CHAPTER 17

PHARMACEUTICALS PROGRAMS

“No amount of experimentation can ever prove me right; a single experiment can prove me wrong.” - Albert Einstein

“It is easy to get a thousand prescriptions but hard to get one single remedy.” - Chinese Proverb

§ 17.1.0 TOP DRUG COMPANIES - NAMES, RANKS, REVENUES & PROFITS

§ 17.1.1 The top 12 drug companies found in the Fortune 500 are listed below. Their revenues posted in July 2007 totaled $383 billion and reported profits totaled $79 billion. Of each dollar they took in, 21 cents was designated “profit”. For each American, they had revenues of $1,276 and profits of $265.

§ 17.1.2 If we compare the profitability of drug companies to the whole of the Fortune 500, we find that they have three times the profitability of the whole Fortune 500.

§ 17.1.3 If we examine profitability, we see that while the whole of America and many companies have felt the economic recession of 2008-09, the profitability of drug companies remains untouched in a time when the revenues and profits of most Fortune 500 companies are turning to losses.

§ 17.2.0 DOLLARS INSIDE BIG PHARMA

§ 17.2.1 For every dollar that big Pharma receives

§ 17.2.1.1 - It spends only about 15 cents on drug development. Some of these services are provided to satisfy

mundane and outdated requirements of the FDA, some of which are senseless and ought to be removed. Some FDA requirements are essential for the very safety of the American public.

§ 17.2.1.2 - It spends about 30 cents on marketing and ADMIN! Drug representatives monitor which doctors prescribe

their medicines and they reward physicians with junkets, novelty items, speaking fees, and research dollars.

This is wrong and must be stopped.

§ 17.2.1.3 - 21 cents is spent on shareholder equity, also known as profit.

§ 17.2.1.4 - It spends about 35 cents on production, distribution, and direct ADMIN of these functions. Also, within this

35 cents, drug marketing companies offer very generous programs for patients in need of their medications but who make low or no income.

§ 17.2.1.5 - R&D expenditures of 15 percent is not robust, although for many years the percentage of their budgets

designated for R&D was significant. I’m all for bigger and more profitable pharmaceutical companies! If they’d develop vaccines for cancer, heart disease, MS, Parkinson’s Disease and Alzheimer’s Disease, I’d pay them a bundle. Big Pharma states that it focuses on problems for which they can see a return on their investment. I don’t know. They seem to have given short shrift to most of the top 10 killers of Americans. Now, if they invented a vaccine for cancer, most of us would pay dearly for it – certainly even more than erectile dysfunction medicines. They ought to be focused on developing medicines that will improve longevity and QOL. Greater investments in R&D and less spending on marketing ought to be an objective of all private and public insurance programs.

§ 17.2.1.6 - Marketing and general ADMIN total $115 billion a year.

§ 17.3.0 BIG PHARMA LOBBYING

§ 17.3.1 One report summarized first quarter 2009 spending of Big Pharma lobbying at $126 million (or $504 million a

year). That’s its own safety net. After all, what politician who receives $1,743,000 a year from big Pharma would vote against big Pharma? As for investments in changing the opinions of the public, Big Pharma is spending nearly $1.5 million a day on public advertising while health care reform is being debated.

§ 17.4.0 MEDICATION ERRORS COSTS

§ 17.4.1 One study reported the number of US deaths due to adverse reactions to medications totaled 100,000 and resulted in 2.1 million serious injuries. This estimate did not include prescription errors, accounted for elsewhere. The costs of medication errors to society (death, life insurance, lifetime of lost income, re-hiring and training, changed family dynamics) and the health care system (e.g., surgery, ICU / CCU, lengthened hospitalizations and greater doctor visits) is tremendous. If doctors’ prescription queries were met with up-to-the-minute safety / interaction warnings, errors would be reduced.

§ 17.4.2 $320 billion in costs from errors when we’re only paying $244 billion a year for prescription medications (in 2003) grabs my attention, especially when longevity is still so far below that of our peers. The unknown variable is the costs to society and health care if the medications were not administered.

§ 17.4.3 EMRs will significantly reduce medication errors.

§ 17.4.4 Constant, real time monitoring of medical records would assure faster identification of potential medical concerns and warnings would be issued much faster.

§ 17.5.0 PRESCRIPTION DOSE CHANGE RECOMMENDATION

§ 17.5.1 Dosages ought to be prescribed factoring in the patient’s weight and, perhaps, metabolism, and liver function. The disparities were not all that significant in the 1940s when most every adult weighed between 100 and 180 pounds. Now, the range, with Anorexia and obesity, is 80 to 400 pounds and, when factoring in children, the minimum can decrease to 5 pounds. Once a medication has been successfully introduced, especially those used on a long term basis, monitoring frequency might be reduced.

§ 17.6.0 POLYPHARMACY

§ 17.6.1 As we age and more things go wrong with us, physicians start prescribing us more medications. Isolated specialists that treat diseases instead of whole people can add medicines without checking for possible interactions. As a patient visits multiple specialists over the years, the number of medications builds up. Polypharmacy’s effects are especially prevalent among the elderly, chronically ill, alcoholics, persons with liver disease, and children.

§ 17.7.0 FOOD AND DRUG ADMINISTRATION (FDA)

§ 17.7.1 I introduce several programs for which I urge expansion of FDA authority and monitoring activities that will save Americans and pharmaceutical manufacturers money.

§ 17.7.2 FDA must be granted the authority to regulate generic biological drugs. I’m amazed that biologic drugs have been on the market for 20 years and this is now the first time that I’ve heard that the FDA doesn’t even have a program in place to regulate such drugs. During the last campaign, I heard that they were needed, but, this nuance is novel. Why did they not develop such a program in the previous two decades? Authority ought to be able to be granted by executive order. But, political lobbying is influential among businesses that stand to lose $20 billion a year, and, if this helps pass responsive healthcare reform, then it must be part of the package.

“Let advertisers spend the same amount of money improving their product that they do on advertising and they wouldn't have to advertise it.” - Will Rogers

§ 17.7.3 The FDA ought to regulate direct marketing of drug and health care companies to potential patients, reducing “demand created advertising”, through imposing fees, perhaps equal to the price of advertising, in combination with regulation.

“Advertisers in general bear a large part of the responsibility for the deep feelings of inadequacy that drive women to psychiatrists, pills, or the bottle.” - Marya Mannes

§ 17.7.4 Approved medications or procedures in some other nations ought to be considered class B. Americans ought to be allowed to purchase these products, provided the items have satisfied a lower threshold of safety and information is openly provided to potential US consumers. US doctors might provide class B procedures or prescriptions for patients who provide informed consent, especially when they face chronic, debilitating, or terminal illnesses. Federal agencies must provide assistance to assure narcotics and illicit drugs are not distributed. This will provide US patients with more alternatives and reduce costs of some items. Of course, while I advocate the use of a centralized pharmacy that can negotiate best prices with pharmaceutical companies, individuals, for-profit, and not-for-profit insurance companies must be permitted to purchase approved medications in foreign countries, if they have obtained less costly products.

§ 17.7.5 Drug development costs are borne by US but must be shared with OECD nations. By partnering companies and nations to invest in drug development, we could increase efficiencies, accessibility, quicken development time, and increase treatments. We must permit a streamlined review process. Drug development costs must be balanced against the potential costs of risks (e.g., 1 in 10,000 might die who is treated with this medicine) versus potential health benefits (e.g., 1 in 3 won’t die).

§ 17.7.6 When drugs come to market, US physicians must spend time reading articles and attempt to determine the

confidence level of findings. The final patient investigative drug trial procedures must not be executed by pharmaceutical manufacturers but rather by university / NIH investigators, with grants to these neutral “double blind” investigators through the FDA and fully paid for by the manufacturer. Costs ought to be at least 10% less using this method and the results would have much greater confidence.

§ 17.7.7 FDA should mandate disclosure laws for all providers and service associations. Before allowing one’s physician to prescribe “x” drug, one ought to be informed that the doctor receives a research grant from that company.

§ 17.7.8 FDA ought to require / fund long term studies of safety, efficacy, side-effects, and interactions. The use of an electronic medical records system could make such studies inexpensive.

§ 17.8.0 CENTRALIZED PHARMACY & HEALTH CARE PURCHASING CENTER

§ 17.8.1 The US spends (in 2003) $752 per person on medication, $3,008 for a family of four, and twice the OECD average.

§ 17.8.2 At $244 billion (in 2003), it’s the third biggest part of health care. With the expanded coverage of Medicare Part

D for elders, in 2009, this is estimated to be $360 billion. Still, we die young.

§ 17.8.3 The US pays more than other OECD nations for same medicines, partly to pay for development costs that other

nations don’t pay.

§ 17.8.4 A centralized US pharmacy could negotiate competitive, fair prices with each drug manufacturer. In English, the process of negotiating fair prices is a critical part of what is called capitalism. The only reason that negotiation of prices would be forbidden is that such negotiation interferes with profits of oligopolies.

§ 17.8.5 An economy of scale would add to savings of more than $5 billion a year.

§ 17.8.6 If the US spent only half more (as in 150%) than other OECD nations PP, we would save $60 billion a year. If the pharmacy were located in Canada and we could purchase medicines in Canada, that would save $90 billion a year. If the pharmacy were located in a low-cost off-shore location such as the Caribbean, an additional $20 billion could be saved.

§ 17.8.7 This could be managed, through bid-contract, by a health insurance company or pharmacy.

§ 17.9.0 DOCTORS NEED UNBIASED INFORMATION ON DRUGS

§ 17.9.1 American doctors spend much more time evaluating drugs’ effectiveness and potential dangers than do

physicians from other OECD nations. Part of the reason is that we get the latest products whereas those in other OECD nations get more “proven” products and benefit from our experimentation. Doctors must individually read and examine research studies on drug benefits provided to them by the drug companies themselves. Even with tremendous levels of oversight by FDA, doctors have marginal confidence in the results of these studies. Unbiased, trustworthy articles providing information on drugs studied by objective researchers must be available. The “objective” research of drug developers, academicians, and physicians with financial interests in the drug are not as likely to induce confidence.

§ 17.10.0 PART D MEDICARE BENEFIT

When the Medicare Part D Drug Benefit Program was presented to the Congress, it was presented by the Bush White House as likely to cost $420 billion over the next ten years. A White House official threatened to fire a Medicare actuary who wanted to disclose the true costs. One month after passage of the act, the cost was next escalated to $520 billion over the next ten years. Another 18 months, and the projected costs were an astounding $1.2 trillion over the next ten years.

CHAPTER 18

INEFFICIENCIES IN ADMINISTRATION (ADMIN)

“It usually takes me more than three weeks to prepare a good impromptu speech.” - Mark Twain

A recent poll showed that managed care had a respectability rating just above the lowest ranked sector, tobacco.

§ 18.1.0 OVERVIEW

§ 18.1.1 Between 2000 and 2007, the profits at the 10 biggest health insurance companies increased 428%. Hundreds of health insurance companies have been purchased by the few biggest companies, leaving only a few remaining health insurance companies. These conditions lead to an oligopoly, which is against all principles of capitalism as defined in 1776 by Adam Smith. Has capitalism changed?

§ 18.1.2 In 2004, US health insurers directly employed 470,000 people (average salary = $61,409). Total employment related to all insurances was 2.3 million.

§ 18.2.0 TOP INSURERS AND ADMINISTRATION COSTS

§ 18.2.1 Where ADMIN and profits totaled $37 billion among a select group of insurance companies, the ADMIN costs if they had been operated by the public sector would have been $6 billion, thus saving taxpayers $31 billion. The savings would pay for a bypass surgery for every American needing one that same year!

§ 18.3.0 EXECUTIVE COMPENSATION

“Fidelity is seven-tenths of business success.” - James Parton

§ 18.3.1 United Health's CEO, William McGuire, received $1.6 billion in stock options plus an $8 million salary. UH director and dean of Columbia’s School of Nursing raved he’s worth every billion, err, dollar. Anyone wish to guess on the prospect of future gifts to Columbia?

§ 18.3.2 OK. In school, I saw Lee Iacoca earn his several million in bonuses for saving Chrysler. So, I defended great CEO compensation, believing if they shrewdly added $1 billion in shareholder equity, I’d pay hundreds of millions to them. However, today, bonuses are no longer tied to performance. Banks and stock trading firms that groveled before the federal government for trillions of dollars in bailouts or they would go bankrupt suddenly found tens of billions of dollars to pay its executives with the taxpayer’s money! If socialism is to be feared by the radical right, let’s start with the $5 trillion is government bailouts that Wall Street has obtained, not even included in the books of the federal government. Further, companies misrepresent facts. SEC filings can no longer be trusted. Today, stock bonuses are designed so the executive saves on taxes by paying only 10% in long term capital gains rather than 36% in salary on bonuses of $1.6 billion. Since these sweetheart stock deals are tied to work and not capital, these executives ought to be paying the maximum labor rate.

