Big Pharma Thanks Congressmen For Their Corporate Welfare

As I’ve said many times, Bush’s Medicare drug plan was a reward to the pharmaceutical and insurance industries for all the money they’ve donated to the Republican Party. The pharmaceutical companies now receive payment in full through the new program to replace discounted payments they had to accept from Medicaid programs in the past, while insurance companies are subsidized for providing inefficient Medicare HMO programs.

If given a huge money making benefit like this, it is only polite for the pharmaceutical companies to send a thank you note. This thank you note was in the form of a multi-million dollar ad campaign. While the U.S. Chamber of Commerce officially takes credit for the ad campaign praising lawmakers for supporting the program, the Pharmaceutical Research and Manufacturers of America actually has footed the bill.

Update: I know more places are linking to blog posts, but was surprised upon checking the stat counter to find that even sites such as this include blog posts along with investment information on companies.

Related stories under the fold.

NY Times Reports on Insurance Company Windfalls From Bush Medicare Plan

Posted by Ron Chusid
July 18th, 2006 @ 10:47 am

The New York Times reports what I’ve been saying ever since the Medicare prescription drug plan was proposed–that it is a windfall for the pharmaceutical companies. The New York Times report on the increased profits due to shifting the costs for medications for people who are in both Medicare and Medicaid to Medicare. Medicaid programs typically negotiate reduced charges for medications, but Medicare is legally prohibited to negotiate reduced charges for medications in Bush’s plan. This is particularly strange considering that Medicare pays reduced fees for everything else they pay for.

In addition to receiving their full charges for medications previously sold at a discount, pharmaceutical companies are also making more money as the previously provided some medications for people who could not afford them, but did not qualify for Medicaid, through patient assistance programs. Most of those plans no longer exist.

Besides the pharmaceutical industry, the other big winner is the insurance industry. Bush’s Medicare legislation also provides for increased subsidies to insurance companies to offer Medicare HMO’s. Care provided by such HMO’s costs significantly more than similar care provided by the Medicare program.

Lack of Choice in Health Care

Posted by Ron Chusid
May 11th, 2006 @ 12:42 pm

Opponents of change in health care often claim that any plan with increased government involvement would lead to a government take over of health care, resulting in decreased choice. An AMA study has shown how little choice we actually have under the current system of private health plans. The report reviewed in the May 8 issue of American Medical News (available on line to subscribers only) found that of 294 metropolitan areas all but fifteen markets in six states had two plans controlling at least 50% of the market. Even these fifteen markets weren’t much better with two plans controlling at least 40% of the market.

When one or two HMO’s or PPO’s dominate the market to this degree it takes away leverage from businesses purchasing the plans, patients, and doctors, leaving the health plans free to set their own rules. This lack of competition also contributes to the steady increase in premiums, leading to more businesses dropping coverage. From personal experience, such dominant health plans are typically much more restrictive than the government plans such as Medicare. Conservatives argue for the preservation of the current system claiming that the market provides more choice than government plans, but in reality the current system is limiting choice and consolidating decisions in large corporations who show more concern for profits than the needs of patients.

One in Five Pay More Under Medicare Drug Plan

Posted by Ron Chusid
April 27th, 2006 @ 10:23 pm

The major problem with the Medicare prescription drug plan is that it primarily helps the pharmaceutical and insurance industries, while providing some benefits for those on Medicare. Not everyone benefits. USA Today presents polls suggesting that about one in five Medicare beneficiaries have higher out of pocket expenses now than previously. This includes people on Medicaid who previously had no copays and now have to pay $1 to $5 per drug, and people who received their medications free from pharmaceutical companies through patient assistance programs. While these polls might not give an accurate count of the number who pay more, this is a definate problem which I’ve encountered with several patients.

Media Finally Catches On To Loss of Patient Assistance Programs

Posted by Ron Chusid
March 5th, 2006 @ 10:31 pm

Much of the factual information posted here comes from the news media, but sometimes we are ahead of them. In discussing the Medicare prescription drug program, I have warned multiple times (starting last fall, and most recently here) that the program would lead to higher costs for many people on Medicare due to no longer receiving free medications from pharmaceutical companies through patient assistance programs. AP caught on to this today. Most of these people do qualify for assistance which provides the Medicare benefits at a discounted cost, but I am finding that many patients are winding up with higher out of pocket costs than previously due to stricter criteria for these benefits than were present in the patient assistance programs.

