Category: Observations

Business, Innovation, Observations

GoodRX? BadRX? How to think about prescription Discount Cards

pollywannamath

When I first saw an advertisement for GoodRx, I assumed it would be a fad for 6 months and then I would never hear about it again. It has been over a year and I still watch their bad Monte Hall commercial before every fifth YouTube video.

Before I describe GoodRx and pass judgement on it, I should describe a little of the prescription market. Major pharmaceutical companies manufacture drugs and determine a list price that will allow them to hit a target profit margin. Much like for clothing or vehicles, the MSRP is not the amount that an average person will pay; the cost to consumer depends on many downstream factors. The pharmaceutical company will sell to a wholesaler, who, in turn, sells to a pharmacy. Pharmacies have relationships with third-party payer and their wholesalers that cause price variance of the same drug between pharmacies. At each level, a little profit is taken. On the demand side of the market, consumers often have two options:

  • purchase the prescription in cash without insurance.
  • purchase the prescription using insurance.

Insurers don’t determine which drugs will be covered under their plans, nor do they determine the price of the drug for their members. Insurers contract that work to a Pharmacy Benefit Manager (PBM). Pharmacy Benefit Managers determine which drugs will be covered by a plan and what a member will owe for the drug, the PBM does not need to disclose the real price of the drug. Insurers pay the PBM a fee for administering the drug plan, and the PBM keeps any rebate or discount that they receive from the pharmaceutical manufacturer. I could write at length on PBMs, but for the purpose of this article, I’ll only note that the position of PBMs are controversial. Some claim that PBMs save consumers money, others note that PBM profits continue to grow at an alarming rate.

GoodRx, and other prescription discount cards, can be thought of as a self-serve Pharmacy Benefit Manager for the uninsured. GoodRx identifies the lowest cost location for a drug in the consumer’s area and negotiates rebates and discounts with pharmaceutical companies for further discounts.

Does that mean that my initial skepticism about GoodRx was unwarranted? Mostly yes. The business model is sound and prescription discount cards are legitimate. However, GoodRx is not a panacea and I have two primary concerns about its use:

The second point deserves some clarification. In 2018, over 43% of Americans were enrolled in a high-deductible health plan. In these plans, a member will generally pay for 100% of their care (either out of pocket or using an HSA/FSA) up to a predetermined dollar amount or deductible. The health insurance industry has a lot of nuance that I can’t begin to cover in this format, but understanding the concept of a deductible is the piece relevant to GoodRx. Deductibles can include or exempt pharmacy costs based on the member’s plan design.

GoodRx cannot be combined with insurance. For many on high-deductible health plans, GoodRx can appear to offer lower cost drugs than even the copay offered by the pharmacy benefit manager. These apparent savings are not as they appear. Over a year, because insurance will often pay for the drug once a deductible is met, members in the scenario described above will often be better off using their insurance and paying a little more early in the year. GoodRx does not make that evident.

GoodRx is a good option for those who are uninsured, or know their current insurance offering and can account for anticipated yearly cost of their drugs. It is not likely a good solution for all. Especially those who would save a little in the short-term and, as a result, spend more over a year by forgoing their insurance.

Observations, words words words

Political Speech is Missing Sax Appeal

pollywannamath

When cataloging moments of great presidential rhetoric, a few speeches immediately come to mind:

I have two books that deal with Presidential rhetoric (Speaking with the People’s Voice [recommended] and America Out Loud), neither reference a single Clinton speech or interview. America Out Loud reduces the Clinton years to a single sentence, “I did not have sexual relations with that woman.” I think that is a mistake.

In retrospect, it is easy to reduce Clinton’s appearance on Arsenio to a single gif of him playing heartbreak hotel.

Sax man, Bill Clinton

However, his interview as the democratic candidate for president with Arsenio Hall is one of the best uses of political speech I’ve heard and deserves to be on the list above. In 1992, candidate Clinton appeared for a 30 minute interview with late night tv host, Arsenio Hall. Hall’s show was hip and Clinton needed to attract a younger audience to beat Ross Perot (and his pointer) and George H.W. Bush.