§ 18.5.0 OLIGOPOLY PROFITS

§ 18.5.1 In most markets (56%) a single payer controls more than half of the insurance business. US health care is sufficiently concentrated to make most prosecutors charge for violations of anti-trust laws, if they were, indeed, able to be prosecuted. Where there is absolute control over a market, monopolistic behaviors occur, and capitalistic competitive spirit is extinguished in favor of assured greater profits. The problem is that the Sherman Anti-trust Act does not apply to insurance companies, as they are not regulated by the Inter-state Commerce Clause and in 1945 Congress passed legislation assuring that they not be regulated by Congress. Given that they have been allowed to grow into oligopolies that are now a clear and imminent threat to America and Americans, Congress must act swiftly to assure safety.

§ 18.5.2 The big 3 insurance carriers in Washington state, Regence Blue Shield, Premera Blue Cross, and Group Health Cooperative’ profits increased from $11 million (2002) to $431 million (2006) (3900% increase). Cash surpluses increased from $833 million (2002) to $2.2 billion (2006) (264% increase). They covered nearly 2.4 million ($5 PP) people in 2002 but only 1.9 million ($227 PP) in 2006 (just 79.2% of the people despite tremendously increased profits)!

§ 18.6.0 PATIENT ADMIN

§ 18.6.1 Here’s something we seldom see – costs of ADMIN by patients. How much time, unpaid, do we spend on the telephone correcting other’s errors? Making sure that our coverage doesn’t lapse or isn’t dropped or reduced? We are the ones who must make certain that insurers pay our doctors so we’re not straddled with unfair attacks on our credit. How much time do we spend reviewing policies, statements, bills, and, pay the ones that are legitimate and fight those that are not? Tell me this: what sickly patient can truly do this? I estimate that the costs of patient personal ADMIN exceeds $100 billion a year, mostly in lost productivity paid for by themselves or their employers. Easily, 80% of this cost could be eliminated, saving the US $80 billion a year. That would pay for most of the projected cost of covering the uninsured in the President’s Health Care Plan.

§ 18.7.0 ADMIN & INSURANCE EXPENSES

§ 18.7.1 Direct ADMIN costs by third party payers totaled $180 billion / year in 2003 ($466 PP versus $66 in other OECD nations). The US spent 7 times more per person than the other 29 OECD nations on direct ADMIN! That was shocking, given that the US is more sickly, die 5 years earlier, and still spends twice as much in health care costs for each person, those $180 billion dollars are not being spent effectively! We, as taxpayers and citizens and payers of insurance premiums and stockholders are not getting the quality or savings that we want. Given that we have a larger population, an economy of scale ought to be realized, but ADMIN is more, not less. If Americans were living healthier, all were covered, had fewer medical errors, QOL was better, and life span was longer, I’d be inclined to conclude, we’re getting our money’s worth. If the costs of private insurance administration were as low as Medicare or other OECD nations, we’d be saving $150 billion a year ($500 PP). That would pay for all treatments for cancer PLUS insure all of the uninsured in America.

§ 18.7.2 Estimates of combined direct (third party payer ADMIN costs) AND indirect (hospital and other provider ADMIN costs) health care ADMIN costs vary greatly.

STUDY ADMIN COSTS % SAVINGS

#1: $400 billion/ yr 16% $100 billion

#2: $580 billion/ yr 23% $280 billion

#3: $833 billion/ yr 33% $533 billion

§ 18.7.3 It is noteworthy that the administrative costs for other OECD nations for their public systems is 3%. That is the same as Medicare’s ADMIN cost. The Senate Finance Committee, chaired by Senator Max Baucus who receives millions of dollars in campaign donations and lobbying gifts, wants to increase private insurer’s ability to charge 75% more for administration (and profit), increasing from 21% to 35%. I guess $1.6 billion bonuses for United Health Care’s CEO just isn’t enough to live on.

§ 18.7.4 Managed care, government compliance, and administrative systems are ineffective – across the board.

§ 18.7.5 Insurance companies pad their programs with bureaucrats to inflate operating costs (and, subsequently, real profits) wherever it is proven that micro-management will result in greater costs (and thus premiums and profits) but it will also eliminate almost all bureaucrats for expensive procedures and medicines (as these result in greater medical costs than their operating expenses could justify) and, thus, profitability increases.

§ 18.7.6 Medicaid programs are redundant systems resulting in tremendous inefficiencies that result in overspending by $19 billion per year. I’m curious why the people who advocate buying private insurance across state lines advocated separate state Medicaid programs. Allowing the private insurance companies to market across state lines will “eat up” the remaining small companies but it will also subject the insurance companies, I think, to the Sherman Anti-Trust Act, which is probably desirable to government and the American people.

§ 18.7.7 ADMIN costs for most federal grants is 20% of the cost of each grant. Streamline administrative costs so more scientific research can be performed that save lives and not just employ administrative specialists. $3 billion per year could be saved based on just NIH current grant funding.

§ 18.7.8 FDA regulations impose tens of billions of dollars worth of mandates. Some of these are inefficient, do not improve safety, or balance safety with cost.

§ 18.7.9 A streamlined review process, especially provisional review for class B items is needed, would save pharmaceutical manufacturers and US patients money.

§ 18.7.10 - Our blindly believing the results of later-trial human efficacy studies by drug companies with vested interests

is foolhardy, at the very kindest. The FDA ought to assess to pharmaceutical manufacturers the costs of studies that will be contracted out to an objective source, say, NIH, thus assuring greater veracity.

§ 18.7.11 - Providers themselves maintain costly record-keeping systems to avoid litigation.

§ 18.8.0 ELECTRONIC MEDICAL RECORDS (EMR)

§ 18.8.1 Imagine every patient has a health care (credit-like) card containing EMRs. Think of the advantages:

Prescriptions, doses, dates, prescribers, doctors, diagnoses, and surgeries are immediately printed out.

Doctors could identify dangerous patterns, potential causes of problems, as well as the occasional patient who “doctor shops”. Patients presenting without communicative ability (e.g., accident trauma) would still be able to provide Emergency Room physicians and surgeons with accurate and reliable information, in a timely manner, that would save many lives.

Providers would have instant, accurate information, thus able to spend more time caring for patients and less time ordering unnecessary tests that cost tens of billions of dollars. This is especially common when one specialist orders one set of tests and, three weeks later, another specialist orders the same tests. If specialists had access to the results of the first set of tests, the second round of tests might not be needed. After the first incident of the above, EMRs could be programmed so that the next time that that first specialist orders a round of tests, he is cued, “last July when you ordered this blood work-up, three weeks later Dr. Jones ordered the same panel, plus CBC.” The first specialist, knowing that CBC would cost $1.00 more, orders that test rather than making the patient undergo another $100 worth of testing. ALSO: automatic reminders would be delivered to patients, caregivers, physicians, nurses – annual physical is due, 3 month blood workup is needed, any problems with new medicine?

As individual patients might not want everyone to have access to everything, I would suggest that certain controls ought to be permitted. For example, a woman might not want the fact that she had an abortion 30 years ago to be available to her neuro-oncologist. This would become restricted information. The only thing that the provider today would see is, “Patient has identified some information to be restricted.” A psychiatric patient who is paranoid, convinced that health care workers are aliens out to kill him might have restricted everything. Providers ought to have right to appeal, immediately, if they can justify need for information at that time.

Medical errors could be reduced, through ease of reading typed font versus physician’s handwriting, and interpretation accuracy, reminder systems, automatic displays, direct and immediate prescription orders, and summaries.

At the time of discharge, ERs, hospitals, physicians and other providers, would provide patients with automatic print outs that summarize disease(s), medicine(s), and behaviors expected of them as well as the treatment plan (e.g., doctor will refer for PT consult). For psychotherapy, this might include the weekly assignment.

§ 18.8.2 The thought of a centralized EMR system might be frightening:

The government might know if I carry the gene for a disease and, if it ever again violates the rights of US

citizens, it might choose to put carriers such as myself into concentration camps or worse.

The government, particularly law enforcement agencies, would be able to glean whether or not I was obtaining

controlled prescriptions from multiple physicians.

§ 18.8.3 I would suggest that both the potential advantages and disadvantages ought to be realized. A citizen’s panel

ought to be established to provide guidance regarding balance of access and privacy.

§ 18.9.0 ELECTRONIC MEDICAL BILLING (EMB)

§ 18.9.1 Insurance plan, co-payment, and deductible information would be automatically given to the provider. With EMB, the insurer immediately deposits payment for the procedure into the bank account of the provider, directly, bank to bank, avoiding credit fees. EMB staff could be reduced by hundreds of thousands, saving tens of billions of dollars each year.

§ 18.9.2 I realize that exceptions can be exceptionally costly to manage when sending out bills, but, I’d think that $2 would be the least that would make the sending of a bill worthwhile.

§ 18.9.3 Given the total premiums paid to private insurers and the current ADMIN costs and the potential costs if they spend the same percentage as Medicare, we could save $200 billion per year!

§ 18.10.0 ELECTRONIC MANAGED CARE

§ 18.10.1 - Managed health care by insurance companies does not work. It has not worked for 25 years! It won’t

suddenly work tomorrow! Admit defeat of that specific useless behavior today and let’s begin something fresh that WILL save money and improve quality of care!

§ 18.10.2 - Pre-authorizations could be replaced with the swipe of a card and entering a procedure code and diagnosis.

If insurance companies need more information, it could be accessed, immediately, via EMRs.

§ 18.10.3 - Most pre-authorizations developed by the insurance industry seem to simply be hurdles that slow the speed

of procedures, increasing the costs for insurance companies that increase profits and bonuses.

§ 18.10.4 - Today’s crisis is often tomorrow’s forgotten memory. When a doctor orders a mammogram and the patient

does not follow through, that doctor ought to be notified immediately and follow-up must be assured. The libertarian in me appreciates that we ought to be allowed to be afraid of procedures and not pursue them. The taxpayer in me sees that an early mammogram can cost $105 and result in successful treatment and a saved life. Sometimes a simple reminder, or shared problem-solving (oh, you don’t have gas – can your husband take you?) is all that is needed.

§ 18.10.5 - US cancer patients wait 38 days before treatment! Stringing a person along during the initial and most critical

5 weeks is inhumane! That is longer than in most other OECD nations with “nationalized medicine”.

§ 18.10.6 - Reduce micro-management and authorizations and providers will be available 15% more! This almost

entirely meets the need for 75,000 new physicians!

§ 18.10.7 – EMRs will result in lower demand, stress, and error amongst health care professionals.

§ 18.11.0 CUTTING THE COSTS OF ADMIN

§ 18.11.1 - I propose that a Citizen’s Committee to Reduce ADMIN Expenses of Health Care be formed. I suggest that it

consist of citizens, government officials, representatives from provider organizations and insurance and health service providers. It must examine all ADMIN expenses, determine unnecessary processes, and find ways to reduce those programs most costly. It ought to be formed within 6 months, investigate for 6 months, and recommendations ought to be implemented within 6 months.

§ 18.12.0 MY HEALTH INSURANCE CONTRACT

§ 18.12.1 - I have a 120 page long contract written in small font, single spaced, in lego-technicalese. It explains all kinds

of exclusions, but not limited, of course, to that booklet.

§ 18.12.2 - It says, “Your health plan does not cover everything … Even more important, payment for services is almost

always conditional. That is, payment may be reduced or even denied for a service if you received the service without observing all the conditions and limits under which the service is covered … Your health benefits are contractual … what you or your employer thinks is covered does not make it a covered service … the same is true even when the issue is life or death: a service is not covered simply because you, your physician, or your employer believe you need the service or because the service is the only remaining treatment which might (or might not) save your life.”

§ 18.13.0 MEDICARE ADVANTAGE

§ 18.13.1 - I’ve not researched this element directly, I defer to a statement made by President Obama in his speech to DNC supporters on 08/20/09, in which I heard him state that the federal government pays insurance companies and HMOs $17 billion a year to provide Medicare Advantage services – in addition to costs. Medicare Advantage started out with the best of intentions. It was to use the knowledge and skills of HMOs to provide health services for the elderly. The executives were brilliant. They built spas and golf courses and clubs and recruited the healthiest senior citizens and excluded sickly seniors. Thus, the federal government paid for Medicare Advantage to offer recreation to seniors whereas it continued picking up the tab for the most costly seniors. That was a nice boon doggle for those seniors and for the executives who thought of that idea, making hefty bonuses.