Now that the media has caught on to this, perhaps they will start to put together the full picture as to how prescription drug program was designed to be a financial windfall for the pharmaceutical and insurance industries rather than to benefit Medicare beneficiaries. Besides receiving payment for medications which they previously provided free through patient assistance programs, pharmaceutical companies are also receiving increased income due to the inability of Medicare programs to negotiate lower fees. The bulk of those signing up for the program previously qualified to receive their medications through Medicaid programs which did negotiate lower prices. The insurance industry benefits from subsidies to Medicare HMO’s which cost more than the government-run program to provide health care, despite cherry picking healthier patients.

Drug Prices Rise Under Medicare Prescription Drug Plan

Posted by Ron Chusid
February 28th, 2006 @ 4:24 pm

Democrats are looking closely at problems with the Medicare drug program including enrollment difficulties and delays in reimbursement to pharmacies. Perhaps the most alarming problem is the increase in drug prices since the plan began last month:

Prices for some of the most popular medicines used by seniors have jumped an average of 4 percent under the new Medicare drug benefit since it began last month, according to a report released on Tuesday.

The report, released by the Democratic staff of the House of Representatives Government Reform Committee, found prices for Pfizer Inc.’s pain reliever Celebrex, Merck Inc.’s cholesterol drug Zocor and eight other top drugs offered by 10 major plans rose during the controversial program’s first seven weeks.

In some cases, drug prices rose 10 percent, it also found. . .

Tuesday’s report found Caremark Rx Inc.’s Silverscript Plus plan raised prices 10.2 percent. Under Humana’s Standard PDP plan, prices rose 3 percent, while they rose 4 percent under AARP’s Medicare Rx plan.

Of the 10 plans reviewed, Avantra’s RX Premier plan was the only one to cut prices, an average of 1.1 percent.

A second report, also released by committee Democrats, found current prices offered by plans are higher than those offered during the last two years with Medicare’s temporary drug cards.

The plan has also been a financial windfall for the pharmaceutical industry as the majority of those who enrolled in the program are low income seniors who also have Medicaid. Many previously received their prescriptions through Medicaid programs which negotiated discount prices while the Medicare program is prohibited from obtaining such discounts. Many others who have enrolled previously received their prescriptions at no charge from the pharmaceutical companies through Patient Assistance Programs.

The big winners under the Medicare Part D program have been the pharmaceutical and insurance industries, both large contributors to George Bush. Insurance companies benefit from the subsidies paid to private insurance companies to cover Medicare patients in Medicare HMO’s, which typically cost more than the government program to provide health care coverage.

John Kerry on the Medicare Drug Plan

Posted by Ron Chusid
January 28th, 2006 @ 2:37 pm

Fix Medicare prescription drug law
The Lowell Sun

Senator John F. Kerry

Two years ago, President Bush signed the new Medicare prescription-drug benefit into law amid much hype and fanfare. But now the only cheers are from the special interests. Insurance and pharmaceutical companies are thrilled with their profits, but Massachusetts seniors now attempting to fill their prescriptions are finding nothing more than broken promises.

Seniors know a bad deal when they see it. That’s why Massachusetts seniors and Democrats in Congress joined together to oppose this fatally flawed proposal when it was first introduced on Capitol Hill. Now, we’re reminded that this Bush boondoggle is an even bigger real-life nightmare for seniors than we ever could have imagined. The time has come to renew our efforts to go back to the drawing board, fix this legislation and deliver real relief to seniors.

Medicare was enacted 40 years ago as a promise to the American people that, in exchange for their years of hard work and service to our country, their health care would be guaranteed in their golden years. America’s seniors deserve a comprehensive and affordable health-care system — and that includes a guaranteed, simple and affordable prescription-drug benefit. The Bush prescription-drug plan fails to meet that standard. In fact, the Medicare prescription-drug law does more harm than good. Massachusetts seniors can attest to that.

Seniors were first subjected to the dizzying task of choosing a plan among a slew of competing programs. Yet among the countless pages of confusing information, seniors could not find out the one thing they really wanted to know: Would their drugs be covered under this plan? I know accomplished health professionals who were unable to help their parents navigate the maze of paperwork and regulations.

