Healthcare

The Beltway Bandit Behind the Healthcare.gov Debacle

Healthcare.gov website down A January 2011 article in Canada’s Globe and Mail was headlined “CGI Spies Opportunity in Obama’s Call for Efficiency.” A new story in the same newspaper about the same company has the title “Canadian IT Firm at Centre of Obamacare Foul-Up Furor.”

U.S. critics of the Affordable Care Act are depicting the widespread computer problems that have accompanied the launch of the ACA’s online healthcare exchanges as a major government failure. To be more precise, it is a failure of government contracting. And the contractor at the center of the mess is CGI Group, a Canadian outsourcing corporation that is little known outside information technology circles.

According to a Government Accountability Office report published in June, CGI’s U.S. subsidiary CGI Federal received the largest share (totaling $88 million) of the contracts awarded for the creation of the Healthcare.gov website, the ACA enrollment portal in the 36 states that declined to create their own exchanges. That report, by the way, warned of possible “implementation challenges.”

The glitches in the ACA rollout are shining an unfavorable light on the widespread practice by governments at all levels of contracting out information technology to the private sector. The Washington Post just published a front-page story reporting that the federal government, which spends some $80 billion a year on outside IT services, ends up purchasing “outdated, costly and buggy technology.” This may be an indication of cluelessness on the part of federal IT procurement officials, but it is also a sign that the private sector is all too willing to take taxpayer dollars for inferior products.

It is not yet clear whether CGI tried to use sub-standard technology for Healthcare.gov or whether it just failed to meet the challenges of creating a complex new system. The company and the feds are saying little about the reasons for the glitches, preferring to issue assurances that everything will soon be running smoothly.

The Post notes that “Federal officials have not yet explained why CGI was given the contract or why it was awarded on a sole-source basis.” They might also want to explain why the contract was given to a company linked to some earlier contracting scandals.

CGI has built its U.S. operation in large part by acquiring existing federal contractors. One of those was Stanley Inc., which it purchased in 2010 for about $900 million. Two years earlier, Stanley found itself under fire when it was reported that some of its employees working on a contract with the U.S. State Department had improperly looked at the passport records of several Presidential candidates, including Barack Obama.

Stanley was also involved in a controversy over its labor practices at the 400-worker processing center of the U.S. Citizenship and Immigration Services in St. Albans, Vermont. As it was about to assume control over the facility, which handles citizenship applications, Stanley announced that it would change job classifications at the facility, resulting in a pay decrease of about 12 percent for up to half the workers. Vermont Sen. Bernie Sanders called on the Labor Department to investigate what he charged was a violation of the Service Contract Act.

Stanley’s move also prompted a union organizing drive by the United Electrical workers. UE official Chris Townsend told me at the time that Stanley was employing a variety of union-busting tactics—from hiring the union-avoidance law firm Seyfarth Shaw to forcing workers to watch propaganda videos. Townsend said workers were held in captive-audience meetings for up to one-quarter of their shifts in the period leading up to the elections—this at a time when the backlog of citizenship applications was a serious problem. Despite these obstacles, UE managed to win representation elections covering most of the workers. In 2011 the U.S. Department of Labor announced that Stanley (by then owned by CGI) and several subcontractors would pay nearly $2.9 million in back wages for workers who had been misclassified.

CGI itself has also had its share of scandals, including a 2007 furor over a C$400 million contract it received from the Canadian government at a time when the Public Works Minister was Michael Fortier, who had been an investment banker for CGI during his time working for Credit Suisse. A 2010 report by the Hawaii State Auditor found that what was supposed to be a five-year contract awarded in 1999 by the state department of taxation to a company later purchased by CGI had been repeatedly extended through non-competitive awards, costing the state far more than originally planned.

The federal government long ago chose to depend on contractors for its vast information technology needs. That decision periodically results in debacles like those surrounding the rollout of the ACA exchanges. It remains to be seen whether fiascoes will also mar the actual insurance coverage being provided through the ACA, which also relies on the supposedly efficient private sector.

