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Dear Group, In keeping with yesterday’s post of a locally placed, thinly disguised ad by an impressive group of pharmaceutical companies aimed at insuring their continued profits I encourage you to: Click and read My Wife’s Expensive Cancer Drug, Doug Muder’s January 14, 2019 entry for his weekly email blog, the Weekly Sift. I have written of my own experience with our un-free market pharmaceutical pricing system in this country. Mr. Muder looks at it in greater depth through his personal experience with his wife’s cancer treatment. Keep to the high ground, Jerry P.S. I encourage you, in the left hand column of The Weekly Sift webpage, to sign up to receive Doug Muder’s weekly email, delivered to your inbox. I find it a level-headed bird’s eye view of the latest national news. I look forward to reading it every Monday. |
My M.D. Gripe with CMR
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Dear Group, Dr. Robert Wirthlin and I presented a written version of the story below to Cathy McMorris Rodgers at a “Coffee with Cathy” on April 11, 2017, asking her to save our patients health care as she hurriedly cobbled together the American Health Care Act. John McCain, may he rest in peace, recognized the bill for what it was. He memorably voted down the last Senate version of the bill on the night of July 27, 2017. McMorris Rodgers did not listen to us April 11, 2017. I sent the following as a letter to the editor to most of the newspapers in eastern Washington. It is the story I have told on many a doorstep. I reproduce it here: In 2010 the Affordable Care Act was passed. People with diabetes, folks previously priced out of the health insurance market by their pre-existing condition, were able to afford insurance. As an ophthalmologist I was able to save or restore the sight of many of these newly insured people before it was too late, people who were then able to continue to work, to drive, to read, to see their wives and children. Over the next eight years I watched in dismay as our U.S. Representative McMorris Rodgers voted time and time again to repeal the Affordable Care Act, pre-existing conditions and all. She did so, it seemed, with a grim determination to turn back the clock. She took every opportunity to peck away at the law, weaken it, make it worse and ultimately unworkable. Now she says, “I’m offended!” at the mere suggestion she could ever vote the way she did, claiming she has always defended pre-existing conditions. Every time I see her I am reminded of the faces of the people whose sight I was able to save thanks to the law she has worked so hard to dismember and destroy. This is the reason I enthusiastically recommend you vote for Lisa Brown, a woman with compassion that extends beyond the protection of her immediate family, a woman who understands that voting matters. Jerry E. LeClaire, M.D. Get out and knock on doors. Keep to the high ground, Jerry |
CMR: “I take offense!”
Dear Group,
On Wednesday, September 17 at the Greater Spokane, Inc. debate at the Fox Theater in Spokane McMorris Rodgers vehemently took offense over pre-existing conditions:
I take offense to anyone who would suggest that I would ever vote against protecting someone with pre-existing conditions. (KXLY video, starting at 01:28)
She said the same thing the next day at the Rotary 21 debate with the same tone of umbrage. Will she use the same line in the debate today in Walla Walla?
“Taking offense” is a rhetorical device. She shifts away from denying what she did to “I’m Cathy McMorris Rodgers. I have a son with Down Syndrome. You are low life to even think I could do such a thing!”
McMorris Rodgers’ declaration of “offense” should ring hollow to anyone paying attention. It is not complicated. Repeal of the Affordable Care Act has a been a shining goal of Republican/Libertarian legislators, word-meisters, right wing talk show hosts, and Fox News ever since the ACA became law in 2010. Attacking the ACA has kept the Republicans very busy passing repeals (without replacement) and filing lawsuits to chip away at every part of the ACA for the last eight years, never offering an alternative apart beyond the miserable status quo ante.
McMorris Rodgers and nearly every Republican in the House who has been in office has voted nine times to flat out repeal the Affordable Care Act–the whole thing–pre-existing conditions clause and all.
It is far easier to tear down than to build. Where was McMorris Rodgers’ defense of her son Cole when she cast those nine votes for flat out repeal? Where was the carefully constructed legislative replacement that would have defended her son’s access to affordable health insurance? Was a replacement going to pop out of thin air?
The time for McMorris Rodgers to “take offense” was at the short-sightedness of her Republican colleagues, the Raul Labradors, the Jason Chaffetzes (both of whom have abandoned their House seats). That was the time when she should have been “working for bipartisan solutions” (another hollow phrase she often uses).