To make matters worse, seniors are not only locked into the first plan they choose; they face a financial penalty for delaying that choice. Every day my office receives hundreds of calls from nervous, confused and worried seniors — and they have every right to be concerned — their options are incredibly confusing, and the government is burdening them with unnecessary pressure on their time and finances.

Even the seniors lucky enough to make sense of this new plan understand that this prescription benefit was falsely advertised. They realize this law, despite all the promises, uses a series of holes in coverage and complex rules to provide shockingly skimpy benefits. Now that we’re seeing the results, our worst fears have been confirmed: wide gaps in coverage, seniors being forced into HMO-style plans, and no price controls. Eventually, elements of this law may even lead to the privatization of Medicare.

Our seniors deserve better than this. If Republicans in Congress are unwilling to scrap Part D altogether and start over, we must at least perform some major surgery on the current law. To begin, we must:

* Simplify the rules, streamline choices, require more transparency, and extend deadlines for making decisions about coverage options.

* Make the benefit comprehensive and end the outrage of charging seniors premiums even after their benefits shut down.

* Restrain double-digit drug price increases and lower out-of-pocket costs for seniors by allowing the federal government to use its bulk purchasing power to negotiate volume discounts on behalf of all beneficiaries.

* Allow for the safe re-importation of affordable prescription drugs from Canada and other industrialized countries.

* Improve the protections for retiree benefits. Millions of seniors are projected to lose their gold-plated retiree prescription-drug plan and be forced into a lesser benefit under the Medicare plan. This is wrong and we must prevent it from happening.

* Cancel the unprecedented $12 billion slush fund to entice private insurance companies to participate in Medicare. If private companies are unwilling engage in fair competition for customers, the federal government should stand ready to offer a plan as a part of its Medicare package. The $12 billion is better used investing in an expanded benefit for seniors than in a massive corporate handout.

Affordable health care is not a privilege for the elected, the connected and the wealthy; it should be a right afforded to all Americans regardless of their background or social standing. The Medicare Modernization Act of 2003 soundly rejects this principle, and we have to pass serious reforms now to repair this program before it becomes entrenched. Our goal should be nothing more and nothing less than assuring that a Medicare prescription drug plan actually does what it’s supposed to do: conveniently provide affordable prescription drugs to all seniors.

Sen. John Kerry has represented Massachusetts in the U.S. Senate since 1984.

John Edwards on Medicare Drug Program

Posted by Ron Chusid
January 11th, 2006 @ 2:08 am

(Following is an email from John Edwards on the Medicare drug program. I agree with Edwards as to the problems, and his solutions would be a step in the right direction, but there is a better overall solution. The current program should be eliminated and replaced by a program within Medicare to provide prescription drug coverage without providing huge government benefits to the pharmaceutical and insurance industries.)

Medicare Corruption Taking a Toll on Our Seniors

Dear Friend,

We all know somebody — a parent, a grandparent, an older friend we talk to around the neighborhood — who is struggling to make heads or tails of the Republican Medicare prescription drug law. It’s just completely confusing, and I know it’s not the best that we can do for our seniors. It may, however, be the best we can do for the pharmaceutical industry, which should be no surprise since it was practically written by the big drug companies.

There’s a lesson to be learned: bad policy that puts special interests before the American people is the cost of the culture of corruption that pervades the Republican Congress and the White House. It is a lesson we see played out in the newspapers each morning and on the television news each night.

Democrats fought against this Medicare sham at the time, and now we’re offering three important solutions that could be implemented NOW: 1) Extend enrollment by six months to allow America’s seniors to make sense of the confusing options before they have to select the option that works best for them, 2) Allow re-importation of safe FDA approved drugs from Canada, which should bring down the costs of drugs in this country, and 3) Allow Medicare to bargain for lower prices on behalf of all Americans. It is particularly offensive that the drug company-written Medicare prescription drug law actually prohibits the government from negotiating with those companies for lower prices.

Today, I am asking you to please join my friends at the Democratic Congressional Campaign Committee (DCCC) by signing their petition to Congress:

Whether it’s you, your family, or just an elderly friend, seniors across America are wondering why providing health care cannot be simpler. The reason is clear: the bill was not made for them. It was made for the Republican special interests and, in fact, much of it was even written by the pharmaceutical industry and its legions of lobbyists. It’s particularly troubling that this program doesn’t do more for the millions of seniors who struggle with poverty every day. Instead of looking out for the people who need our help the most, the Republicans sided with the people they always look out for — the powerful special interests.