UPDATE: I subsequently learned that in September 2012 the Toronto Star reported that the government of Ontario had canceled a C$46 million contract awarded to CGI to create a diabetes registry after the company failed to meet deadlines.

The ACA Employer Penalty Gap

walmart_jwj_subsidies Along with the scandalous number of the uninsured, one of the biggest healthcare outrages in the United States is the ability of large companies employing low-wage workers to avoid providing reasonable group coverage, letting those employees enroll instead in public programs such as Medicaid.

Those programs were meant for poor people not in the labor force or those working for marginal employers. In the absence of any legal obligation to provide workplace coverage, giant prosperous corporations such as Wal-Mart exploit the public programs and thus shift costs onto taxpayers.

A recently updated report by the Democratic staff of the U.S. House Committee on Education and the Workforce estimates that the workforce of a typical Wal-Mart Supercenter costs taxpayers some $250,000 a year in Medicaid costs (as part of at least $904,000 a year in overall safety net costs per store).

One might think that this is going to change under the Affordable Care Act that is gradually taking effect. While the law contains a requirement for individuals to have coverage, there is no real employer mandate to provide that coverage to workers. Instead, the ACA imposes penalties on certain employers for failing to provide affordable and inadequate coverage. Yet there are no fines levied when a boss pushes a worker onto the Medicaid rolls.

In fact, the ACA’s provisions encouraging states to adopt expanded Medicaid coverage, while a good thing for the uninsured, will make it easier for low-wage employers both to avoid providing group coverage and to escape penalties for doing so. This largely overlooked fact is worth keeping in mind when businesses complain about the supposedly onerous employer penalties in the ACA—penalties whose implementation the Obama Administration announced in July will be delayed for a year. (Also being delayed, we just learned, are provisions limiting the out-of-pocket costs insurance companies can impose.)

The ACA’s employer penalties have an exceedingly narrow scope. They will apply only when an employee of a firm with 50 or more full-time workers (the law’s definition of a “large” employer) seeks non-group coverage from an insurance company through one of the new state Exchanges that are being constructed and the employee qualifies for a premium or cost-sharing subsidy based on his or her household income.

Those individual subsidies are available only for workers whose household income is between 100 and 400 percent of the federal poverty line (FPL) for their family size and whose employer either fails to provide any group coverage or provides coverage that is unaffordable or inadequate. Coverage for people in that income range is deemed unaffordable if the premium (for self-only coverage) exceeds 9.5 percent of household income or the plan covers less than 60 percent of medical costs.

This means that employers of people earning less than the FPL or more than 400 percent of the FPL face absolutely no risk of penalties for failing to provide decent coverage, while the workers in those income ranges are denied subsidies from the Exchanges. Those earning less than the FPL may or may not be eligible for Medicaid, depending on the state. Those earning more than 400 percent of the FPL are not eligible for Medicaid in any state.

Penalties may also not apply when “large” employers fail to provide affordable coverage to those in the 100-400 percent of FPL range. That’s because some of those workers will for the first time qualify for Medicaid if they live in a state that accepts the optional federal incentives in the ACA for expanding Medicaid eligibility.

Do those conservative state legislators refusing to go along with Medicaid expansion realize that they are increasing the likelihood that employers will have to pay ACA penalties?

Some concern has been expressed about the potential coverage gap for those low-income families which are not eligible either for an Exchange subsidy or Medicaid, but much less attention has been paid to what amounts to an employer penalty gap.

A primary aim of the ACA is to reduce the ranks of the uninsured, but the rejection of a single-payer system means that workplace-based coverage needs to be strengthened. That should have meant a rigorous employer mandate. Instead, the ACA went with a pay-or-play system whose penalties turn out to be full of holes. Companies such as Wal-Mart may thus find it easy to continue shifting their healthcare costs onto the public.