The interview started with Clinton’s infamous sax performance, but quickly ran into substantive issues. Clinton was grilled on his views about race in the aftermath of the Rodney King riots. Hall continues to be a staunch activist for civil rights and social equality and it was clear in the interview that he was not looking for political answers from the candidate, he wanted to know how Clinton was different.

Whether or not Clinton was different is irrelevant. The interview is like nothing I’ve ever seen from a candidate. Clinton appears vulnerable. He doesn’t try to play the role of invulnerable politician, he doesn’t promise he will fix every problem in the US. He tells an embarrassing story about his first experience with marijuana, he jokes that Hall will need to pay more taxes, he openly lets viewers know that he needs to narrow his scope if he hopes to get anything done.

The interview was in 1992. There are moments that come across as insensitive, and he discusses race and gang affiliation in ways that should make Americans a little uncomfortable. But, language gaffs and poor examples aside, his views and policy decisions on minority groups remain salient today. If you told me that his interview took place in 2020, I’d tell you that I was excited we had a young moderate in the race.

Why is this interview not considered a moment of great political rhetoric? Maybe because it was an interview, not a speech. Maybe we remember only the saxophone. Maybe Arsenio wasn’t considered “serious” enough. I never experienced this interview in its time.

I wish I had. I hope in the next decade we will have a number of politicians that revere this interview. I’d love to see a series of presidential hopefuls baring their soul to Ira Glass, Malcolm Gladwell, Joe Rogan, Conan, or the next generation of great interviewers. Interviews that leave the audience with the impression that they understand the person, not just the platform, that is trying to win their vote.

Watch the full interview here:

Clinton on Hall
Education, Observations

Things education in the US can’t stand: People who are intolerant of other people’s cultures, and the Dutch.

pollywannamath

Forgive the Austin Powers reference, I haven’t blogged in a while and I’ve regressed as a result. Throw me a frickin’ bone here. On the topic of Austin Powers, there is a scene where Mr. Powers is attempting to get up to speed on decades of American history in a single night. He sums it up in a single sentence, “Jimi Hendrix Deceased, Drugs. Janis Joplin Deceased, Alcohol. Mama Cass Deceased, Ham Sandwich.”

While I was in middle and high school, there was a shift away from teaching students an Anglocentric history. Our books primarily taught US history still, but there was an increased focus on the social history and experience of American Indians, women, and, later, immigrant populations. When studying world history, China loomed as large as Rome. Generally, I think the shift away from Anglocentric, whig history is a positive step. Students should be exposed to history that connects with them, history should be taught in an inclusive way that contextualizes history with the cultures, influences, and aftershocks that make up the events taught in class.

With an increased focus on the individual cultures and peoples that built the United States, one might assume that US students learn more about the Dutch element of US history. The Dutch gave us Santa Claus, New York, doughnuts, and brought African slavery to the Colonies. Despite the influence that the Dutch had on the form of the US government, stance on religious tolerance, and economic growth through the Dutch East India Company, the AP US history curriculum devotes more attention to Spanish colonialization than the influence of the Dutch on the US.

I think the lack of focus on the Dutch has a couple of causes:

  • Dutch influence is hard to separate from English influence and it is much easier to teach the English narrative.
  • The golden age of the Netherlands occupies a period of time not focused on in US history.
    • Students generally learn about the founding of the colonies, and then jump to the war for independence. Any time devoted to the 1600’s tends to focus on American Indian relations and religious tolerance. The Dutch aren’t necessary to teach either.
  • There is no cultural/political benefit to separating the Dutch from other subsets of white, western history.
    • The Dutch are definitionally WASPs and benefited from whig history, spending time focusing on their contributions might diminish the benefits of the more contextualized history taught today.
    • Dutch culture is German culture, and western education tends to value Latin cultures more than German cultures.
    • The Netherlands are not a global superpower today; there is no reason to specifically identify Dutch influence on American history to help students contextualize current events.

Does it matter that Dutch contributions to American society, good or bad, are not highlighted as Dutch? I’m not sure. However, I am sure that the Dutch are not the only culture to have their influence on American minimized in childhood education. I would be interested to find other examples and identify a way to give students an opportunity to learn about cultures or peoples that interest them and close these education gaps.