Let’s look at a few numbers compiled at the time the bill was passed:

* Estimated increase in Drug Industry Profits: $182 billion
* Washington lobbyists employed by the Drug and HMO Industries: 952
* Amount spent by drug and HMO industries on lobbying in 2003: $141 million
* Political contributions from the drug industry to Republicans in 2002: $21.7 million (74% of total)
* Price of a one-month supply of Lipitor (the drug most frequently prescribed to seniors) with a Medicare Discount Card in 2003 survey: $67.07
* Price of a one-month supply of Lipitor on : $62.99

And that doesn’t even get to the confusing mess caused by the dozens and dozens of plans. It doesn’t mention the fact that while seniors are locked into a plan for a year, the providers have free rein to raise their rates at any time, which is particularly troubling for the seniors who are living below the poverty line. Meanwhile, re-importation of drugs from Canada — which even a top executive with Pfizer has said is perfectly safe — has been kept illegal to ensure pharmaceutical industry profits. And if that wasn’t enough, Medicare is barred from bargaining for lower prices like the VA does for veterans.

The bill was disgraceful when it was passed, but now the seniors among us are about to start paying the price. We have one last chance to get it right.


John Edwards

P.S. — This is about what kind of country we want to live in — do we want to stand together to make sure our seniors don’t have to choose between medicine and food, or will we instead allow the pharmaceutical companies to pad their wallets and to pay their lobbyists to keep Congress in their pockets?

I hope you’ll stand with me and the DCCC in telling Congress to do the right thing.

Boston Globe Identifies Flaws in Medicare Prescription Plan

Posted by Ron Chusid
December 31st, 2005 @ 12:53 am

The Boston Globe has an excellent summary of the problems we are seeing so far with the Medicare prescription drug plan. The problem stems from the initial political goals:

It was clear back in 2003, when the Bush administration rammed this bill through the Republican Congress, that the purpose was not to devise an affordable prescription drug program for seniors. Rather the administration wanted to help two friendly industries, the pharmaceutical companies and the HMOs, and to get bragging rights for the 2004 election that President Bush had helped seniors. Few voters would grasp just how bad the law was, since its effective date was deliberately put off until 2006.

They provide more information on how the plan both provides inadequate benefits for beneficiaries and increases profits for pharmaceutical companies. It should be added that, while the plan is very poorly designed, many who qualify should still strongly consider signing up. The plan is better than nothing for most, and the penalties for signing up after May make it a better deal to sign up by then.

The column has a number of recommendations for improving the plan:

First, get rid of the costly crazy-quilt of private programs and bring the ‘’Medicare” drug program back into public Medicare.

Second, allow Medicare to negotiate bulk discounts the way the VA does.

Third, get rid of the doughnut hole, and design a simplified benefit structure with modest copays and then 100 percent coverage after a set annual cap on out-of-pocket costs.

Finally, if the savings from the bulk price discounts are not quite sufficient to cover the costs of filling in the doughnut hole, take back a little of Bush’s tax cuts to the richest 1 percent.

I have already encountered a number of problems while assisting patients in signing up for the plan. I’ll wait until January, when the plan is actually in operation, to discuss this in more detail.

Medicare Drug Program Carries High Costs

Posted by Ron Chusid
November 22nd, 2005 @ 11:29 pm

The Washington Post looks at one of the problems of the Medicare prescription drug program: “The new Medicare drug benefit fails to deliver drug prices as low as those found at the Department of Veterans Affairs, in Canada and at high-volume U.S. pharmacies, a congressional report said yesterday.”

“The prices offered by the Medicare drug plans are higher than all four benchmarks, in some cases significantly so,” the report concluded. “This increases costs to seniors and federal taxpayers and makes it doubtful that the complicated design of Medicare Part D provides any tangible benefit to anyone but drug manufacturers and insurers.”

While I agree that the plan was written as a form of corporate welfare for the pharmaceutical and insurance industries, this opinion that it does not provide any benefits to anyone goes too far. While Medicare beneficiaries could have been offered a much better plan more economically, for many this is still an improvement over no coverage.