At the state level, one of ways activists have sought to fight such cost-shifting has been to push for the disclosure of data showing which companies account for the largest number of enrollees in Medicaid and other public plans. Such shaming lists have been published for about half the states, with Wal-Mart or McDonald’s typically appearing at the top.

The ACA will require “large” employers to file reports indicating whether they provide group coverage (the effective date of this has also been pushed back). There is no indication in the ACA itself whether these reports can be made public, but given that they will be submitted to the IRS, it is likely that they will be treated as confidential. Not only does the ACA fail to impose a real employer mandate; it also appears to miss an opportunity to shame those freeloading employers which expect taxpayers to pick up the tab for their failure to provide decent coverage.

Cadillacs versus Corollas in the Healthcare Debate

solidgoldcadillac Over the past couple of years it has appeared that critics of the Affordable Care Act were virtually all die-hard Tea Party types who couldn’t accept reality, including a ruling of the U.S. Supreme Court.

We are now seeing reminders that those who have misgivings about the ACA are not only those misguided souls who believe it amounts to a government takeover of healthcare.

One group that had raised objections to at least part of the plan are now finding that a compromise they made is coming back to haunt them. That group is the labor movement, particularly public sector unions, which had questioned the dubious decision of Senate Democrats and the Obama Administration to include an excise tax on higher-cost health plans when drafting the ACA; the provision was designed to help fund the costs of subsidizing new coverage for the uninsured.

That decision was particularly galling because Obama had strongly opposed John McCain’s proposal for health plan taxation during the 2008 Presidential campaign. Unions denounced the provision, but in early 2010 they agreed to support a modified version of it. The modifications included a delay in its effective date (until 2018 for plans covering state and local government employees or ones covered by collective bargaining agreements) and an increase in the threshold levels above which the tax would apply.

The issue has been little discussed during the past three years, but now there are reports that local governments across the country are using the coming excise tax to pressure public employee unions to accept less expensive coverage—i.e., plans in which the worker pays more and gets less—or face the prospect of other contract concessions or layoffs.

What the proponents of the excise tax chose to ignore is that unions, especially in the public sector, have often focused on negotiating better benefits because significant wage increases were not possible, either for political or fiscal reasons. In other words, better benefits were not a giveaway to public unions, as anti-government types like to claim, but rather a form of compensation for insufficient pay rates.

When the excise tax was being debated in 2009, proponents misleadingly referred to it as applying only to “Cadillac” plans. It was meant to give the impression that only luxurious coverage of the type offered to corporate executives would be affected. Now it appears that those who drive Corollas may get hurt most by the provision.

The labor movement is also worried that the ACA will weaken the multiemployer benefit plans that some unions negotiate for their members. The concern is that unionized small employers participating in those plans will be end up in a competitive disadvantage compared to non-union competitors which will be able to purchase lower-cost group coverage through the Exchanges being created by the ACA.

Last month the Wall Street Journal reported that the heads of three major unions—the Teamsters, the Food and Commercial Workers and Unite Here—were trying to get the Administration to do something about ACA’s impact on multiemployer plans but were being “stonewalled.” The unions are also concerned that the law prevents low-wage workers in group plans from gaining access to the premium and cost-sharing subsidies that will be available to those who purchase individual coverage through the Exchanges.

The lack of action in response to labor concerns contrasts with the surprise announcement last month by the Administration that it was delaying the implementation of the ACA provisions imposing financial penalties on certain employers that fail to provide affordable group coverage to their workers. The post on the White House website was entitled WE’RE LISTENING TO BUSINESSES ABOUT THE HEALTH CARE LAW.

Despite the scare-mongering that has been going on in parts of the media, the penalties for failing to provide group coverage (or for providing unaffordable coverage) are far from onerous. To begin with, they don’t apply to employers with fewer than 50 full-time workers, and the penalties don’t actually kick in unless there are more than 80 full-timers. Penalties are calculated according to the number of full-timers only, ignoring part-timers and seasonal workers.