CHAPTER 19

SAVINGS PATIENTS CAN MAKE

“I've been married to one Marxist and one Fascist, and neither one would take the garbage out.” - Lee Grant

“To wish to be well is a part of becoming well.” - Seneca

§ 19.1.0 PREPARE A LIVING WILL AND ADVANCED DIRECTIVES TODAY

§ 19.1.1 Each of us ought to have a will, living will, and advanced directives. Before the Democrats suggested this recently, the Republicans had embraced this idea. They bitterly dispute this amongst themselves. I advocate this, regardless of the political winds of the moment. If something happens to you and you have costly life saving measures keeping you alive, doctors will know to pull the plug so that instead of your family going bankrupt, your partner can send your kids to college. You might choose something else. You might speak with your clergyman, lawyer, and doctor in order to get necessary information. I suggest that each of us ought to prepare a living will today.

§ 19.1.2 One problem I hear often is this. Organ donors haven’t made their wishes clearly known. So, if untoward events suddenly occur, that person’s organs are often not offered to those who might need them. I suggest that each of us give some combination of a copy of our will, living will, and advanced directives to our lawyer, physician, hospital nearest our home, clergyman, and family (you might not want beneficiaries to have the will).

§ 19.1.3 These items could be scanned into EMRs. Diagnosis of a degenerative disorder or terminal illness ought to always lead to a discussion of a living will, use of heroic measures should the need arise, and cost / benefit analyses. Every time that a provider asks about these documents, they ought to pull out a sample for the patient to complete then and there.

§ 19.1.4 Doctors order $140,000 in services that extend the average person’s life an extra month or so near the end. That’s the cost of one or two college educations! Time with family, in the end, is the only thing that matters.

§ 19.1.5 So I’ve heard, creation of a living will can help some taxpayers to transfer assets without paying gift taxes on them.

§ 19.2.0 EXTEND SERVICES WHEN YOU SAFELY CAN

§ 19.2.1 Gene’s physician wants an MRI every 12 months. Gene gives him one every 15 months. He figures that in his lifetime, he will save maybe 3 MRIs and $15,000 for US healthcare. He pushes out annual doctor’s visits by one to two months. That month is not going to be significant. If experiencing symptoms at that moment, I recommend that you call promptly.

§ 19.3.0 FAMILY

“How strange is the lot of us mortals! Each of us is here for a brief sojourn; for what purpose he knows not, though he senses it. But without deeper reflection one knows from daily life that one exists for other people.”

- Callimachus

§ 19.3.1 In recent decades, people move from their family of origin, divorce is more common, and children move away. Thus, older adults are often without loved ones near by to help care for their needs.

§ 19.3.2 Without grandma, younger people don’t know if a baby’s symptom is serious, so they see a doctor.

§ 19.3.3 Older people with ailments without a support network obtain medical services more often than those with a support network.

§ 19.3.4 The “aloning” of America costs money and reduces QOL.

§ 19.3.5 People ought to call family and discuss ailments. Neighbors ought to look after neighbors.

§ 19.3.6 We could provide funds to move poor elders with diseases close to their families who can provide care for them.

This action would save hundreds of millions of dollars per year.

§ 19.3.7 We can encourage people to log onto the computer and research a disease or join a disease chat room, talking

with others with similar ailments. They often feel comfort from this connection and seek providers less often. On-line chat rooms have been an immense help to caregivers, reducing stress and burdens.

§ 19.3.8 Historically, women are more likely to “enmesh” identities with extended family members and experience the “empty nest” syndrome. They move on by finding purpose in new projects.

§ 19.3.9 Historically, men are more likely to “enmesh” identities with work. At retirement, they leave work, often have few family contacts, take up few causa sui projects, grieve losses, and die 6 years earlier than women.

§ 19.4.0 ELECTRONIC RECORDS

§ 19.4.1 Patients would like greater access to health care providers through the internet. Some e-mail consultations might be billable, at a reduced rate from office visits, saving money. I find that I often get more comprehensive answers by providers through emails than office visits.

§ 19.4.2 Patients would like access to medical records via internet. Why not provide access for patients to their own medical records or perhaps the EMRs of those for whom they provide care? This might reduce some expensive office visits. It would increase accuracy.

§ 19.4.3 On-line appointment scheduling is also desired and ought to be available in many cases for existing patients.

§ 19.4.4 Lawyers might also like EMRs. EMRs couldn’t be changed to hide medical errors.

§ 19.4.5 Third party payers would cover some consultations via the internet. Simple questions could be asked of the PCP, nurse, specialists at NIH or CDC, for which bills might be generated and sent to third party payers.

§ 19.5.0 PAYMENT METHODS

O Gold!

I still prefer thee unto paper,
Which makes bank credit like a bark of vapour.

- Lord Byron

§ 19.5.1 Small business people will immediately see the need for revising health care payment methods. Currently, a service is provided. A bill is sent to the third-party payer. As often as not, it seems, the bill is first denied. Then, once approved, they send their payment. Then the doctor can send a bill to the patient for the outstanding co-insurance. This takes several months! Let’s say that one-fifth or $500 billion is out at any one time for collection for three months on average. As doctors have to pay upfront for money they borrow to pay their first 3 months of debt, this deferred payment scheme costs providers $15 billion a year.

§ 19.5.2 Next time you pull out a credit card, ask what’s it going to cost me to use this? A provider usually pays something like $40 a month, 50 cents a transaction, plus 5% to banks. These costs are added to your fee. The good thing is that the doctor gets paid immediately and has to haggle less often over bounced check fees. Americans pay over $15 billion per year (in addition to the above cited $15 billion) for this convenience that could be reduced if patients wrote checks or paid with cash for medical procedures rather than credit cards. My $35 co-payment would cost my doctor $2.25 in bank fees.

§ 19.5.3 Perhaps medical cards would contain checking account data, allowing the doctor’s clerk to debit authorized amounts. That would provide consumers with convenience and doctors with immediate payment. Wow! If EMRs would save $30 billion per year alone in banking fees, that would be significant.

§ 19.6.0 IMPROVING “PATIENT COMPLIANCE”

§ 19.6.1 One of the single most costly factors is patient non-compliance. This might sound awful! Most of the time, patients don’t really mean to be “non-compliant”, they just often don’t understand what they are to do the way their doctor, with his 40 years of medical training and experience, instructed them in the last 17 seconds of their speedy visit. Doctor and patient must be certain that the patient comprehends and can perform after-care procedures: by reducing physician ADMIN to 1/3^rd, we could lengthen the time available doctors can spend with a patient by 3 minutes. A verbal summary by a patient isn’t the same as showing the provider what they understand they ought to be doing. A “dry run” practice session between nurse and patient, occasional follow-up phone calls or emails by a nurse or automated system, or even a post-card twice a year can improve patient compliance, increase positive outcomes, reduce medical complications and reduce costs. If a patient with a quick compliance question could send an email to the provider, that would increase compliance. Alcohol related traumas presented to the ER can have recidivism reduced by 50% through a 5 minute discussion with a health educator. Further enhancement might be achieved by a follow-up call 3 months later. Patients who tend to forget to take their medicine or insulin might benefit from automatic reminder systems, bells, alarms on their watches, automated phone calls. I’ve noticed that the patients who write down observations or recommendations are much more likely to incorporate them in their daily lives. What incentive does a hospital have to assure patient compliance? They’re paid more if the patient returns and paid nothing extra if compliance is assured at a cost of $8.

§ 19.7.0 SHARED RESPONSIBILITY

§ 19.7.1 In US and European systems, we both share responsibility. In the European system, responsibility is shared by everyone. In the US, responsibility is borne by the individual and, sometimes, collectively by those with insurance, and, of course, collectively for the very poor, children, and elderly. Both systems have advantages and disadvantages.

§ 19.7.2 Patients always ought to think about diagnoses, accuracy, possibility of errors, procedures, drugs, side-effects, prices, interactions, and benefits / costs to my family and society and employer or school. Involvement in treatment can enhance treatment efficacy, reduce medical errors and costs, and extend the life expectancy.

§ 19.7.3 If a procedure is “elective”, patients ought to share in paying a portion of the cost. Patients who are encouraged to share in the decision making (not even sharing costs) choose 25% fewer surgeries and they have better outcomes. Thus, it would seem that the surgeries recommended for those 25% of patients might not have been truly necessary and the outcomes seem to support that conclusion.

§ 19.7.4 On the other hand, if my oncologist prescribes me a drug to fight cancer, I am going to take it no matter what the cost. As such, I don’t really have options nor ought I share responsibility of cost in the decision. Should a third party payer penalize me for wanting to live? Of course not! As such, I argue that co-payments are not beneficial for reducing the use of these medicines or procedures. Now, on the other hand, let’s say that there are two medicines available for a condition. Doctors recently visited by a pharmaceutical salesman might prescribe the latest drug that costs $300 a month or you might inquire about a less costly alternative. Oh, it’s $6 a month. Does the newer drug offer substantially better results or fewer side effects? If so, consider the options. If not, I recommend going with the less expensive choice.

§ 19.7.5 Many private policies cover ambulance services or ER visits partially unless hospitalization follows OR, get this, the ER or ambulance is pre-authorized! One might not be sure of the need for the ambulance or not, so, one calls at the first sign. Once at the ER, if faced with a $2,000 bill if one is sent home or a $35 bill if admitted, one might feign or exaggerate symptoms. Thus, the $2,000 bill becomes $3,500, so the person can save $35. At $1,000 a ride and the potential of depriving someone in critical need with life saving support and transportation, it is nothing to take lightly. Who benefits from this expensive care? The insurance company that profits 20% will either profit $400 off of the ride and ER stay or $700 if one stays overnight.

§ 19.7.6 For many of the poor, shared responsibility policies lead them to not obtain needed EMT or ER treatments. If

making $7 a hour and suffering chest pains, one might be more likely to walk to the ER or shrug it off and not

obtain needed treatment.

§ 19.7.7 Increasing SSA payments by $100 a month and then charging higher corresponding co-payments, based on level of medical necessity, would increase the sense of cost “sharing” while providing necessary funds for needed procedures. This procedure so often back-fires, as seniors may be more conscientious and not seek care due to the $5 co-payment, resulting in expensive late-stage treatments or death.

§ 19.7.8 Let’s say that you pay the same for medicines, regardless of cost. You are rewarded to think about what’s in your best medical interest. If you shared a portion of the cost (say, 20%), or received reward, you would be motivated to think more broadly, balancing costs of medicines with medical benefits. Sadly, introducing these types of reward / shared cost systems often lead more concrete thinkers and the poor to think only in terms of cost reduction.

§ 19.7.9 Patients on Medicaid have a no-show rate for their medical visits twice the rate of others. Physicians deal with this by scheduling 5 private pay patients an hour or 9 Medicaid patients an hour. In psychotherapy, where a whole hour is reserved for the patient, sometimes therapists must schedule and sit in the office for 60 hours in order to see 30 patients.

§ 19.8.0 MEDICAL SERVICES FOR LONELY OR HYPOCHONDRIASIS

“If you start to think about your physical or moral condition, you usually find that you are sick.”

- Johann Wolfgang von Goethe

§ 19.8.1 For some lonely people, the friendliness and respect of providers offers something. Thus, they may exaggerate or be hyper-sensitive to ailments in order to see their physician. Doctors, fearful of lawsuits or perhaps loosing these patients, practice defensive medicine with these over-reporters, resulting in unusually high expenses.

§ 19.8.2 Most people who over-use do not suffer hypochondriasis. However, many people with hypochondriasis actually feel the fear of having a serious medical condition. Web surfing, usually recommended, can worsen conditions. When a doctor recognizes this disorder and attempts to confront the patient, the patient often doctor-shops until another doctor takes seriously their complaints.

§ 19.8.3 These individuals incur medical costs 14 times that of the average person. IT and integration of behavioral health services with primary care could efficiently address, in a less threatening manner, this condition and reduce medically not necessary procedures. This might alleviate some of the burden on the physician, give the patient the service that they need, and reduce health care expenses.

§ 19.8.4 Cognitive-behavioral group and individual counseling programs are more efficacious than any other intervention at this time for this disorder.

§ 19.8.5 When a person incurs a large number of “elective” procedures, a referral ought to immediately be sent for that person to see a psychologist for evaluation and / or treatment.

§ 19.8.6 “Elective” procedures ought to be taxed.

§ 19.9.0 MALINGERING

§ 19.9.1 Malingering is the deliberate feigning of symptoms in order to obtain some kind of secondary reward.

§ 19.9.2 For example, the student might not have to take an exam, the employee can stay at home rather than deliver a stressful presentation, the prisoner facing trial can claim Not Guilty By Reason of Insanity or Not Competent to Stand Trial, people tired of working in unfulfilling unrewarding circumstances might seek disability benefits so they do not have to work.

§ 19.9.3 The Texas Department of Insurance estimates US societal costs of malingering at $150 billion a year.

§ 19.9.4 Cognitive-behavioral group and individual counseling programs would result in net savings. In fact, if only effective half the time, hiring every psychologist in the country to work only on malingering would cost $15 billion a year and save $60 billion a year.

§ 19.10.0 BE ACTIVE AND ASK QUESTIONS

§ 19.10.1 - Before each doctor’s appointment, patients ought to write on paper symptoms, questions, and everything

you want to ask (most of us forget things when we get in the room). Pull out your paper and pen. When with your doctor, ask each question and check them off as they are asked.

