”

And that is exactly what we need.
The appellation is now obvious. Listen to Trump talking about the wall. He quakes and quails about the nasty, dangerous, scary dark skinned people on the other side of the border, and he wants to build a wall to keep them out.

He is terrified. Dark people scare him. Violent people scare him. He will not visit the troops because he's afraid of being shot. 

He is, in fact, a Big Sissy, which would make it B.S. "Big Sissy" Trump.

All this time we have been searching for alliteration.
And all along the truth was right in front of us.

Liberal Excesses

Betsy DeVos is no liberal's idea of an enlightened mind.
But, as Trumplings are apt to do, she is very good at finding the seams in the liberal armor and striking there.


She has attacked the campus rules governing responses to accusations of sexual assault and harassment.

Listening to a Harvard professor on NPR, who found herself unable to avoid saying the words, "I have to agree, DeVos is right on this one,"  Mad Dog had to begrudgingly agree.


As the professor described the process, where a boy accused of sexual assault, rape or harassment was often called to a meeting without prior notice, unable to confront his accuser, unable to even get a clear statement of the offense, it sounded like something out of an old movie, a "Darkness at Noon," the ultimate in authoritarian nightmare, where the accused has no rights, no chance to defend himself.


This connects to the #MeToo phenomenon, hard to call it a "movement," more of a "cultural revolution" redux, where the dogma, never to be questioned, is that when a woman accuses a man of rape,  fondling, anything really, she is to be believed, which means, ipso facto, if the man denies it, he is to be disbelieved.

Few things have done more to discredit liberal figures than the blind embrace of "the woman is always right," credo. This stance simply rejects the whole notion of fairness, of the importance of discussion, of cross examination.


"Oh, but you then traumatize the victim twice!" is the cry.
Well, what of the trauma to the accused?


If the woman cannot be in the same room as the accused, because she is such a delicate flower, where does that leave justice?


Mad Dog well remembers the first case of "date rape" reported decades ago, in his college alumni monthly, and the few details of the event raised multiple alarm bells in his own mind about whether or not a rape had occurred: Not the least of which was the fact the girl accuser, awakening in the boy's dorm room bed the next morning wrote down her actual, real phone number and gave it to him, presumably so they could repeat the experience. But when she got back to her dorm room, she decided, after speaking with her friends, she had been raped. The boy was expelled from the college, not tried by a criminal court, where rules of evidence, cross examination would have been available. He was tried in a Star Chamber at the college and expelled. In his junior year.

Such things do more than hurt individuals caught in the snare of these events, they utterly destroy the trustworthiness of the liberals, mostly women, who defend and espouse them.
The sine qua non of the liberal mind has got to be an openness of mind, a willingness to hear the other side. Aude alteram partem.
When you lose that, you lose everything.
I would argue the women who embrace the current mess governing campus sexual assault charges are not true liberals. They are Gospel Zealots, Strident Infallibles. But they are not any with whom true liberals should want to be associated.


 

Should America be Soup or Salad?

Reading over the letters to the editor in the "Failing New York Times" this morning, in response to Paul Krugman's piece on the the "Senate America" in which he decried the structure of our government which allocates 2 United States Senate seats to 600,000 Wyoming residents but only 2 to the 40 millions in California, I was struck by the argument that we need to honor local sentiment, folkways, beliefs, customs which distinguish life in the smaller states from that of the "elite" coastal urban states. A law professor from Berkeley, no less, suggested we can have our cake and eat it too if we simply remember the 21st amendment, which struck down a national prohibition against alcohol and allowed local jurisdictions to decide whether or not the risks of demon rum were worth the benefits of legalizing it.

But that professor fails to recognize the 18th amendment which was put into place because of outsized power of Bible Belt states.  Today, 50 United States Senators represent just 17% of the American population, which puts the Bible Belt in the driver's seat.  A man from Terre Haute, MO tells Mr. Krugman, "Quit whining about how stupid the voters are and work harder to convice us in flyover country that your policy beliefs are the best way forward for our nation." 
As if you can actually fix stupid.

But another writer (from New York) noted: "In the 21st century, the United State is not a federation of separate states, as it was in 1776 or 1787. It is a radically integrated nation in a radically integrated world." 

All this crystallized the basic problem: significant parts of the country have not been integrated into the global hole, and they fear and resent the idea that they ought to be.

Of course, the good citizens of Iowa who sent the repugnant Steve King to Congress do not object to being integrated, some would say, "homogenized" into the rest of the country and the world by commercial forces: I have never driven through Steve King's district, but I would be astonished if I did not see Home Depot, McDonald's, Kentucky Fried Chicken, Staples, Starbucks, Walmart, Target and all the other big national chains, with their recognizable and uniform logos and colors. 

Obadiah Youngblood

It's the "blindfold and the parachute" test: Drop me blindfolded over any big American city: New York, Washington, Boston, New Orleans, San Francisco, Minneapolis, Seattle, Miami, and allow me to whip off that blindfold and look around, walk around for 5 minutes and I will be able to identify where I am. But drop me into any rural area of Pennsylvania, Rhode Island, Kansas, Iowa and it's all "Alabama in between." Most of rural and even suburban America looks pretty much the same. You might pick up a regional accent in the South or in New England, but even in Pennsylvania what you will hear is a "rural" accent, not a Pennsylvania accent. 