And the penalties don’t apply at all unless one of the workers denied affordable group coverage on the job qualifies for a premium or cost-sharing subsidy when purchasing individual coverage through an Exchange. Those subsidies will not be available to anyone with household income above 400 percent of the federal poverty line. This means that even larger employers that fail to provide decent coverage but whose pay rates are somewhat above poverty levels may be able to skirt the penalties entirely.

Perhaps the Obama Administration should be listening a bit less to business and more to workers and their unions.

Obamacare’s Dangerous Dependence on the Private Sector

After holding out as long as possible in the hope that Mitt Romney would be elected and the Affordable Care Act would be repealed, various red states are now being forced to decide whether they will set up the insurance exchanges mandated by the act or let the federal government do it for them. While this is a defeat for die-hard opponents of Obamacare, it is a windfall for a group of companies that regard the exchanges as a huge business opportunity.

Those companies are not just the private health insurance carriers, whose continued existence was guaranteed by Obamacare’s rejection of both single payer and the public option, and whose services will be hawked on the exchanges. It turns out that the creation of the exchanges, whether done under the auspices of a state or the feds, will involve private contractors.

Some of the states that have already opted to set up their own exchanges are doing so with the help of corporations that make a business out of government services. For example, California awarded a $359 million contract to consulting giant Accenture. Xerox got a $72 million contract from Nevada, and Maximus was awarded $41 million by Minnesota.

Maximus is also reported to be among those companies competing for a federal contract that may be awarded to help the tardy states catch up. This would be in addition to several hundred million dollars in contracts already awarded by the Department of Health and Human Services to three contractors to help build the federal exchange.

While it is dismaying to see large amounts of taxpayer money going to the private sector for what is supposed to be a public service, it is even more dismaying to see which companies are at the front of the gravy train.

Take the case of Maximus, which was established in the 1970s but whose business really took off in the wake of the welfare “reform” of the 1990s. Among other things, the Personal Responsibility and Work Opportunity Act opened the door to state government use of contractors to administer public assistance and other social programs. The annual revenues of Maximus soared from $88 million in 1995 to $487 million in 2001.

That was great for its executives and shareholders, but taxpayers and participants in the social programs the company helped administer were often less enthusiastic. Maximus ended up at the center of one controversy after another as its performance faltered and its promises of vast savings from contracting-out frequently failed to materialize.

For instance, after Maximus took over In Connecticut’s program of child-care benefits for poor families in 1996, the system soon fell into such as state of disarray that the New York Times published an article about the situation headlined IN CONNECTICUT, A PRIVATELY RUN WELFARE PROGRAM SINKS INTO CHAOS.

In Wisconsin, where former Gov. Tommy Thompson put Maximus in charge of the state’s welfare-to-work program, a legislative audit found that the company was using public money for unauthorized purposes such as staff parties. At the same time, Maximus was found to be doing a poor job in getting clients into full-time jobs.

Maximus has also been accused of filing false claims with the federal government for its state and local clients. In 2007 the company had to pay $30.5 million to resolve Medicaid fraud charges related to its contract with the District of Columbia.

In Texas, Maximus was embroiled in a scandal relating to work directly relevant to health insurance exchanges. In 2005 the Texas Access Alliance, an entity formed by Accenture and Maximus, received a whopping $899 million contract from the state to develop a social services enrollment system. It turned out to be a disaster. There was a high volume of glitches in the computer system and poor performance by the related call centers. The Alliance eventually lost the contract and was sued by the state. The case was settled under a deal in which the Alliance agreed to forgo $70.9 million in payments and Maximus agreed to pay $40 million in cash and provide a $10 million credit against future work.

The rollout of the Obamacare insurance exchanges is already operating on a tight deadline. It is difficult to believe that the situation will get better by putting companies such as Maximus and Accenture in the picture. Using these contractors may instead provide more evidence of the Affordable Care Act’s dangerous dependence on the private sector.