§ 19.10.2 - Be your own investigator. If you can, look up your symptoms on the internet or at the public library before

your doctor’s visit. What could it be? What are the treatment options? Do any medicines interact with what you already take?

§ 19.10.3 - Your doctor has about 10 minutes for you. It is your only body and life. YOU have the vested interest. If your

questions haven’t all been asked, tell him you have more questions and can he see you next week?

§ 19.10.4 - Take a second person along so they can objectively listen to what the doctor says and give you objective

observations.

§ 19.10.5 - Ask questions – the doctor is YOUR employee (actually, according to the IRS, your contractor). Don’t be too

intimidated to ask questions.

§ 19.10.6 - Write down or record your doctor’s answers so you can consult records later. I prefer to focus 100% on our

communication. If you can’t take a loved one into the consultation room with you, perhaps you might take in a voice recorder that you could consult later.

§ 19.10.7 - If prescribed medicine, ask about costs / benefits and less costly alternatives. If ordering a test, might there

be less expensive tests available?

§ 19.10.8 - Be sure you understand what you must do to treat your ailments.

§ 19.10.9 – After you leave the office, take a minute. Think about what just happened, what was said, what you’re to do.

Doctor’s visits are often like a whirlwind. Breathe, relax, and write down any new questions. The next day, email or call your doctor or nurse and discuss. I ask every doctor for his or her email address, but, I’ve only emailed one doctor once. It maybe useful to have.

§ 19.11.0 IMMEDIATELY REVIEW YOUR BILL

§ 19.11.1 – Imagine if we spent as much time reviewing our medical bills as we do the bills from restaurants. I often

don’t examine medical bills, as almost all of them are mostly paid by an insurance company. The provider only cares if he’s underpaid (trust me on this, its RARE that a third party payer will overpay a provider). How can the insurance company know what the hospital actually did, unless you speak up?

§ 19.11.2 - Well, that’s the nice thing about EMRs. A bill is submitted electronically the moment that the nurse

administers the antibiotic. If there’s an error, it is known immediately.

§ 19.11.3 - I think that bills ought to:

· Be fully explained prior to incurring the expense, whenever possible.

· Be given to patients at the time of the service, or, for inpatients, a summary of each day’s fees.

· Contain specific services, dates, providers, and costs.

· Break down fees from provider; negotiated rates; payments from third party payers; and the amount due from the patient immediately.

· All OP visits, ER visits, hospitalizations, etc. ought to contain a patient satisfaction survey that can be completed at a computer console in the waiting room or on a specific web page or by paper and pencil.

· It seems odd that errors are almost always in favor of the hospital. One study found that 90% of hospital bills were in error, on average by over $1,300. When such mistakes are made, so frequently, and to such a sizeable extent, one might wonder if intent to pad these bills might be implied. I suspect that few of us have ever accidentally received a check from the hospital of $1,300 for overpayments.

§ 19.12.0 WHAT WOULD SAM WALTON DO?

§ 19.12.1 - I say this somewhat in jest. How might health care services be delivered if Sam Walton were doing it? I’d

imagine he’d increase PAs, NPs, and dental hygenists. He’d provide an assembly-line of health care services – vision, dental, shots, wellness visits, coughs and flu visits, generic drugs. Everything would be the least expensive possibility and he would negotiate the very best price for Wal-Mart. Where can we, providers, hospitals, insurance companies, or government agencies use this successful model in health care?

§ 19.13.0 PATIENT CHOICE

§ 19.13.1 – It’s interesting to note that when an employer gave employees a fixed health benefit and gave them a choice

of 3 or more options, their choice saved an average of $480. Other studies have also found that giving patients several choices leads them to select less costly options much of the time, even when they personally don’t benefit. Of course, one confound is that large employers (e.g., federal government) can negotiate a cheaper price, resulting in the appearance of artificial savings.

CHAPTER 20

HOSPITALS

“All our knowledge merely helps us to die a more painful death than animals that know nothing.” - Maurice Maeterlinck

"Your money, or your life." We know what to do when a burglar makes this demand of us, but not when God does.” - Mignon McLaughlin

§ 20.1.0 RECENT DEVELOPMENTS

§ 20.1.1 Hospital administrators recently met with Vice President Joe Biden and they agreed to reduce hospital costs by $155 billion over the next decade (that’s $15.5 billion / year). Given that hospitals will generate revenues of $7.8 trillion during that time, without inflation, that’s 2%. With inflation factored in, it’s about 1%. Where’s the real savings that we need? Hospitals consume 27% of the US health care budget. They must produce greater savings.

§ 20.1.2 I dislike lack of transparency. When Vice-President Biden and President Obama met with health care and Big Pharma executives before laying out a health care plan, I got suspicious. When Senator Baucus accepted millions of dollars in campaign donations and gifts from lobbyists and company paramours, I tend to see personal greed overcoming duty to country. What promises had been made to assure big businesses that their bottom line or executive bonuses wouldn’t be threatened? This bears resemblance to what happened during the opening days of the Bush administration when Cheney held the meeting with oil executives about energy policy and then the price of gas sky rocketed.

§ 20.1.3 The White House has reported savings by health care giants of about 1/10^th of what I find is reasonable reductions in cost by those same industries. Could there be lack of skill on my part, dishonesty on their part, or simply an absence of real negotiation? Having observed the White House for 8 months now, I am wondering if it has the ability to negotiate.

§ 20.2.0 CEO COMPENSATION

§ 20.2.1 Personally, I am willing to compensate a CEO almost anything if he provides an ethical and abundant ROI. This willingness is now being abused.

Columbia / HCA CEO Fraud $324 million Stocks

Tenet CEO Fraud $111 million Stocks

Health South CEO Fraud $112 million

United Health CEO $1.6 billion Stocks

§ 20.3.0 5 MOST COSTLY CONDITIONS

§ 20.3.1 The 5 most costly conditions to treat in hospitals are presented below. Essentially, these five conditions can be clustered into two conditions – heart disease and neonatal care. With disproportionate costs, these are the first places I would look to reduce costs.

coronary atherosclerosis pregnancy and delivery newborn infants

acute myocardial infarction congestive heart failure

§ 20.4.0 HOSPITAL ADMIN, INSURANCE, & COMPLIANCE

§ 20.4.1 US hospitals are the biggest expense, at $780 billion ($2,600 per capita in 2003).

§ 20.4.2 The fastest rising part of hospital costs is ADMIN, billing, and compliance.

§ 20.4.3 The US has more hospital staff per bed, the same number of direct care staff per bed but the most administrators per bed. US hospitals have about 80% of the number of beds, have about 80% of the average length of hospital stays, and 80% of the rate of acute admissions as other OECD nations. The cost of that hospital bed that’s used is 225% more in the US than in the other OECD nations, yet we have similar hospital mortality rates and higher infection rates. Capitalists ought to be asking, “Why pay so much more for an inferior product for 95% of the population?”

§ 20.4.4 The typical US hospital spends three times more on administrative expenses than do hospitals at other OECD nations.

§ 20.5.0 DEMOGRAPHICS

§ 20.5.1 Women utilize hospital beds at a rate of over twice that of men. This is partially confounded by age, as women live six years longer than men during the years in which the most health expenses occur. Further, women must obtain gynecological care regularly and they must obtain obstetrical neonatal care. Further, many women experience life-long complications from birth related developments.

§ 20.5.2 Asian Americans utilize hospital beds at a rate about two-thirds that of other races. African American men’s longevity is so low that they barely qualify, as a whole, for SSA and Medicare, yet they work all their lives and contribute to these programs.

§ 20.5.3 This can get quite hairy. We might raise premiums 10% for women, reduce premiums 12% for Asians, increase premiums 12% for smoking, reduce premiums 10% for being thin. So, what’s the premium for this person? Ultimately, is it fair to discriminate on health costs based on demographic factors? Is it fair to discriminate based on choices the person makes? If one has a disease that drives one to drink alcohol or a thyroid condition that reduces metabolism and increases BMI, should that person be punished by having to pay more for health care?

§ 20.6.0 TAX WRITE-OFFS FOR CHARITY

§ 20.6.1 The wealthy hospital chain that bought my community hospital enjoys a special tax benefit. They are entitled to write-off uncollected fees, using due diligence, as tax deductions. You and I can’t. This was a “gift” to the industry, as it was required to provide Emergency Room and basic care for indigents. No where else in the tax code are “theoretical” fees allowed to be written off. This adds up to giving the hospitals a back door way to hide tens of billions of dollars from the government and taxpayers.

§ 20.6.2 These theoretical write-offs increase bankruptcy filings and escalate hospital expenses. Tax law allowing for these write-offs must be changed. By assuring that everyone has health insurance, this backdoor benefit would no longer be necessary to assure that hospitals continue to provide care for the uninsured.

§ 20.7.0 INFECTIONS

§ 20.7.1 The number of skin infections among the uninsured during hospitalizations increased 167% from 1997 to 2006 from 27,900 to 74,500.

§ 20.7.2 One of the most costly problems facing third party payers is infections in hospitals. Greater study of this problem by NIH and CDC is needed. One problem that I see is this: hospitals are paid by third party payers additional money for each patient infection that it treats. At the same time, there are no financial incentives offered to hospitals or doctors to prevent hospital-based infections from occurring.

§ 20.7.3 This statistic might be nothing but it could be an early alarm. Are Americans becoming more susceptible to infections? Are antibiotics less effective? Are hospitals doing things differently now that increase the rate of infections?

§ 20.7.4 The prevention programs within the FHCs could assume the lead on this issue. Effectively addressing this issue could reduce health care expenses tens of billions of dollars each year.

§ 20.7.5 The most common carriers of infections are health care providers. We pull out a patient chart, turn the pages, close it up, and dash off to see the patient. Washing of hands ought to be mandatory for at least 30 seconds before and after providers visit each patient. Using alcohol-based hand sanitizers or wearing plastic gloves might reduce many costly infections.

§ 20.8.0 SMALL SAVINGS

§ 20.8.1 Elsewhere, I propose significant reductions in ADMIN, defensive medicine, malpractice insurance, increased access to alternatives (such as HHC, elder care programs, NHs, and hospice housing), Electronic Medical Records utilization, QA advancements. With these programs alone, hospitals would reduce expenses by $150 billion per year. In addition, hospitals could –

§ 20.8.2 Authorize nurses to deliver prn OTC medications (aspirin) and make greater day-to-day decisions;

§ 20.8.3 Reduce outside lighting;

§ 20.8.4 Use more efficient energy / HVAC systems;

§ 20.8.5 Use solar and wind energies to reduce energy costs and greenhouse gases;

§ 20.8.6 Replace water spigots with water / O2 spigots;

§ 20.8.7 Renovate unused hospital wings for medical offices. Or, close up and insulate them.

§ 20.8.8 Make purchases of equipment, surgery materials, medications, through a cooperative and share the use of the most costly equipment.

§ 20.9.0 PATIENT EDUCATION

§ 20.9.1 Re-admissions can be reduced (and compliance increased) by designating a nurse or health educator to review with patients (family or care givers) the reasons for admission, symptoms, treatments, and expectations for self-care and medical follow-up (providing an easy to comprehend, written copy is recommended). Twenty percent of older patients are re-admitted to the hospital shortly after their initial stay. Much of these costs can be reduced by a single in-hospital post-discharge planning session followed up with a telephone call to the patient’s home. Older patients might be assigned a geriatric nurse practitioner to visit periodically in the person’s home to assure comprehension of and adherence with medical regimen.

§ 20.9.2 The average savings for those who received full discharge information were $412. There are 35 million standard hospital discharges per year.

§ 20.9.3 While this study did not include the benefits of health education following ER visits (119 million visits each year) other studies have found reduced recidivism and cost.

§ 20.9.4 IP and ER discharge health information briefings total 154 million a year and could save $64 billion a year.

§ 20.9.5 Chronic Disease Management Programs most effectively reduce health care costs among those with lower risk but result in somewhat ambiguous outcomes among those with higher risk. Targeting interventions toward those at lower risk would thus be logical. For those with more severe conditions, new information often is introduced too late in the disease development process to make a significant change. Further, individuals with more advanced stage disorders might be less amenable to information, due to previous cognitive functioning, disease progression, or side-effects of medication. Regardless, information in high risk cases probably ought to be targeted to care givers.

CHAPTER 21

POSSIBILITIES FOR INCREASED REVENUES

“Money is like manure. You have to spread it around or it smells.” - J. Paul Getty

Years ago, the robber barons knew something. When the economy was good, they made out. When it was bad, they spent money they weren’t making at the time, propping up the national economy and the common man, so that he could keep consuming their products. The “robber barons” of today don’t seem to realize this.

§ 21.1.0 WHO OUGHT TO PAY?