The fact is, our states no longer are sufficiently different from one another to actually represent distinct entities. Yes, Montana is vast and different from Maine, but the problems of low population density and small industrial base are pretty much the same. And yes, water rights and grazing rights are more ascendant in Utah and New Mexico  than in Connecticut and Vermont, but the dividing lines of thought and concern are not contained within the state lines any more, "state and local concerns"  are historical relics, the shed chrysalis of  the of a country which has metamorphosized beyond its larval stages.

State boundaries do more to hinder the progress, financial and economic well being of the USA than they serve any justifiable purpose in the 21st century. 

Edward Hopper

This is not to say there are not cultural differences between Mississippi and New Hampshire. 

It is entirely possible people in Ohio and Mississippi may decide that life begins at fertilization and will not allow abortions because there are enough people there who cannot be budged from that conviction. Ohio is on its way to passing legislation to forbidding  abortion after a heartbeat is audible at 6 weeks.

Mad Dog, for one, could certainly live with a reversal of Roe v Wade, and sending the question of abortion back to local control. 

Within our current state structure, that would mean if you are carrying an unwanted pregnancy, you would have to leave Ohio or Texas  and get thee to a Northern state for your abortion. Unless, of course, you can buy abortion pills over the internet and have them sent to your home in Akron or Biloxi.


But  even if you are too far along for an abortion pill, you could get a safe, legal abortion. You'd just have to make plans and travel. 

Mad Dog realizes this would mean poor, uneducated women, women with little in the way of financial resources would likely opt to have unwanted children, then give them up, or they might go back to the back alleys.

Edward Hopper

Likely, this will result in a substantial  increase in births of unwanted infants in these states. Ohio, Texas and other states who insist on bringing into the world these children, unwanted, predestined to sad, violent lives would not be the only places to suffer the consequences as these children come of age. 

Likely, many of these unwanted children would be sent North, where adoptive parents would care for them, much as Southern states are now the main source for "rescue dogs" in New England. 

But we can make accommodations for all this. The better educated "elite" in the coastal cities have supported the less educated populations of Ohio, sending government munition contracts to Jim Jordan's district there, and sending defense contracts to the poor Southern States. These less educated, determinedly ignorant are the educated man's burden. 

Trump and all his Trumplings are fond of saying "countries need borders." And Mad Dog emphatically agrees: Nations need borders. If 300 million Chinese and 300 million Indians and Pakistanis decided to immigrate to the USA tomorrow, we would have a country Mad Dog would not recognized or desire. 

But one might ask, why do these United States need state borders? The framers of the Constitution settled on agreements which the current European Union now envy: Louisiana cannot tax goods coming in from Illinois; no passport is required to travel from New Hampshire to Massachusetts; and since Marbury v Madison, a law which forbids denial of voting rights, public education and restaurant use to Negroes/African Americans in South Carolina cannot stand if the Supreme Court of these United States says borders cannot be used to deny basic human rights.

Photo by Obadiah Youngblood

The impulse toward empty space protections, whether it be in Idaho, Wyoming or Montana is an impulse to say, "Leave me alone. I do not want to be part of anything larger. I want to reject the rest of the world and live on my own land, with my six wives, my 20 white children, who will never be vaccinated, never learn to read, and I will be king of my own castle. I will graze my cattle on land no matter who may claim it; if I can string up barbed wire, it's mine. I will teach my children the White Race is under siege and we will live here awaiting the final Armageddon." 

Mad Dog can live with that. Let the Aryan nation claim parts of Idaho.  Hopefully, they'll stay on their reservations. 

Seventy seven years ago, when Pearl Harbor exploded, Americans from very different worlds within the same country amalgamated to form an army, produce war materials and boys from Georgia joined boys from Wisconsin and discovered they were more like each other than they were like Frenchmen, Belgians or Italians or even the English. Exposure to the greater world changed Negro men from Alabama, so when they returned home they were no longer docile. Women who worked in factories  were no longer content to sit home with children and their new refrigerators. 

Photo by Obadiah Youngblood: Lock 8

Until the 21st century, there were only three TV networks disseminating news, and Hollywood formed values and desires. In that sense we were, even then, radically integrated. With the Internet, we can be even more so.

It's a new world now, but we still  have an 18th century government. 

It used to be America was like a salad: you could stick a fork into one part and get a tomato and into another and get an anchovie. Now, it is more like soup--dip a spoon into any part of it and you get to taste the whole of it. Of course, there may be clams in there, like the difference between the cities and the rural areas, but the differences in different parts of the soup are minimal, compared to the salad. 

Fact is, things will not change without a fight. Montana has the power to exert outsized effect and will not give that up willingly. Right or wrong has nothing to do with it. 
But eventually, if we keep pushing, we can change.