When the Electoral College handed McMorris Rodgers and her Republican/Libertarian colleagues a willing president in 2016 they suddenly realized their votes might actually matter beyond obstructionism. “Oh my! We actually need to craft something!” They hurriedly cobbled together the American Health Care Act, the bill to which John McCain, recognizing the travesty it was, famously gave the thumbs down in the Senate. Much has been written dissecting the AHCA, noting that, indeed, it does not broadly protect people with pre-existing conditions like Cole Rodgers from being excluded or charged ridiculous premiums in many instances. But one doesn’t need to dive into the weedy details to see McMorris Rodgers’ “taking offense” is a diversion to her claimed sincerity, a diversion away from the truth of her voting record.
Every one of McMorris Rodgers’ nine votes for repeal of the ACA was a vote against people with pre-existing conditions. Every vote was taken without a replacement. Every repeal bill she voted for would have taken us back to the time people with pre-existing conditions either went bankrupt or went without. And now she is “offended????”
Vote her out.
Keep to the high ground,
Jerry
P.S. A good source for more on the Republican duplicity on pre-existing conditions can be found here and here in the Washington Post.
P.P.S. McMorris Rodgers’ devotion to Republican/Libertarian ideology blinds her to the plight of ordinary people. She votes to repeal the ACA without replacement nine times while confident her upper middle class bubble will protect Cole from losing access to health insurance. She cannot conceive of not having the money to pay every premium on time. For McMorris Rodgers, if you miss paying your premium for two months it must be evidence you are trying to game the system, not that you’ve legitimately fallen on hard economic times. For her it is alright to vote for a bill that offers state waivers allowing an insurance company to refuse or charge more to a person who misses two monthly premiums, regardless of hardship. It is a prevalent Republican and Evangelical Christian attitude: The nuts I saved up for the winter are evidence of my worth. If, for whatever reason, you didn’t save up enough nuts that is evidence of your profligacy. Jason Chaffetz, former Representative from Utah, guest and darling of the local Spokane Republican Party was most eloquent on this point with his statement (paraphrased), “If only people didn’t have to have that new iPhone they could afford health insurance.”
Indivisible–Tu–CMR, Pre-Existing Conditions, and Fuzzy Economic Thinking
Dear Group,
When McMorris Rodgers says, “I believe we must protect people with pre-existing conditions and ensure their health care needs are met,” (Spokesman, September 30) she is sincere, but she is also shining light on a fundamental misunderstanding of insurance and economics.
Of course she is sincere. She is a concerned mother of a child with Down Syndrome, a clear example of a pre-existing condition. Health insurance for a person with Down Syndrome in the pre-Affordable Care Act days (pre-2009) was either astronomically expensive or simply not available, not offered. Why would an insurance company sell insurance to cover an individual with known Down Syndrome, a condition with many known complications that are expensive to treat? Being forced to cover a lot of patients with pre-existing conditions like Down Syndrome is economic suicide for a health insurance company. It is in the best interests of every health insurance company to steer such patients elsewhere, or charge them premiums consist with the cost of providing their care.
McMorris Rodgers understands preexisting conditions on a very personal level. She really does want other people with pre-existing conditions to be able to avoid paying directly for treatment they need. That’s just right, isn’t it? After all, Down Syndrome really isn’t a result of poor choices in life so it is rightand justthat insurance companies should take on the economic risk of the disease.
But wait a minute. Isn’t this the same Congresswoman who voted to repeal the Affordable Care Act some fifty times over the last eight years, voted to repeal without considering the mandate to cover pre-existing conditions would vanish with it? Where was her personal sincerity over the plight of her son with Down Syndrome while she was mouthing the Republican talking points about restoring the “free” market, about “choice,” and how the government mandating the purchase of health insurance was “unconstitutional?”
Now, she and Republicans are busy backfilling. “No, no, actually, we want to protect people with pre-existing conditions! Forget what we voted for! We really didn’t mean it. We really are compassionate and caring. Quick, quick, we just put some bills in the hopper in the House that prove our sincerity!” I encourage you to read this article from the October 11 Washington Postfor full review of the Republican backfill efforts on pre-existing conditions. Or read Shawn Vestal’s scathing critique (May 3, 2017 Spokesman) of McMorris Rodgers’ lack of commitment to the pre-existing conditions clause in the lead up to the Republican AHCA, their failed, high profile, “repeal and ‘replace’” attempt.