Interested in what students learn across the country? Find more here.

*The author of this post does not identify as Dutch, nor does he have any particular affiliation to the Netherlands.

Legal, Observations

What Firemen and the Military Get Right

pollywannamath

A building is burning; inside an elderly couple is struggling to survive. A group of firefighters arrive on scene. Seeing the fire, they decide the elderly couple are likely to die and drive away.

The United States is on the precipice of war, the military is on alert and readies all troops, aircraft, and ships. Before the enemy can attack, the entire US military evacuates to allied nations. The US is bombed and US citizens pay the price.

Both scenarios are unbelievable. The military and firemen understand that they exist to protect the citizenry. I expect that both groups would be willing to face a greater chance of dying at a chance save a US citizen. Firemen and members of the US military take place in a social contract where their lives are valued less than the lives of other US citizens. For that reason, we celebrate these civil servants; they value their lives less than they value the lives of an average citizen.

Are police civil servants? Did they sign the same contract? Obviously not, although I’m not sure how the police ended up in a different position in the societal priority stack. In contrast to the military or firemen, we value police lives higher than the lives of other US citizens. As evidence of this claim, we need only to look at rates of police deaths vs deaths caused by police in the US. In 2018, 106 police officers died on duty (an increase over the year before). In contrast, in the same year, police killed 582 people--in California alone… Nationally the police killed over 900 people. I could never point to a statistic where US firefighters killed 8 citizens with fire per one citizen saved. It’s evident that society values police lives at over an 8:1 ratio in favor of police lives.

Is that because police arrest criminals and firefighters save innocents? I hope not. If that were the case than the US should abolish the innocent until proven guilty standard. It should not be up to the court of public opinion to determine the position of a police officer compared to the life of an alleged criminal.

Is it possible that the police have only killed alleged criminals that pose an imminent existential threat to numerous, non-police citizens? Sure it is possible that it is sometimes the case, but it wouldn’t explain the death of George Floyd (see Protests for more info).

What am I advocating? I’d like to see the US reprioritize where police fit in the societal priority stack. Disarming traffic cops is not a radical proposition when compared to the expectations of firemen and our military. I am not advocating for the total removal of police or creating a government that is unable to protect its citizens. In fact, I am advocating the opposite, a police force that kills more than is killed is incapable of protecting us.

Observations

What Changed?

pollywannamath

In my last post concerning the Minneapolis protests, I said that this time feels different. Is it different because people no longer blame themselves for their material position or position in society?

Kurt Vonnegut describes the American Dream in Slaughterhouse Five:

America is the wealthiest nation on Earth, but its people are mainly poor, and poor Americans are urged to hate themselves. To quote the American humorist Kin Hubbard, ‘It ain’t no disgrace to be poor, but it might as well be.’ It is in fact a crime for an American to be poor, even though America is a nation of poor. Every other nation has folk traditions of men who were poor but extremely wise and virtuous, and therefore more estimable than anyone with power and gold. No such tales are told by the American poor. They mock themselves and glorify their betters. The meanest eating or drinking establishment, owned by a man who is himself poor, is very likely to have a sign on its wall asking this cruel question: ‘if you’re so smart, why ain’t you rich?’ There will also be an American flag no larger than a child’s hand – glued to a lollipop stick and flying from the cash register.

Americans, like human beings everywhere, believe many things that are obviously untrue. Their most destructive untruth is that it is very easy for any American to make money. They will not acknowledge how in fact hard money is to come by, and, therefore, those who have no money blame and blame and blame themselves. This inward blame has been a treasure for the rich and powerful, who have had to do less for their poor, publicly and privately, than any other ruling class since, say Napoleonic times. Many novelties have come from America. The most startling of these, a thing without precedent, is a mass of undignified poor. They do not love one another because they do not love themselves.”

Criticizing the quote, or that I chose Vonnegut as my reference point is easy. Maybe its warranted, but why have the protests persisted? Maybe its just a result of the COVID lockdowns, but maybe the Vonnegut passage was once more true than it is now.