Unless someone on Medicare both has private coverage and received documentation that the plan qualifies as a credible plan under the current law, most Medicare beneficiaries would benefit from signing up. Just keep in mind when doing so that the Republicans may be giving a program with some benefits, but you could have received so much more if not for the manner in which the program was devised to help the insurance and pharmaceutical industries.

Krugman on the Deadly Doughnut

Posted by Ron Chusid
November 11th, 2005 @ 9:40 pm

This doughnut is one of the many flaws in the Medicare prescription drug plan. Paul Krugman tears apart Bush’s Medicare prescription drug plan:

At first, the benefit will look like a normal insurance plan, with a deductible and co-payments.

But if your cumulative drug expenses reach $2,250, a very strange thing will happen: you’ll suddenly be on your own. The Medicare benefit won’t kick in again unless your costs reach $5,100. This gap in coverage has come to be known as the “doughnut hole.” (Did you think I was talking about Krispy Kremes?)

One way to see the bizarre effect of this hole is to notice that if you are a retiree and spend $2,000 on drugs next year, Medicare will cover 66 percent of your expenses. But if you spend $5,000 – which means that you’re much more likely to need help paying those expenses – Medicare will cover only 30 percent of your bills.

A study in the July/August issue of Health Affairs points out that this will place many retirees on a financial “roller coaster.”

People with high drug costs will have relatively low out-of-pocket expenses for part of the year – say, until next summer. Then, suddenly, they’ll enter the doughnut hole, and their personal expenses will soar. And because the same people tend to have high drug costs year after year, the roller-coaster ride will repeat in 2007.

How will people respond when their out-of-pocket costs surge? The Health Affairs article argues, based on experience from H.M.O. plans with caps on drug benefits, that it’s likely “some beneficiaries will cut back even essential medications while in the doughnut hole.” In other words, this doughnut will make some people sick, and for some people it will be deadly.

The smart thing to do, for those who could afford it, would be to buy supplemental insurance that would cover the doughnut hole. But guess what: the bill that established the drug benefit specifically prohibits you from buying insurance to cover the gap. That’s why many retirees who already have prescription drug insurance are being advised not to sign up for the Medicare benefit.

If all of this makes the drug bill sound like a disaster, bear in mind that I’ve touched on only one of the bill’s awful features. There are many others, like the clause that prohibits Medicare from using its clout to negotiate lower drug prices. Why is this bill so bad?

The probable answer is that the Republican Congressional leaders who rammed the bill through in 2003 weren’t actually trying to protect retired Americans against the risk of high drug expenses. In fact, they’re fundamentally hostile to the idea of social insurance, of public programs that reduce private risk.

Their purpose was purely political: to be able to say that President Bush had honored his 2000 campaign promise to provide prescription drug coverage by passing a drug bill, any drug bill.

Krugman shows some faults in the plan, as well as some of the political motivation behind this sham. He leaves out one important fact–most likley something he realizes but he could not get everything in one article. The Medicare drug bill was never intended to provide benefits for Medicare beneficiaries. This was written by opponents of the Medicare program to attempt to destroy the program while providing corporate welfare to the pharmaceutical and insurance industries.

Only in Bush World does the government prefer to provide welfare to pharmaceutical and insurance companies as opposed to elderly people who are having difficulty paying for their medications.

Republican Senators Right on Medicare Cut

Posted by Ron Chusid
November 4th, 2005 @ 5:02 pm

Yes, you read that headline right. I realize that the gut reaction by any Democrats to Republican Senators making a cut in Medicare would be opposition, until they understand the specifics. If you doubt me on this, note that President Bush is threatening to veto the bill containing the spending cuts. That’s George Bush, who has yet to veto anything. If he is threatening to veto a bill containing a cut, you can be sure that money is really a case of corporate welfare for his supporters and not money which benefits Medicare patients.

The cuts proposed by the Republican Senators which I support are the subsidies to the Medicare Advantage program–not the traditional Medicare program which, if anything, should receive more funds.

Medicare Advantage is a plan to privatize Medicare by providing extra money to private insurance companies to handle Medicare patients. Despite placing more restrictions on patients and physicians, it costs more money to treat patients in a Medicare HMO than in the traditional Medicare program. One provision Bush added to the Medicare prescription drug program was to pay private companies extra money so that they can make money doing what the government does better and more efficiently.