§ 21.1.1 “People who choose unhealthy lifestyles like smoking, drinking, overeating ought to contribute to added costs.” But, where does this nickel and diming end? Should we charge skiers more since they have a 1% higher rate of injuries? Should we charge more to the young man who statistically has a 50% chance of acquiring Huntingdon’s Disease within 10 years?

§ 21.1.2 “People who disproportionately consume resources ought to contribute to added costs.” Asian American (AsA) women live 20 years longer (on SSA) than African – American (AA) men and receive eight times more SSA / Medicare benefits than African American men. Women, in general, live while receiving Medicare / SSA twice as long as men and cost three times more than men. There is no active discrimination here. It’s just what cards we’ve been dealt. Years ago, women used to ask men to take their cars in for inspection, as they suspected that mechanics would overcharge them for procedures. Is that tendency also found in health care today? Perhaps.

§ 21.1.3 “People who work and contribute day in and day out ought to contribute to costs.” We know we must make sacrifices to better the plight of our nation and our children, so, as good but struggling Americans, we’re going to do our best.

§ 21.1.4 “The wealthy ought to contribute to added costs.” I want to reward ingeniousness and industriousness so that those individuals can prosper and the American economy and its people grow and benefit economically from their creations. But, I am much less inclined to prop up the lavish lifestyles of trust fund babies who contribute nothing to society but whose granddaddy worked hard to build a nest egg. These “trust fund babies” pay little in taxes, spend much on lavish lifestyles, and do not make contributions to bettering society. Of course, we can think of sublime examples of humanity that are exceptions. As more of our nation’s wealth sifts into the hands of these most affluent, we must re-distribute it when the nation faces economic decline, in order to bring hope to the less prosperous Americans who can then obtain health care, education, and invent the next thing that will lead America to its next period of greatness. Then, taxes on the wealthy ought to be reduced again, to encourage creativity, ingenuity, and industriousness. We keep reporting that fewer people own a greater portion of American’s wealth. The latest figure is that 1% of the people own more than the lowest 95% of people own.

§ 21.1.4.1 – The maximum federal income tax rates in the 1950s. It was 92%. The decade of reconstruction following WW2, the GI Bill, the Korean War and Eisenhower Interstate system required lots of investments in our national infrastructure. It was republicans like Dwight Eisenhower and Richard Nixon that brought this nation to prosperity, in part, through “socialistic” programs.

§ 21.1.5 In summary, I propose that everyone must share costs.

§ 21.2.0 FEDERAL EXCISE TAX ON NICOTINE

§ 21.2.1 The costs of providing health care for nicotine-related diseases back in 1995 totaled $137 billion per year. Given the pattern of reduced consumption but greater increase in medical expenses, the total cost of treating nicotine-related diseases today is $220 billion / year. Selling 18 billion US packs, American society must pay $12 in smoking-related health care costs for each pack of cigarettes smoked, plus manufacturing. I propose a graduated tax increase on domestic cigarettes up to $5 per pack with all of the proceeds to be designated for providing health care for smokers and other users of nicotine products. This would still only pay 41% of costs, but it would raise $90 billion a year that would directly be paid to the federal government and it would be utilized to pay for federal health programs for smokers.

§ 21.3.0 EXPORT TAX ON NICOTINE

§ 21.3.1 I propose a graduated tax increase on the 10 billion exported cigarette packs each year. Revenues would be invested into new health programs overseas, creating medical, dental, nursing, and allied health schools outside the US and using medical – electronic technologies, improving access to health care and pharmaceutical products, especially in rural foreign communities. I propose that this would generate $50 billion in revenue per year.

§ 21.4.0 FEDERAL EXCISE TAX ON ALCOHOL

§ 21.4.1 The costs of providing health care for alcohol-related diseases back in 1995 totaled $175 B. Given modest consumption reductions and increased health care costs, this estimate exceeds $275 billion today. The social costs (law enforcement, domestic violence, burglary, auto accidents, courts, attorneys, and prisons) exceed $100 billion per year. Premature deaths, at 100,000 per year, cost $200 billion per year. Thus, total alcohol related costs exceed $575 billion per year!

§ 21.4.2 Complicating this issue is the consistent finding that moderate alcohol consumption seems to be related to higher QOL, less disease and health care costs (more than $2,000 a year less per person than the average of those abstinent or those who abuse), and greater longevity. Thus, a small regular use of alcohol might be beneficial for those without a personal or family history of alcohol abuse or alcoholism.

§ 21.4.3 Racially, Native Americans consume the most alcohol per person and Asian Americans consume the least alcohol per person. Women are more likely to abstain than men by nearly 1.6 to 1. The poor are more likely to abstain than are the wealthy. Alcohol consumption correlates with education – the more education, the more likely one is to consume alcohol.

§ 21.4.3 I propose a graduated tax increase on alcohol, peaking at $30 billion a year. All of that money ought to be

designated for serving the health needs of those who consume alcohol and related costs.

§ 21.5.0 SUBSTANCE ABUSE FINES & SERVICES

§ 21.5.1 Elsewhere, I recommend a fee of $2,500 for NIH research paid for by the 2 million Americans convicted of DUI, DIP, possession, and other such offenses each year. That money would be designated for NIH to conduct substance abuse research on prevention, genetic vulnerability, vaccines, treatment, and safety.

Advocates of the legalization of marijuana point to several things - 300,000 prisoners could be released from jails saving $12 billion a year for non-violent, “victimless” crimes. They also site that if the government were to regulate marijuana, it could assign assessments of tens of billions of dollars. With lower street prices, some property crime (e.g., robbery and burglary) would decrease. Advocates also site that $100 billion that is sent out of country for illicit marijuana would be kept in the US, adding to the GDP and reducing the trade deficit. Advocates also site that the government could assure safety and consistency, thus lessening surprise combinations or variations in quality or dangerous products. They cite that marijuana users are less likely to commit crimes (other than those directly related to the marijuana) and users are not likely to suffer great ill medical effects from use. They also cite that founding fathers grew and smoked marijuana.

Opponents of legalization also point to several things. They recite the slippery slope argument – legalization of marijuana would lead to legalization of other drugs. They suggest that government “taxation” and legalization of marijuana is one step away from the government doing the same for other crimes. They cite that smokers of marijuana are more likely to have slowed perceptual and motor skills thus making them more likely to be involved in automobile accidents. Opponents cite that marijuana use does, indeed, have some effects upon cognition and pulmonary functioning, possibly leading to long term chronic effects.

§ 21.6.0 RISK PREMIUMS

§ 21.6.1 Private insurance providers might charge a government regulated risk premium for those who use nicotine, drink alcohol to excess, or who weigh 10% more (or less) than they should, perhaps not due to medical conditions.

§ 21.6.2 Recently, ambulances made the news, as they assess a premium on individuals weighing too much, thus requiring special equipment. Some premium for individuals in control of behaviors that increase their risk and costs of care ought to be allowed within reasonable limits.

§ 21.6.3 Risk premiums ought to be set at a given figure – say 10%. Part of me regrets saying this, but, perhaps hypochondriacs and over-users of elective services might pay higher co-payments and co-insurances.

§ 21.7.0 EXCESS PROFITS TAX ON PROVIDERS; INSURANCE, HEALTH CARE, & PHARMACEUTICAL COMPANIES & EMPLOYEES

§ 21.7.1 In 2005, health insurance companies made $100 billion dollars of profit on revenues of $800 billion – 12%. My retirement fund manager might say that’s an average ROI. But, when we’re experiencing an economic contraction, it seems like a lot of profit. While insurance companies continue to post double-digit profits, the US economy contradicted 4.8% last year and the profits and market value of most other sectors contradicted more than 4.8%. I propose a tax on excessive profits so that insurance companies, executives who receive excessive salaries and bonuses, hospitals, imaging services, doctors, and other health care providers who profit excessively might be subject to an excessive health services profits tax of some percent. This would likely be costly to implement but it would be one of the most effective ways of reining in the speedy excessive growth in health care costs. Perhaps a general formula could be imposed: “any time that an executive, provider, or company makes more than 20% of its peers, without clear justification, it would be imposed a tax on the surplus amount, of an additional 25%.

§ 21.7.2 Think about it. Capitalism is a system in which a product is made and, through competition, is delivered to and purchased by consumers. The health care companies and insurance companies are now oligopolies. They don’t play any more by the rules of capitalism. Consumers are being backed in the corner, extorted or forced to keep paying more and more to a ravenous bully. I don’t like taxes, personally. But, taxes are one way that our government can restore the rules of fair capitalist play.

§ 21.7.3 As the Congress lowered the capital gains tax rates, corporate executives began to see that high salaries were not as advantageous as were large bonuses disguised as long term capital gains. I’d tax these bonuses as wages, since they were not gained through capital. This ought to be true throughout all fields and sectors.

§ 21.7.4 Taxing excessive profits might bring on-board persons who might otherwise not be concerned about reducing health care costs. At a tax rate of 36% and “excessive profits and salaries” of $300 billion in health care, $108 billion a year in added revenue would be generated.

§ 21.8.0 U.S. UNIQUELY TAXES CAPITAL GAINS LESS THAN WAGES

§ 21.8.1 An Example: The chief lemonade seller at a lemonade stand earns $50,000 a year. With Social Security, Medicare, federal, state, and local taxes, she will directly pay $9,000 and forego indirectly the $3,800 match for SSA and Medicare. Thus, she pays $12,800 on $53,800 (23.8%). The owner lived in the house in which the business is operating and over the last 5 years, remodeled it, turning it into a $750,000 property for which $100,000 had been paid. The owner sells the property and the business (valued at $750,000), making a gross profit of $1,500,000. The profit on $500,000 in real estate profit isn’t taxed. The owner pays $150,000 x 15% = $22,500 for real estate. The owner pays a 15% long term capital gains tax on $750,000 or $112,500 or 7.50%. That totals $135,000 on a return of $1.4 million, just less than 10%. The employee earned $269,000 and paid $64,000 (23.8%). Alright, the owner took risk with $120,000 start up capital. But, the chief lemonade seller took risk investing his labor and livelihood for 5 years. Opponents would argue that since the owner had already paid taxes on the $120,000, that it should not be taxed a second time, which, technically, it never is, it is the profit grown from that money that is subsequently taxed.

§ 21.8.2 What’s so special about capital in America that our government chooses to place a higher value on capital than labor? Labor can be taxed up to 36% but capital can be taxed as low as 5%. The only people who benefit from having a capital gains tax lower than a labor tax are the wealthiest 1% of Americans. If you are among them, then it would be logical to insist on continuation of a federal tax system that places higher value on capital than labor. Logically, if the US is a democracy, the 99% or 297 million people who pay more taxes for their labor than the 3 million people pay taxes for their capital ought to communicate to their congressmen that they want the labor and capital taxation rates to be the same. The far left progressives might even argue that during a period of economic decline that in order to stimulate the economy, there ought to be a higher tax on capital than labor. Given that tens of trillions of dollars of capital flows in and out of the US each year, some assessment on these assets might be logical.

§ 21.8.1 If the US were to tax LTCG, STCG, and dividends at the same rate as it taxes labor, significant income would be generated. By taxing LTCG, STCG, and dividends at the same rate as labor, even for a 10 year period, an additional $225 billion per year would be realized. That pays for the interest on one-half of the deficit that was racked up over the previous 8 years.

§ 21.9.0 ASSESSING “DANGEROUS” FOODS FEES

“The wisdom of man never yet contrived a system of taxation that would operate with perfect equality.” - Andrew Jackson

§ 21.9.1 In the last 15 years, the proportion of Americans suffering from obesity or being overweight is now one-third, with one-sixth of children being obese or overweight.

§ 21.9.2 I remember reading one study that showed that the 1600% increase in esophageal cancer occurred over the

same decades in which there was a 1650% increase in soda consumption. I know that correlation doesn’t equal causation, but, such findings grab my attention. Americans consume about 200,000,000,000 sodas a year. That’s 2 per day per person.

§ 21.9.3 Obesity has been identified as being more dangerous now to the health of Americans than smoking and drinking. It results in significantly elevated risk for heart disease and cancer ( … knee surgery … ).

§ 21.9.4 Not only are disease risks increased by the consumption of dangerous foods, but, treating those diseases is growing more costly. Treating diabetes costs $116 billion a year and is expected to cost $465 billion in 10 years. The costs of cancer and heart disease are over $500 billion a year …

§ 21.9.5 Assessing a foods tax (e.g., snack foods, candies, soda) that is related to the health costs that the item imposes would have the doubly desired effect of reducing consumption and generating revenue. It seems draconian, especially to those of us who consume lots of sugary products, but it seems fair.