But here’s the deeper background: McMorris Rodgers must have missed Economics 101. Her fuzzy economic thinking is on display.
1) Any person with a whiff of a pre-existing condition will cost more to take care of on average than a person with a clean health record. Insurance companies know this. They will do anything they can get away with to charge higher premiums to such people or turn them away. Insurance companies stuck with more patients with pre-existing conditions are automatically at a competitive disadvantage in the marketplace. They will raise premiums for everyone…or they will go bankrupt. That is basic “free market” economics.
2) In the same Spokesman article McMorris Rodgers says four times her goal is “affordable” health insurance (or health care). How does driving up insurance prices (as in #1) make insurance more affordable? Hmmm.
Points 1 and 2 are economically incompatible, but there is one more:
3) McMorris Rodgers expressed breathless excitement of Republican “momentum”when they repealed the Individual Mandate as part of the Tax Cuts and Jobs Act. The Individual Mandate, the requirement under the Affordable Care Act that everyone acquire health insurance or pay a fine, well, that was “unconstitutional,” and an infringement on citizens’ rights. I’m sure her excitement was real. After all, Republicans imagine themselves as the champions of such things. But wait. The economics of health insurance guarantee that if healthy people at little risk of illness do not buy health insurance then insurance prices will go up because the remaining folks are, on average, sicker and more expensive to care for.
#3 contradicts the goal of affordability, just like #1 does. This is basic economics of insurance. McMorris Rodgers gets a failing grade. Her thinking is fuzzy. As mother to a child with Down Syndrome she gets honorable mention for sincerity. She is not acting. She is real. She really doesn’t understand what she is doing…
If you listen a little longer to McMorris Rodgers, or any other current day excuse for a rational Republican, you will hear them trail off mumbling about “continuous coverage requirements,” “high risk pools” and “Pharmacy Benefit Managers.” These are paltry attempts to deal with problems of fundamental economics McMorris Rodgers doesn’t have the bandwidth to grasp.
Vote for Lisa Brown. She has a grasp of reality well beyond the economic basics at which McMorris Rodgers fails.
Keep to the High Ground,
Jerry
A Tale of a Drug and What it Means
Dear Group,
The chemical 5-fluorouracil (5-FU) was patented originally in 1956. It came into medical use only six years later in 1962. As a drug It interferes with DNA production, fouling up the machinery necessary for rapidly growing cells to divide and multiply. 5-FU is used in the treatment of systemic cancers, including cancer of the breast, ovary, and colon. It is NOT a fancy new drug requiring expensive research and development.
Some of my readers may have used this drug as a topical treatment for the precursors of skin cancer. As a topical 5% cream 5-FU is remarkably safe and effective, and, until recently, was quite inexpensive. Never heard of 5-FU, you say? How about the trade names Efudex, Carac, or Fluoroplex?
I visited my dermatologist recently and received a prescription for Efudex Cream 5% to “Apply to Scalp BID [twice a day] until red, raw, irritated.” Along with the prescription came some non-medical advice. “Your price point is around fifty dollars,” she said.
“Fifty dollars!” I exclaimed.
“Oh, yes,” she said. “A while ago patients started calling me back to say they couldn’t afford the Efudex I’d prescribed. Some of them told me of charges up to $300 for a 40 gram tube. Now I spend a portion of every day explaining how to avoid paying ridiculous prices for a drug that used to be cheap. If I don’t spend the time explaining, some of my patients will simply skip the treatment and show up later with invasive skin cancer requiring major surgery.”
I was stunned. This is a drug I heard about in medical school in the early 1980s. The last time I bought a 40 gram tube of Efudex (5-FU), maybe ten years ago, it was about twenty dollars.
Forewarned, I called my usual pharmacy to ask what it would cost me to fill the prescription.. “Your net cost after insurance will be $100,” I was told.
“After insurance?” I asked. “What would it cost me if I bought it outright?”
“Two hundred and eighty-four dollars.” she said. I wanted to scream…but it wasn’t her fault. She’s caught in the same un-free market that I am.
Let’s think about this a minute. I could hand over my credit card and accept the $100 cost. If I weren’t a physician myself and if my dermatologist hadn’t prepared me, I probably would have just grumbled and paid, just like a lot of busy people. But what are the consequences to the whole cost of medical care in an un-free market like ours?