Historically Medicare HMO’s have been a disaster. Typically companies would find that they could not make enough money providing health care to the Medicare population, and would drop the program, leaving beneficiaries abruptly without coverage. Even if all things were equal and they didn’t require subsidies to remain in business, it is a poor idea. Ultimately it is far more efficient to have all seniors in the traditional Medicare program where there is a single set of regulations and a single method of claims submission.

Due the increasing deficit, and the need to pay for Iraq, Katrina rebuilding, and their next tax cut to the ultra-wealthy, some Republican Senators have decided that there is no point in providing the insurance industry this subsidy. The are right, except that rather than just cutting subsidies to companies participating in Medicare Advantage, the program should be abolished.

How Pharmaceutical Companies Restrict Information

Posted by Ron Chusid
August 5th, 2005 @ 10:30 am

While the editorial pages of the Wall Street Journal consistenly takes the corporate Republican line, the news pages often do show what is really going on in the world. Today they provide insight into how pharmaceutical companies influence prescribing of their medications. The article looks at Eli Lily and Cymbalta, but this applies to other pharmaceutical companies as well.

From TV commercials to pitches in doctors’ offices, drug companies try to cast their products in the best possible light. Some use a far less visible approach: contractual restrictions on what insurers, hospitals and other health facilities can tell doctors about certain drugs.

Drug makers commonly offer price breaks to insurers, hospitals and other medical facilities. In exchange, they often get favorable placement on drug formularies, the lists these entities use to encourage prescriptions of certain products. Some of the contracts go further, restricting insurers and medical organizations from making unflattering statements about the costs and risks of drugs when they communicate with health practitioners.

A case in point is the discount contract Eli Lilly & Co. has offered health facilities in connection with Cymbalta, an antidepressant that the Food and Drug Administration approved last year and that faces competition in some cases from cheaper generics. The contract illustrates tactics that some insurers and prescribers say they find troubling.

The Cymbalta discount contract offers large purchasers of antidepressants a 5% discount, but specifies that they could lose most of that discount if they engage in, among other things, “negative D.U.R. correspondence to physicians.”

While not defined in the contract, D.U.R. is industry shorthand for “drug utilization review,” a kind of analysis of prescription patterns that insurers often use to identify inappropriate or risky practices and often also to cut costs. Prime Therapeutics LLC, an Eagan, Minn., pharmacy-benefits manager owned by nine Blue Cross Blue Shield plans, used drug utilization reviews to try to reduce what it determined was overprescribing of Vioxx and Bextra, painkillers that were later pulled from the market because of safety concerns.

The article later discusses further restrictions on communication:

Also restricted under the Cymbalta contract is “negative educational counterdetailing.” Counterdetailing is the industry name for efforts, often made by insurers, to counterbalance drug makers’ sales pitches (which are often referred to as “detailing”). Counterdetailing efforts commonly push patients toward generics or poke holes in drug makers’ claims about their products.

People in the drug industry say counterdetailing often serves to steer patients toward cheaper drugs. Counterdetailing “language is probably in everyone’s contracts,” says Jack Cox, a spokesman for Pfizer Inc., New York. He declines to comment on Eli Lilly’s or Pfizer’s practices specifically, but adds that insurers and others who make drugs available to patients “will come in with clinical data, but their goal is financial.”

Information from insurance companies sometimes also appears biased towards their goals of reducing costs. It would be best if all parties remained free to provide their best arguments, preferably supported by scientific data, and to allow physicians to decide upon the prescription with all information available.

States Rebelling Against Medicare Drug Plan

We’ve known all along that Bush’s Medicare prescription drug plan was actually a massive act of corporate welfare to benefit the pharmaceutical and insurance industries. The states are finding that it is also a new trick to get money out of them and into the federal treasury. While Republicans will not openly raise taxes, they will make virtually everyone pay more, even if hidden in state taxes.

The New York Times describes how states are rebelling. In theory the state governments might have saved money due to being relieved of some of the burden of paying for prescription drugs for Medicaid beneficiaries who are also on Medicare. The Medicare act does require that, in return for these benefits, the states make payments to the Medicare Trust Fund. State governments are now finding that these payments, along with administrative costs, are greater than the benefits they expect to receive.

Just as some states are rebelling against the unfunded mandates of No Child Left Behind, states are starting to rebel against the required Medicare payments.  Texas is leading this rebellion as the Republican Governor has vetoed a $444 million appropriation covering their contribution for the next two years.

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