§ 21.9.6 Imagine this: Your neighbor and yourself both belong to the same health insurance plan, each paying the same premium each month. You drink lots of water, don’t drink but 5 glasses of wine a week, you never smoke, watch your weight, and exercise. She, on the other hand, is 150 pounds overweight, drinks soda and consumes unhealthy snack foods. She smokes 3 packs of cigarettes a day and she drinks several cases of beer each week. If she requires knee replacements, bypass surgeries, and cancer treatment, do you ever wonder if it is fair that you pay more for your health insurance so that she can continue to choose to live an unhealthy lifestyle. Maybe assessing a dangerous foods fee might make some sense.

§ 21.9.5.1 - Americans spend over $300 billion per year in restaurants, $200 billion of which is spent on foods and beverages that have high fat content, result in elevated cholesterol, high sugars, etc. A federal tax of 10% on these “dangerous” foods and beverages would generate revenue of $20 billion a year and it would be projected to reduce consumption of these “dangerous foods” by at least 15 percent.

§ 21.9.5.2 - A tax of five cents per sugary beverage would generate $20 billion a year and would reduce consumption of unhealthy beverages by another 15 percent.

§ 21.9.5.3 - A tax of 20% on salty and sugary snack foods would generate about $15 billion a year and is estimated to reduce consumption of unhealthy snack foods by 15 percent.

§ 21.9.6 The total revenues from these assessments, totaling $55 billion per year, could be designated for obesity

prevention programs and perhaps healthful foods production incentives and research as well as treatment programs due to obesity.

§ 21.9.7 Some, including food and beverage manufacturer’s associations, argue that since consumption of these

products is disproportionately made by poorer Americans, that such a tax would be unfair to the poorest Americans. Yes, they are right that poorer Americans tend to consume more unhealthy foods and beverages. However, is it wrong to tax people, with the intent of reducing consumption of unhealthy products and raising money to pay for their unhealthy consumption patterns? If these manufacturers were really truly concerned about poor people, they would not be taking advantage of them with products that kill them and make the investors profits.

§ 21.10.0 WEALTHY SUPPLEMENTAL TAXES

“This country will not be a good place for any of us to live in unless we make it a good place for all of us to live in.” - Theodore Roosevelt (R – NY)

§ 21.10.1 - In troubled economic times, the wealthiest Americans have always stepped up to the plate and they have done their duty to country and their fellow citizens. Most of the US wealth is controlled by a few and the proportion of that wealth grows and the proportion of the population that controls it shrinks. Skeptics argue that the US economy is ultimately headed to a feudalistic economy.

§ 21.10.2 - In periods of national economic prosperity, I argue that lower maximum tax rates encourage ingenuity and economic development. Now is not one of those times. In times of economic contraction, we must encourage consumer confidence and consumer spending.

§ 21.10.3 - It is noteworthy that 20% of Americans earn 50% of the national income and 8% earn 29%.

§ 21.10.4 - I suggest an 8% higher tax be imposed on those in the top 8% (thus, generating $190 billion a year) and a 4% higher tax be imposed on those in the top 20% (generating $76 billion a year). People would only pay one surtax, a maximum of 8%. The total of these taxes would generate $266 billion a year. This would bring the maximum marginal tax rate back down to that in the 1970s under the Nixon and Ford administrations.

§ 21.10.5 – If the wealthy strongly oppose paying more taxes to help cover the uninsured, then let’s target this $266 billion to debt reduction to pay down the costs of the socialistic $2 trillion gifts to corporations and the $1 trillion so far spent on wars.

§ 21.10.6 – Each time in the history of the US where national debt neared the heights of the GDP, taxes had to be

increased and infrastructure investments were made, leading to a bounce back of the US economy.

§ 21.10.7 – As discussed elsewhere, I propose that capital and labor ought to be taxed at the same rate.

§ 21.10.8 – Supply side economists will cringe with this thought! If capital gains were taxed at the same rate as labor,

this would generate income of more than $225 billion a year.

§ 21.10.9 – Such a tax on dividends, STCG, and LTCG would reduce speculative trading, which is behind much of the

financial instability, the bubbles and bursts of recent years. Since much has been made in recent years of the inability of the government to monitor potentially deceptive practices on Wall Street AND daily stock trading has led to much of the bubble growth and burst economy of the last 15 years, I propose that the government impose a tax of 1 percent of the market value of each trade. The proceeds of these added funds will be used to pay for enforcement of financial regulations, including programs through the Treasury Department, IRS, SEC, and health agencies.

§ 21.10.10 - Simple taxation of capital and labor would address the shift in income in the US from wages to profits,

Professional Corporation income, and capital gains.

§ 21.10.11 – I am not an expert on estate taxes. While we face economic crisis, we might subject higher estate tax rates

on the wealthiest 5% for a short time while the country recovers from the economic crisis. Part of the proceeds from this tax might be targeted to paying more for funeral expenses among the poorest Americans, raising the Social Security funeral contribution from $250 to $4,000. No legislator wants to pay more for funerals, who’ll vote for them? It is necessary for the poorest 20% of Americans.

Perhaps a Medicare “fee” would be assessed upon estates of the recently deceased who consumed more than $10,000 worth of services by Medicare on average, for the previous 3 years, when the net estate is worth over $1 million, reimbursement of ½ of Medicare costs would be assessed.

MAXIMUM INCOME TAXES

The follow table reports maximum tax rates for married couples filing jointly.

Tax year	Top marginal tax rate (%)	Top marginal tax rate (%) on earned income, if different	Taxable income over--
1913-15	7		500,000
1916	15		2,000,000
1917	67		2,000,000
1918	77		1,000,000
1919-21	73		1,000,000
1922	58		200,000
1923	43.5		200,000
1924	46		500,000
1925-28	25		100,000
1929	24		100,000
1930-31	25		100,000
1932-35	63		1,000,000
1936-39	79		5,000,000
1940-41	81.1		5,000,000
1942-43	88		200,000
1944-45	94		200,000
1946-47	86.45		200,000
1948-49	82.13		400,000
1950	84.36		400,000
1951	91		400,000
1952-53	92		400,000
1954-63	91		400,000
1964	77		400,000
1965-67	70		200,000
1968	75.25		200,000
1969	77		200,000
1970	71.75		200,000
1971-76	70	60, then 50	200,000
1977-78	70	50	203,200
1979-80	70	50	215,400
1981	69.125	50	215,400
1982	50		85,600
1983	50		109,400
1984	50		162,400
1985	50		169,020
1986	50		175,250
1987	38.5		90,000
1988	28		29,750
1989	28		30,950
1990	28		32,450
1991	31		82,150
1992	31		86,500
1993	39.6		89,150
1994	39.6		250,000
1995	39.6		256,500
1996	39.6		263,750
1997	39.6		271,050
1998	39.6		278,450
1999	39.6		283,150
2000	39.6		288,350
2001	39.1		297,350
2002	38.6		307,050
2003	35		311,950

§ 21.11.0 SHIFTS IN MEDICARE / SSA TAXES TO NEW REVENUE SOURCES

§ 21.12.1 - Wages of yesteryear have been replaced with bonuses, capital gains, Professional Corporation income, real

estate turn-over profits … These are not taxed and ought to be subject to taxes and required contributions as

are wages.

§ 21.12.0 OFF SHORE HAVENS

§ 21.12.1 - Some companies have located off-shore to reduce what they must pay in US taxes. Some companies ought

to pay Medicare and SSA taxes and contributions and federal corporate income taxes on relevant income.

§ 21.12.2 – Nations that operate Off Shore tax havens, in sum, total less than 1% of the world’s population, have 26%

of the world’s wealth, and 31% of the net-income of US multi-nationals. This totals about $6 trillion. If the US were to tax, only rightly I might add, 5% of this total per year, that would generate $300 billion per year!

§ 21.12.3 – As much as $1.5 trillion each year is believed to be “laundered” through these banks – drugs, human slavery,

prostitution, illegal gambling, weapons, tax evasion, and terrorism. The US to world GDP ratio yields 24% or about $360 billion a year. No doubt, the share of unlawful proceeds accounted for by the US is at least 36% or $540 billion. If the US government devised a system in which those revenues were subject to federal taxation, it would generate revenues in excess of $135 billion each year.

§ 21.12.4 – Even after tightening of regulations following 9/11, these tax havens are allowed to exist because the rich

and powerful in the US insist that they be allowed to exist.

§ 21.13.0 MEDICARE & DISABILITY TAX INCREASE

§ 21.13.1 - Medicare had been projected to become insolvent in 2018 and will incur negative income before that. [Where

I come from, if I spend more than earn and I have no assets, that is insolvency!] We must increase assessments for Medicare and Disability. This tax ought to be increased to 3.40% in 2010 (generating $47.5 billion/ year) and to 3.90% starting in 2017 ($95 billion/ year) and only be used for Medicare or debts to Medicare. While SSA is beyond the scope of health care reform, I believe that an increase from 6.20% assessed upon both employer and employee ought to increase in 2010 to 6.70% (generating an additional $95 billion a year used only to pay down the debt to Social Security), 7.20% for each starting in 2017 ($190 billion a year), and 7.7% for each starting in 2024 ($285 billion), again, only for use by Social Security.

§ 21.13.2 - The amount of income protected from taxation for those on SSA ought to be decreased. I know this does not

seem just, as they had foresight to save where others did not, but in these extremely dire economic times, it is needed.

§ 21.13.3 - I also advocate that the amount of income that is subject to Social Security tax be increased 20% for each of

the next 25 years.

§ 21.14.0 MEDICARE PREMIUMS AND CO-PAYMENTS

§ 21.14.1 - The average cost to Medicare for people in that system is $10,000 PP. A premium of $1,300 does not begin

to cover the true expenses from this program. [That mere 2.9% of salary over the past years hasn’t

compounded to cover the annual costs of this program. Further, we live longer, consume more SSA and

Medicare, so, premiums must be increased if this system is to remain economically sustainable.

§ 21.14.2 - A Medicare premium increase is a great burden on all, especially for those fully dependent upon SSA.

Increased premiums ought to be considered. A premium increase of, say, $2,400 per year could be offset by an increase of $2,400 per year in SSA, all of which, as described above, would be taxable.

§ 21.14.3 - The “donut hole” in which Medicare beneficiaries pay the full amount of medications, lobbied for by drug

companies so nobody could negotiate price with them as is done in other capitalistic - valuing countries, must be eliminated, as it creates a hardship on elderly who cannot pay that extra money on medicines. Medicare ought to cover the full cost of all medicines with standard co-payments or co-insurances.

§ 21.14.4 - Co-payments on “elective” and, perhaps “medically recommended” Medicare services could be increased,

thus, decreasing the payments that Medicare pays for these procedures. Procedures “of medical necessity” would never incur co-payments nor would any preventive medicine, ever. This could increase revenues $10 billion for, essentially, all elective procedures.

§ 21.15.0 ASSESSING MEDICARE, DISABILITY, & SSA TAXES ON FOREIGN STUDENTS / NATIONALS

§ 21.15.1 - The US has the finest system of higher education in the world. Medicare, SSA and federal income taxes

might be assessed on incomes / deposits of students from foreign countries who study in the US, generating over $5 billion per year.

§ 21.15.2 – Non-US citizens who work in the US ought to pay taxes in the US. I have worked with several foreign

nationals [in critical health care fields] who return to their home nation for 6-ish weeks every year so that they don’t have to pay US taxes. Of course, the potential costs [loss of access to labor in vital fields] must be weighed against the tremendous lost income.

§ 21.15.3 – Services provided at US hospitals might be subject to a premium, particularly for elective procedures,

generating an additional $5 billion per year.

§ 21.16.0 “SALES” TAXES

§ 21.16.1 - At this point, wealthy foreign citizens who obtain treatment in the US pay no taxes, sales taxes, or fees.

Imposing a “sales tax” would generate revenues of a few billion dollars a year.

§ 21.16.2 – The US ought to impose a modest export tax on knowledge to create health care products and

pharmaceuticals that are patented in the US and sold overseas. I suppose when this is applied to products, it is

an export tariff.

§ 21.17.0 ENVIRONMENTAL TAXES

§ 21.17.1 - Many health disorders today are due to environmental pollutants and waste products. Modest increases in

taxes or user fees for some of these products will fund health care services for disorders due to these products and related research.

§ 21.17.2 – I propose that automobile emissions contribute to asthma, pulmonary disease, some forms of cancer, and

ought to be taxed at a federal rate of $0.25 per gallon for health research and treatment. With about 150 billion gallons of fuel sold per year, this would generate about $37.5 billion per year while also reducing carbon emissions and dependency on foreign oil.

§ 21.17.3 – The US consumes about 1 billion short tons of coal per year at a cost of about $70 each. A federal fee of

$7.00 per short ton would generate about $7 billion a year while also reducing carbon emissions and encouraging private investors to seek less costly or unhealthy alternatives. Of course, these revenues ought to be designated for clean emissions research, treatment for black lung, etc.