I don’t know how much of the quoted $284 goes to the pharmacy, how much to the drug company and how much to the stockholders, but I can guarantee we feel the economic effect in our health insurance bills. Consider: as this scenario is repeated across all the subscribers to my health insurance, the insurance company has to ramp up the premium by some amount to cover the payment to the pharmacy. Insurance, you recall, serves to smooth out unexpected cost over all the subscribers. As long as their money-making business model is not threatened, insurance executives have little reason to try to micromanage ridiculously inflationary drug costs. Why should they bother? Just pass through the average extra cost to the whole pool of subscribers. The drug company and the insurance company both make a profit and the subscriber is none the wiser.
While the patient/consumer understandably complains about the ever rising cost of insurance, McMorris Rodgers and her Republican/Libertarian colleagues blame the Democrats and the Affordable Care Act, intoning “free market,” “personal choice,” and the evils of “government intrusion” into our personal lives.
A free market requires symmetry of information for supply and demand to establish the proper price for an item, but in the drug and insurance world the corporations have a massive advantages they wield in their pursuit of profit. First, the patient/consumer often feels as though there is no choice about whether or not to buy the drug. To add to the asymmetry, pharmaceuticals are marketed under multiple brand names, a generic name, and multiple sizes and formulations. Sorting out the history, side-effects and efficacy of any given drug can be a time-consuming task. The doctor prescribing the drug and the pharmacist filing the prescription have dozens of other things they should be spending their time on besides trying to make the patient/consumer aware of the price structure for every medicine.
How much time is there in a life for every patient/consumer to dig around the way I did with 5-FU to figure out the least expensive method of obtaining a drug? “It’s my health! The doctor prescribed it. I must buy it, if I can’t come up with that kind of money, well, I’ll just have to make do without it.” Life goes on…until a vastly more expensive and dangerous surgical procedure might be required to treat the disease easily dealt with by the original prescription.
The ridiculously inflated price of 5-FU has another unintended effect: For a caring doctor trying to provide treatment for pre-cancer that a patient can afford there is another option, an in office light treatment that is often fully covered by health insurance. Never mind it is not quite as effective and never mind it requires repetitive monthly $200 visits. But, voila! the patient/consumers out of pocket cost (the $100 I was quoted for a tube of Efudex) might be less or nothing. Never mind the overall accumulated cost to the health care system is more…
Run this economic scenario through your head again and again with different drugs and different patients and you will have a hint of how broken our system is, why it is so ridiculously expensive, and why we, as a country, have worse health outcomes and pay more for health care than much of the developed world.
Meanwhile, McMorris Rodgers’ solution to the problem? Here’s her full statement from her essay published September 30 in the Spokesman:
I also believe we need to address skyrocketing prescription drug prices. I’ve led on legislation to bring transparency to Pharmacy Benefit Managers (PBMs) who are the middlemen between drug companies and local pharmacists and are often the source of pricing increases. Just this week, I supported legislation to ban gag clauses – contractual provisions that bar pharmacists from informing patients when it’s cheaper for them to pay out-of-pocket for their prescriptions than go through their insurance. If our pharmacists, health insurers and PBMs can know the real cost of prescriptions, so should our patients.
What?? We’re going to control drug prices in a hopelessly rigged and complex market by empowering (not mandating) middlemen to tell patients about drug prices? This is going to result in cost reduction? Even if she grasps some part of the problem of the lop-sided un-free market, this is barely the beginning of a solution.
In contrast, Lisa Brown wrote in her essay of the same day:
I will work to lower the cost of prescription drugs – the federal government can and should use its buying power to negotiate lower costs.
That comment suggesting government intervention is unthinkable to a doctrinaire “free” market Republican/Libertarian like our incumbent. McMorris Rodgers offers to tinker with an un-free market problem that is beyond tinkering. Have her pharmaceutical sponsors convinced her that to have huge government volume buyers like Medicare use their bargaining power in the marketplace would be unfair to them and their stockholders?
By the way, that $284 tube of 40 grams of 5% Efudex for my scalp? I’m getting it through a Canadian pharmacy for $51.58 USD. I took time out of my life and I had the resources to play the game. Not everyone has that time and resources–nor should they be expected to. It should be a function of government to guard our health care system from profit driven predation in an un-free market.
Read Lisa Brown’s whole essay here. It is a breath of fresh air and comprehension. Lisa gets it.
Keep to the high ground,
Jerry
Lisa Brown’s Clarity v. CMR’s Fuzzy Thinking on Health Care
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Dear Group, On Sunday, September 30, the Spokesman Review ran a Round Table page in the Business Section entitled “Health care in America” presenting McMorris Rodgers’ “My Goal is Quality and Affordability” and Lisa Brown’s “We Need Solutions, Not Slogans.” Each is worth the time to read. (To do so either click on each individually or, if you have access to the online Spokesman, read here with both on the same page as presented in the paper.) McMorris Rodgers leads off by revving up her base. For them the ACA is “Obamacare,” the Republican word-meister’s way of deprecating the ACA by linking it to a man they’ve been primed to despise. She writes O….care “isn’t working.” No small wonder there. She and her party have fought hammer and tong legislatively, through the courts, and through right wing media to block every essential provision of the Affordable Care Act since its inception in 2009. One of her proudest achievements was the repeal of the individual mandate of the Affordable Care Act (as part of the infamous Tax Cuts and Jobs Act of December 2017), a repeal that assures that health insurance premiums under the ACA will rise. Now she laments that it “…isn’t working?” Mission accomplished. You broke it, you own it. She goes on, “Right now we are continuing to see the cost of health care and insurance soar.” That is re-statement of problem. The next paragraph begins with, “…I’ve supported and will continue to advance real solutions.” I’m waiting…waiting…what are these solutions? She moves on to a series of “what I’m for” statements to fill out the paragraph…no solutions there. So what does McMorris Rodgers propose? Here’s the stripped out list of “solutions” from the rest of her essay: 1) By making Medicare and Medicaid pay a higher percentage of what rural hospitals bill she’ll fix the fiscal crisis in rural health care. Really? Read Mike Bell’s analysis (candidate in State Legislative District 7) and my puzzlement over McMorris Rodgers fuzzy economic thinking. 2) By blaming the “high population of Medicare and Medicaid patients” for whom rural hospitals struggle to provide care. Does she wish to limit reduce their numbers? The problem is not Medicare and Medicaid patients, it is the un-reimbursed cost of caring for patients forced to seek care in rural Emergency Rooms, people priced out medical insurance, a problem you, McMorris Rodgers, have helped make worse. 3) By “…leading in advancing solutions that make health care more affordable and accessible” as co-chair of the Rural Health Coalition. What solutions? That is yet another restatement of the problem, not a solution. 4) By extending the Children’s Health Insurance Program (CHIP) [but only after holding the renewal of the program hostage]. CHIP was established in 1993 in a strong bi-partisan effort. There are no Democrats who oppose it. Republicans act as though it were an act of sacrifice on their part to extend the program. 5) By supporting residency programs. [That is a nice, rare, bi-partisan effort. It does not address the cost of health care OR health care insurance.] and, finally, McMorris Rodgers proposes to bring down drug costs By 6) Leading on legislation to bring transparency to Pharmacy Benefit Managers (PBMs). [leaving it to consumers to spend even more time researching the prices of each drug they’re prescribed in a rigged and hopelessly distorted market]. Oh, yes, and in the second to last paragraph McMorris Rodgers is going to foster innovation through the 21st Century Cures Act. 21st Century Cures’ main thrust is to strip away regulations around the testing and approval of drugs and medical devices. These regulations help ensure that drugs and medical devices are safe and effective before they get tested out on us, the “consumers.” She is promoting a Republican effort to make drug companies even more profitable and suggesting that will unleash “innovation.” These are NOT solutions. It does not require a Ph.D. in Economics to recognize McMorris Rodgers’ fuzzy thinking. There is nothing in her essay to suggest she even understands health care economics, much less that she can formulate a solution to a problem she has only made worse. Lisa Brown’s essay is a breath of fresh air. I encourage you to read it. I quote below just three examples her clear thinking: I will work to lower the cost of prescription drugs – the federal government can and should use its buying power to negotiate lower costs. We should not seek to lower prices by bringing more insurance companies into the market. Competition among private companies isn’t the answer – companies can change their coverage rules on a whim, resulting in more substandard insurance plans which don’t offer what families need for health care security. Additionally, I strongly support the principles of universal coverage and recognize there are a few different paths to getting there – something we should do. In fact, we already have costly universal coverage in this country: the emergency room. Hospitals can’t turn away people in need of care, and end up with overwhelming costs. There are more effective ways of treating more people, notably by expanding eligibility for Medicare, which is a universal system. In November let the voters of eastern Washington reject McMorris Rodgers’ mentally blinkered Republican thinking. Let us elect Lisa Brown, a leader with the mental bandwidth to both understand the problem and offer real solutions. Let each of us go forth, knock on doors, and proclaim the good news to dispirited, disengaged voters! Join in canvassing. Keep to the high ground, Jerry |
Was He Punished for Drug Pricing? Look again.