APPENDIX A: LOBBYING AND CAMPAIGN CONTRIBUTIONS

TOP SPENDERS ON LOBBYING

1998 – 2009 AND 2009 ALONE

Lobbying Client	Total
US Chamber of Commerce	$488,458,180
Am Medical Assn	$208,472,500
General Electric	$183,895,000
Am Hospital Assn	$172,940,431
AARP	$164,072,064
Pharm Rsrch & Mfrs of Am	$154,533,400
Northrop Grumman	$133,515,253
Edison Electric Institute	$128,645,999
Business Roundtable	$127,980,000
National Assn of Realtors	$127,977,380
Exxon Mobil	$124,626,942
Blue Cross/Blue Shield	$120,491,385
Verizon Communications	$118,344,841
Lockheed Martin	$115,567,888
Boeing Co	$108,728,310
General Motors	$104,774,483
Southern Co	$97,670,694
Freddie Mac	$96,194,048
Altria Group	$88,380,000
Ford Motor Co	$86,329,808

Lobbying Client	Total
US Chamber of Commerce	$26,196,000
Exxon Mobil	$13,590,000
Pharmaceutical Rsrch & Mfrs of Am	$13,060,000
Chevron Corp	$12,815,000
General Electric	$12,286,000
Pfizer Inc	$11,720,000
National Assn of Realtors	$9,617,000
Blue Cross/Blue Shield	$9,529,747
AARP	$9,380,000
Verizon Communications	$9,330,000
ConocoPhillips	$9,250,928
American Hospital Assn	$8,497,176
American Medical Assn	$8,470,000
AT&T Inc	$8,191,618
BP	$7,640,000
Altria Group	$7,500,000
Business Roundtable	$7,360,000
Eli Lilly & Co	$7,030,000
National Cable & Telecommunications Assn	$6,880,000
Lockheed Martin	$6,781,247

TOP LOBBYING FIRMS - 2009

Lobbying Firm	Total
Patton Boggs LLP	$18,365,000
Akin, Gump et al	$16,130,000
Van Scoyoc Assoc	$13,000,000
Podesta Group	$11,810,000
Holland & Knight	$10,310,000
Dutko Worldwide	$10,000,000
Cassidy & Assoc	$9,970,000
K&L Gates	$9,440,000
Brownstein, Hyatt et al	$9,170,000
Hogan & Hartson	$8,920,000
Ogilvy Government Relations	$8,870,000
Williams & Jensen	$8,420,000
BGR Holding	$8,160,000
Quinn Gillespie & Assoc	$6,730,000
Ernst & Young	$6,329,701
Cornerstone Government Affairs	$6,050,000
Ferguson Group	$5,770,000
Carmen Group	$5,430,000
DLA Piper	$5,380,000
Alcalde & Fay	$5,380,000

INSURANCE

2009 LOBBYING = $81,528,794

TOTAL LOBBYISTS REPORTED: 875

HEALTH PROFESSIONALS

2009 LOBBYING = $39,408,563
TOTAL LOBBYISTS REPORTED: 722

HOSPITALS / NURSING HOMES

2009 LOBBYING = $50,290,605

TOTAL LOBBYISTS REPORTED: 1,106

PHARMACEUTICALS / HEALTH PRODUCTS

2009 LOBBYING = $134,458,183

TOTAL LOBBYISTS REPORTED: 1,545

MEDICAL SUPPLIES MANUFACTURING & SALES

2009 LOBBYING = $15,678,495

PHARMACEUTICAL MANUFACTURING

2009 LOBBYING EXPENSES

TOTAL: $92,615,557

HEALTH SERVICES / HMOs

2009 LOBBYING = $34,646,637

TOTAL LOBBYISTS REPORTED: 924

2008 CYCLE:

HEALTH PROFESSIONALS:

TOP CONTRIBUTORS TO FEDERAL CANDIDATES AND PARTIES: $95,690,005

Rank	Organization	Amount	Dems	Repubs
1	American Dental Assn	$2,127,690	54%	46%
2	American Medical Assn	$1,875,468	57%	43%
3	American Society of Anesthesiologists	$1,466,400	49%	51%
4	American Optometric Assn	$1,381,784	69%	31%
5	American College of Radiology	$1,312,250	56%	44%
6	American Assn of Orthopaedic Surgeons	$1,260,353	51%	49%
7	American College of Emergency Physicians	$1,159,750	55%	44%
8	American Physical Therapy Assn	$1,098,520	49%	51%
9	American Assn of Nurse Anesthetists	$1,041,574	59%	41%
10	American Academy of Ophthalmology	$1,018,352	56%	44%
11	National Assn of Retail Druggists	$832,956	70%	30%
12	US Oncology	$812,350	51%	49%
13	American College of Cardiology	$803,916	57%	43%
14	College of American Pathologists	$786,894	56%	44%
15	American College of Surgeons Prof Assn	$771,000	58%	42%
16	American Nurses Assn	$728,191	79%	20%
17	American Podiatric Medical Assn	$701,000	71%	29%
18	American Academy of Family Physicians	$691,943	62%	38%
19	American Osteopathic Assn	$480,700	46%	54%
20	American Assn of Orthodontists	$477,813	32%	68%

2008 CYCLE:

HOSPITALS & NURSING HOMES:

TOP CONTRIBUTORS TO FEDERAL CANDIDATES AND PARTIES: $23,213,677

Rank	Organization	Amount	Dems	Repubs
1	American Hospital Assn	$2,096,731	63%	37%
2	American Health Care Assn	$1,104,800	64%	36%
3	Kindred Healthcare	$640,316	72%	28%
4	American Seniors Housing Assn	$482,500	36%	64%
5	Hercules Holding	$464,312	51%	49%
6	Federation of American Hospitals	$459,537	52%	48%
7	Genesis HealthCare	$409,125	63%	37%
8	Manor Care Inc	$391,300	56%	44%
9	American Surgical Hospital Assn	$388,000	44%	56%
10	Sun Healthcare	$358,662	71%	29%
11	NHS Management	$273,450	78%	22%
12	Mayo Clinic	$233,829	54%	45%
13	HealthSouth Corp	$222,034	67%	33%
14	Beverly Enterprises	$220,700	66%	34%
15	Promise Healthcare	$188,500	22%	78%
16	Medical Facilities of America	$182,200	45%	55%
17	Triad Hospitals	$179,701	51%	49%
18	Premier Inc	$158,119	62%	38%
19	LifePoint Hospitals	$153,400	61%	39%
20	Options for Senior America	$147,887	63%	37%

2008 CYCLE:

HEALTH SERVICES / HMOs:

TOP CONTRIBUTORS TO FEDERAL CANDIDATES AND PARTIES: $14,278,231

Rank	Organization	Amount	Dems	Repubs
1	UnitedHealth Group	$1,330,127	64%	36%
2	Blue Cross/Blue Shield	$770,096	38%	62%
3	Aetna Inc	$597,482	56%	44%
4	Kaiser Permanente	$559,164	85%	14%
5	DaVita Inc	$498,411	64%	36%
6	Humana Inc	$492,875	41%	59%
7	Medco Health Solutions	$488,541	54%	46%
8	Express Scripts	$359,627	64%	36%
9	Fresenius Medical Care	$337,295	58%	42%
10	Health Net Inc	$286,968	63%	37%
11	Triwest Healthcare Alliance	$204,420	23%	77%
12	Vitas Healthcare	$194,850	99%	1%
13	Solomont Bailis Ventures	$179,500	100%	0%
14	Centene Corp	$175,792	39%	61%
15	Radiation Therapy Services	$173,800	81%	19%
16	Acadian Ambulance Service	$159,804	68%	32%
17	FHC Health Systems	$156,122	98%	2%
18	Blackstone Group	$146,500	41%	59%
19	Molina Healthcare	$143,773	62%	38%
20	Amerigroup Corp	$134,933	38%	62%

2008 CYCLE:

PHARMACEUTICALS / HEALTH PRODUCTS:

TOP CONTRIBUTORS TO FEDERAL CANDIDATES AND PARTIES: $29,384,371

Rank	Organization	Amount	Dems	Repubs
1	Pfizer Inc	$1,749,387	52%	48%
2	Amgen Inc	$1,456,964	50%	50%
3	Johnson & Johnson	$1,262,242	61%	39%
4	GlaxoSmithKline	$1,187,200	40%	59%
5	Merck & Co	$971,241	51%	49%
6	Roche Holdings	$950,936	68%	32%
7	Eli Lilly & Co	$942,853	49%	51%
8	Abbott Laboratories	$941,756	46%	54%
9	AstraZeneca PLC	$855,128	50%	50%
10	McKesson Corp	$730,631	44%	56%
11	Wyeth	$620,888	53%	47%
12	Novartis AG	$597,863	45%	55%
13	Medtronic Inc	$589,497	56%	44%
14	Schering-Plough Corp	$553,114	43%	57%
15	Bristol-Myers Squibb	$452,432	36%	64%
16	Boston Scientific Corp	$427,713	40%	60%
17	AmerisourceBergen Corp	$361,500	36%	64%
18	C8 MediSensors	$276,224	100%	0%
19	Pride Mobility Products	$275,200	14%	86%
20	Baxter International	$272,569	54%	46%

2008 CYCLE:

MEDICAL SUPPLIES:

TOP CONTRIBUTORS TO FEDERAL CANDIDATES AND PARTIES: $6,543,849

Rank	Organization	Amount	Dems	Repubs
1	Medtronic Inc	$589,497	56%	44%
2	Boston Scientific Corp	$427,713	40%	60%
3	C8 MediSensors	$276,224	100%	0%
4	Pride Mobility Products	$275,200	14%	86%
5	Baxter International	$272,569	54%	46%
6	Invacare Corp	$264,455	35%	65%
7	Direct Supply Inc	$247,501	50%	50%
8	Tyco International	$237,522	60%	40%
9	Starkey Laboratories	$198,230	0%	100%
10	Medline Industries	$187,750	89%	11%
11	SCOOTER Store	$182,504	58%	42%
12	Advanced Medical Technology Assn	$176,283	50%	50%
13	A-Dec Inc	$174,400	1%	99%
14	St Jude Medical	$130,521	27%	73%
15	Covidien Ltd	$111,500	40%	60%
16	Novo Nordisk	$107,500	59%	41%
17	Stryker Corp	$104,075	58%	42%
18	Pacific Pulmonary Services	$95,100	61%	39%
19	CR Bard Inc	$89,545	47%	53%
20	Energex Systems	$86,600	0%	100%

2008 CYCLE:

PHARMACEUTICAL MANUFACTURING:

TOP CONTRIBUTORS TO FEDERAL CANDIDATES AND PARTIES: $15,610,772

Rank	Organization	Amount	Dems	Repubs
1	Pfizer Inc	$1,749,387	52%	48%
2	Amgen Inc	$1,456,964	50%	50%
3	GlaxoSmithKline	$1,187,200	40%	59%
4	Merck & Co	$971,241	51%	49%
5	Eli Lilly & Co	$942,853	49%	51%
6	Abbott Laboratories	$941,756	46%	54%
7	AstraZeneca PLC	$855,128	50%	50%
8	Wyeth	$620,888	53%	47%
9	Novartis AG	$597,863	45%	55%
10	Schering-Plough Corp	$553,114	43%	57%
11	Bristol-Myers Squibb	$452,432	36%	64%
12	Roche Holdings	$415,380	62%	38%
13	Pharmaceutical Rsrch & Mfrs of America	$247,260	54%	46%
14	King Pharmaceuticals	$218,550	1%	99%
15	Bayer AG	$208,426	38%	62%
16	Sanofi-Aventis	$207,039	58%	41%
17	Melaleuca Inc	$197,027	0%	100%
18	Celgene Corp	$195,036	16%	84%
19	Solvay SA	$184,550	31%	69%
20	Mylan Laboratories	$164,000	52%	48%

Cycle 2008:

Insurance Companies:

NON-LOBBYING CAMPAIGN CONTRIBUTIONS: Money to Congress:

All Senators

Candidate	Amount
McCain, John (R)	$2,431,406
Obama, Barack (D)	$2,267,323
Clinton, Hillary (D-NY)	$1,212,490
Dodd, Chris (D-CT)	$857,006
McConnell, Mitch (R-KY)	$400,583
Coleman, Norm (R-MN)	$395,129
Chambliss, S (R-GA)	$340,136
Sununu, John E (R-NH)	$303,804
Cornyn, John (R-TX)	$287,569
Baucus, Max (D-MT)	$287,350
Dole, Elizabeth (R-NC)	$280,062
Smith, Gordon H (R-OR)	$230,350
Collins, Susan M (R-ME)	$215,700
Reed, Jack (D-RI)	$202,050
Wicker, Roger (R-MS)	$170,200
Johnson, Tim (D-SD)	$164,586
Roberts, Pat (R-KS)	$158,650
Shelby, RC (R-AL)	$157,249
Reid, Harry (D-NV)	$148,900
Durbin, Dick (D-IL)	$135,400
Pryor, Mark (D-AR)	$124,315
Specter, Arlen (R-PA)	$122,848
Landrieu, Mary L (D-LA)	$121,148
Sessions, Jeff (R-AL)	$107,250
Rockefeller, Jay (D-WV)	$105,174
Harkin, Tom (D-IA)	$103,080
Voinovich, G V (R-OH)	$102,000
Graham, Lindsey (R-SC)	$101,100
Biden, Joe R Jr (D-DE)	$100,000