Dear Group,
Remember Martin Shrkeli, the nasty, un-repentent founder and chief executive of Turing Pharmaceuticals? He was briefly infamous for jacking up the price of a tablet of Daraprim (an old antibiotic) from $13.50 to $750.00 overnight in 2015. Do you remember a sense of satisfaction when he was sentenced to prison for seven years? Did you think, well, he got what was coming to him for such a heinous act? Think again. He may have gotten what was coming to him, but he wasn’t sent to prison for an immoral price hike that put people’s lives at risk. He was put in prison for defrauding the investor class.
Think about that. In 2015 Daraprim (pyrimethamine) had been around for sixty-two years. As an ophthalmologist, I used Daraprim to treat a vision-threatening infection by a parasite, Toxoplasma gondii. Later, its main use was for treatment of AIDS patients with a life-threatening systemic infection with the same pathogen. In 2015 when Shrkeli hiked the price of Daraprim, Turing was the only manufacturer. Cost to produce a tablet? In India at the time a dose of pyrimethamine could be purchased for as little as $0.10. The price hike left patients (and their doctors) scrambling to find funding for vision-saving or even life-saving treatment. The money from the inflated prices went to Shrkeli and Turing’s stockholders. Some patients no doubt had to forego treatment. These were folks too sick to navigate the complex web of pharmacy insurance or lacking the wherewithal to smuggle the drug into the country, Such people are in no condition to mount a political campaign. In our system they can be allowed to suffer. Their collective voice is too quiet for a free market Republican to hear.
It is a grim irony that Shkreli went to prison not for a price hike that fell on the vulnerable, likely blinding some and hastening the death of others. No, he went to prison for “defrauding investors in two failed hedge funds.” Such is our system, such is the fealty the Republican/Libertarians pay to the “free market.” There were dramatic hearings in 2015 in the Republican majority House…and no action whatsoever.
What does Daraprim cost today in the United States? $746.18 per tablet at Costco according to a quick online search. In Canada? $1.38 per tablet is the highest price I could find.
Outraged yet? It would take only a minute to come up with numerous other examples of immorally priced drugs, each affecting a relatively small group of patients, patients who spend time struggling with health insurance companies for coverage of inflated drug prices, patients who go without essential medicines or take half doses because they simply can’t afford the price, patients who pay ridiculous insurance premiums in part because of the unconscionable prices drug companies are allowed to charge.
If you take this issue to McMorris Rodgers’ local office, perhaps her staff (funded by your tax dollars-Member’s Representational Allowance) will help you find some compassionate program to help you pay the bill…or perhaps you can appeal to Go-Fund-Me. What you will NOT get from McMorris Rodgers is any action to rein in the cost of pharmaceuticals. You will not get a bill to encourage reimportation from Canada. You will not get legislation to allow Medicare/Medicaid to volume bargain with the drug companies on price. Those straightforward ideas are contradictory to Republican/Libertarian “free market” ideology. Never mind health care and drugs are not part of a free market.
While McMorris Rodgers remains in office and in a Republican majority remains in Congress there will be no relief. Voting her out won’t fix this right away, but it is a necessary beginning. Lisa Brown understands health care economics and will work toward rational drug pricing. Here is your chance to elect a Representative to get things started.
Keep to the high ground,
Jerry
P.S. Please understand I am convinced of Cathy McMorris Rodgers’ fundamental desire to do good, but I fear she lacks the open mind, the education, and the mental bandwidth to deal with many issues. Her deep, unfounded faith the “free market” will solve all problems blinds her to circumstances where the market is not free. Drug prices and health care are cardinal examples.