All Members of the House

Candidate	Amount
Rangel, Charles (D-NY)	$370,090
Kanjorski, Paul (D-PA)	$346,048
Pomeroy, Earl (D-ND)	$277,925
Cantor, Eric (R-VA)	$254,100
Bean, Melissa (D-IL)	$253,308
Crowley, Joe (D-NY)	$234,868
Boehner, John (R-OH)	$225,525
Tiberi, Patrick J (R-OH)	$215,581
Frank, Barney (D-MA)	$202,798
Neal, Richard E (D-MA)	$195,250
Royce, Ed (R-CA)	$185,701
Larson, John billion(D-CT)	$168,079
Hoyer, Steny H (D-MD)	$162,900
Murphy, Chris (D-CT)	$145,774
English, Phil (R-PA)	$145,542
Emanuel, Rahm (D-IL)	$144,200
Moore, Dennis (D-KS)	$143,700
Bachus, S (R-AL)	$140,500
Camp, Dave (R-MI)	$139,151
Jones, S Tubbs (D-OH)	$131,999
Kind, Ron (D-WI)	$129,816
Tanner, John (D-TN)	$128,697
Gerlach, Jim (R-PA)	$128,125
Ryan, Paul (R-WI)	$124,150
Roskam, Peter (R-IL)	$123,650
Davis, Artur (D-AL)	$121,549
Pelosi, Nancy (D-CA)	$120,500
Bachmann, M (R-MN)	$119,050
Andrews, Robert (D-NJ)	$117,549
Shays, Chrisr (R-CT)	$115,300
Meeks, Gregory (D-NY)	$114,500
Putnam, Adam (R-FL)	$113,940
Kirk, Mark (R-IL)	$112,275
Udall, Mark (D-CO)	$111,858
Biggert, Judy (R-IL)	$111,800
Blunt, Roy (R-MO)	$109,650
Klein, Ron (D-FL)	$107,197
Davis, Geoff (R-KY)	$106,350
Feeney, Tom (R-FL)	$105,500
Schwartz, A (D-PA)	$105,500
Porter, Jon (R-NV)	$103,900
Castle, Michael (R-DE)	$102,275
Clyburn, James (D-SC)	$101,250

Cycle 2008

Health Professionals: Money to Congress

All Senators

Candidate	Amount
Obama, Barack (D)	$11,737,545
McCain, John (R)	$5,260,636
Clinton, Hillary (D-NY)	$4,017,746
Cornyn, John (R-TX)	$571,363
McConnell, M (R-KY)	$542,350
Coleman, Norm (R-MN)	$403,525
Chambliss, S (R-GA)	$372,659
Barrasso, J A (R-WY)	$368,250
Baucus, Max (D-MT)	$353,241
Harkin, Tom (D-IA)	$337,398
Collins, S M (R-ME)	$336,669
Smith, G H (R-OR)	$309,676
Roberts, Pat (R-KS)	$307,950
Landrieu, M L (D-LA)	$256,088
Durbin, Dick (D-IL)	$254,034
Wicker, Roger (R-MS)	$242,000
Dole, Elizabeth (R-NC)	$231,596
Biden, Joe (D-DE)	$229,650
Rockefeller, J (D-WV)	$215,850
Specter, Arlen (R-PA)	$199,883
Reid, Harry (D-NV)	$196,700
Johnson, Tim (D-SD)	$173,690
Alexander, L (R-TN)	$165,350
Reed, Jack (D-RI)	$159,100
Sessions, Jeff (R-AL)	$156,460
Dodd, Chris (D-CT)	$144,500
Grassley, Chuck (R-IA)	$141,800
Pryor, Mark (D-AR)	$140,945
Kerry, John (D-MA)	$135,550
Brown, Sherrod (D-OH)	$118,900
Levin, Carl (D-MI)	$116,700
Salazar, Ken (D-CO)	$116,500
Lautenberg, F R (D-NJ)	$106,300
Enzi, Mike (R-WY)	$102,049

All Members of the House

Candidate	Amount
Paul, Ron (R-TX)	$611,428
Pallone, Frank Jr (D-NJ)	$506,068
Price, Tom (R-GA)	$438,251
Gingrey, Phil (R-GA)	$359,281
Stark, Pete (D-CA)	$308,600
Rangel, Charles billion(D-NY)	$297,599
Kirk, Mark (R-IL)	$290,842
Udall, Mark (D-CO)	$284,340
Dingell, John debt (D-MI)	$278,850
Gordon, Bart (D-TN)	$255,450
Burgess, Michael (R-TX)	$240,750
Boustany, Ch W Jr (R-LA)	$240,250
Ellison, Keith (D-MN)	$227,891
Hoyer, Steny H (D-MD)	$226,600
Schwartz, Allyson (D-PA)	$221,050
Camp, Dave (R-MI)	$206,650
Kagen, Steve (D-WI)	$201,814
Pomeroy, Earl (D-ND)	$201,775
Udall, Tom (D-NM)	$191,722
Jackson Lee, S (D-TX)	$189,766
Berkley, Shelley (D-NV)	$185,435
Matheson, Jim (D-UT)	$183,043
Deal, Nathan (R-GA)	$180,850
Barton, Joe (R-TX)	$179,834
Klein, Ron (D-FL)	$175,800
English, Phil (R-PA)	$173,000
Blunt, Roy (R-MO)	$169,400
Shadegg, John (R-AZ)	$168,324
Green, Gene (D-TX)	$164,696
Capps, Lois (D-CA)	$164,350
Sessions, Pete (R-TX)	$163,750
Cantor, Eric (R-VA)	$163,250
Ross, Mike (D-AR)	$163,225
DeGette, Diana (D-CO)	$161,849
Becerra, Xavier (D-CA)	$160,560
Thompson, Mike (D-CA)	$155,400
Pelosi, Nancy (D-CA)	$151,850
Murphy, Tim (R-PA)	$150,975
Emanuel, Rahm (D-IL)	$150,100
Whitfield, Ed (R-KY)	$147,251
Kind, Ron (D-WI)	$144,800
Boehner, John (R-OH)	$140,750
Altmire, Jason (D-PA)	$139,750
Shays, Christopher (R-CT)	$139,700
Van Hollen, Chris (D-MD)	$137,700
Eshoo, Anna (D-CA)	$129,875
Doggett, Lloyd (D-TX)	$129,291
Gonzalez, Ch A (D-TX)	$128,799
Bilirakis, Gus (R-FL)	$128,542
Capito, Shelley M (R-WV)	$125,775
Murphy, Chris (D-CT)	$125,021
Hinojosa, Ruben (D-TX)	$122,650
Porter, Jon (R-NV)	$122,150
Simpson, Mike (R-ID)	$121,400
Giffords, Gabrielle (D-AZ)	$120,750
Kennedy, Patrick J (D-RI)	$120,612
Sullivan, John (R-OK)	$119,900
Towns, Edolphus (D-NY)	$119,700
Clyburn, James E (D-SC)	$118,650
Rogers, Mike debt (R-AL)	$116,450
Obey, David R (D-WI)	$114,850
Pitts, Joe (R-PA)	$113,800
DeLauro, Rosa L (D-CT)	$111,996
Myrick, Sue (R-NC)	$111,800
McCarthy, Carolyn (D-NY)	$110,310
Waxman, Henry A (D-CA)	$110,217
Buchanan, Vernon (R-FL)	$108,650
Yarmuth, John A (D-KY)	$107,628
Lewis, John (D-GA)	$106,700
Berry, Marion (D-AR)	$105,717
Reichert, Dave (R-WA)	$105,628
Gerlach, Jim (R-PA)	$105,300
Dent, Charlie (R-PA)	$105,250
Schultz, debt W (D-FL)	$104,400
Stupak, Bart (D-MI)	$103,988
Diaz-Balart, Lincoln (R-FL)	$102,025
Buyer, Steve (R-IN)	$101,980
Andrews, Robert E (D-NJ)	$101,900
Shimkus, John M (R-IL)	$101,300
Rodriguez, Ciro debt (D-TX)	$100,750
Cuellar, Henry (D-TX)	$100,235

2008 Cycle

Hospitals & Nursing Homes:

Money to Congress

All Senators

Candidate	Amount
Obama, Barack (D)	$3,331,894
Clinton, Hillary (D-NY)	$1,017,010
McCain, John (R)	$727,654
McConnell, Mitch (R-KY)	$299,150
Baucus, Max (D-MT)	$218,951
Coleman, Norm (R-MN)	$172,925
Specter, Arlen (R-PA)	$153,416
Sununu, John E (R-NH)	$141,250
Rockefeller, Jay (D-WV)	$134,650
Alexander, Lamar (R-TN)	$127,000
Smith, Gordon H (R-OR)	$123,737
Reid, Harry (D-NV)	$123,600
Chambliss, S (R-GA)	$123,100
Roberts, Pat (R-KS)	$120,100
Cornyn, John (R-TX)	$112,310
Durbin, Dick (D-IL)	$109,650

All Members of the House

Candidate	Amount
Rangel, Charles billion(D-NY)	$193,050
Altmire, Jason (D-PA)	$117,235
Paul, Ron (R-TX)	$105,667
Pomeroy, Earl (D-ND)	$105,050
Pelosi, Nancy (D-CA)	$91,750
Hoyer, Steny H (D-MD)	$87,000
Boehner, John (R-OH)	$86,800
Pallone, Frank Jr (D-NJ)	$86,299
Clyburn, James E (D-SC)	$83,050


Murtha, John P (D-PA)	$68,130
Cantor, Eric (R-VA)	$65,650

Cycle 2008:

Health Services / HMOs:

Money to Congress

All Senators

Candidate	Amount
Obama, Barack (D)	$1,411,450
Clinton, Hillary (D-NY)	$614,696
McCain, John (R)	$426,478
Baucus, Max (D-MT)	$231,150
McConnell, Mitch (R-KY)	$150,350
Collins, Susan M (R-ME)	$119,950
Salazar, Ken (D-CO)	$100,150
Rockefeller, Jay (D-WV)	$100,050

All Members of the House

Candidate	Amount
Rangel, Chs (D-NY)	$127,950




Pallone, Frank Jr (D-NJ)	$59,550
Boehner, John (R-OH)	$50,800

2008 Cycle:

Pharmaceuticals / Health Products:

Money to Congress

All reported contributions by this sector are less than $100,000 for ALL senators and ALL representatives.

Cycle 2008

Medical Supplies:

Money to Congress

Bottom of Form

All Senators

Candidate	Amount
Obama, Barack (D)	$367,238
McCain, John (R)	$186,478
Coleman, Norm (R-MN)	$131,978
Clinton, Hillary (D-NY)	$129,409
McConnell, Mitch (R-KY)	$95,285
Baucus, Max (D-MT)	$94,044

All Members of the House

All reported contributions by this sector are less than $100,000.

Cycle 2008:

Pharmaceutical Manufacturing:

Money to Congress

All Senators

Candidate	Amount
Obama, Barack (D)	$1,109,428
Clinton, Hillary (D-NY)	$341,124
McCain, John (R)	$311,188
McConnell, Mitch (R-KY)	$192,150
Specter, Arlen (R-PA)	$168,200
Baucus, Max (D-MT)	$162,520
Cornyn, John (R-TX)	$105,200

All Members of the House

Candidate	Amount
Dingell, J debt (D-MI)	$116,800
Boehner, J (R-OH)	$100,300

Clyburn, J E (D-SC)	$92,996

Pallone, F (D-NJ)	$88,700

Hoyer, S (D-MD)	$86,800


Rangel, Chs (D-NY)	$81,500

HEALTH CARE REFORM PROP

Sunday, October 4, 2009

HEALTH CARE REFORM CHAPTERS 16 - 21 - APPENDIX

TOP SPENDERS ON LOBBYING

1998 – 2009 AND 2009 ALONE

INSURANCE

HEALTH PROFESSIONALS

HOSPITALS / NURSING HOMES

MEDICAL SUPPLIES MANUFACTURING & SALES

HEALTH SERVICES / HMOs

Cycle 2008:

All Senators

All Members of the House

Cycle 2008

All Senators

All Members of the House

2008 Cycle

Hospitals & Nursing Homes:

Money to Congress

All Senators

All Members of the House

All Senators

All Members of the House

2008 Cycle:

Pharmaceuticals / Health Products:

Money to Congress

Cycle 2008

All Senators

All Members of the House

All reported contributions by this sector are less than $100,000.

Cycle 2008:

Pharmaceutical Manufacturing:

Money to Congress

All Senators

All Members of the House

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