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Corporate Greed is the Real Threat to Medicare

Now that fiscal hatchet man Paul Ryan is on the Republican ticket, the presidential race has turned into a free-for-all over the future of Medicare.

Recognizing the unpopularity of their goal of slashing entitlement spending, Ryan and Romney are instead straining credulity by painting themselves as defenders of Medicare against $700 billion in cuts scheduled under the Affordable Care Act.

This, of course, is a reprise of the tactic long used by opponents of healthcare reform of deliberately conflating Obamacare’s negotiated cuts in payments to healthcare providers with cuts in actual services to seniors.

Such obfuscation can have some success because most people continue to view Medicare solely as a government social program, when it is also a massive system of contracts that transfer more than $500 billion in taxpayer funds each year to the private sector. Medicare took the profit out of providing health insurance to seniors but it left untouched the profit motive in the delivery of their medical services. In fact, Medicare’s billions have played a central role in building the commercial healthcare industry into the leviathan it is today.

Not content with making a reasonable amount of money from serving this huge market legitimately, providers regularly try to bilk the system for more than what they are entitled to. This is not just a matter of the proverbial Medicare mills in which individual physicians or small operations charge for services provided to imaginary patients or else overbill when treating real ones.

Some of the biggest instances of Medicare fraud have been perpetuated by Fortune 500 companies such as for-profit hospital operators, medical device manufacturers and pharmaceutical producers.

Let’s start with the drugmakers, since they have been at the center of several recent cases involving the illegal marketing of their pills for unapproved purposes, which among other things results in more high-priced medications getting prescribed for Medicare patients, thus inflating system costs. A few weeks ago, Glaxo SmithKline agreed to pay $3 billion to resolve federal criminal and civil charges relating to the improper marketing of its best-selling anti-depressants.

In May, Abbott Laboratories agreed to pay $1.5 billion to settle similar charges relating to the off-label marketing of its drug Depakote. Although Depakote was approved only for treating seizures, Abbott created a special sales force to pressure physicians to use it for controlling agitation and aggression in elderly dementia patients. This was both a safety risk and an added financial burden for Medicare and Medicaid. Illegal marketing charges had previously been settled with companies such as Novartis, AstraZeneca, Pfizer and Eli Lilly—in other words, pretty much the whole industry.

Medical device makers also contribute to escalating Medicare costs by pressing doctors to use their expensive products in place of cheaper alternatives or perhaps when they are not really medically necessary. Last December, Medtronic paid $23.5 million to resolve federal charges that it paid illegal kickbacks to physicians to induce them to implant the company’s pacemakers and defibrillators. Several months earlier, Guidant paid $9 million to settle federal charges of having inflated the cost of replacement pacemakers and defibrillators for Medicare and Medicaid patients.

And then we have the for-profit hospitals. A decade ago, HCA, one of the pioneers of the industry and still its biggest player, paid a total of $1.7 billion in fines in connection with charges that it defrauded Medicare and other federal health programs through a variety of overbilling schemes. Chief executive Rick Scott—now the Republican governor of Florida—was ousted but managed to avoid prosecution.

It now looks HCA is at it again. The New York Times just published a front-page exposé of how the company—now controlled by a group of private equity firms including Bain Capital—is making fat profits through “aggressive” billing of Medicare as well as private insurers. The Times reported that HCA’s tactics are now “under scrutiny” by the Justice Department.

The debate over Medicare’s supposedly out-of-control costs is surprisingly devoid of discussion of how much of the problem is the result of aggressive billing or outright fraud by the likes of HCA, the device makers and the pharmaceutical producers. Seniors cannot be expected to suffer cuts in their benefits as long as the giant corporate healthcare providers continue to gouge the system.

The Unlikley Regulator

Since the Citizens United ruling in January 2010, it has appeared that the U.S. Supreme Court was doing everything possible to increase the dominion of corporations. Yet in its astonishing ruling on the Affordable Care Act (ACA), the Court, among other things, affirms the right of the government to put far-reaching restrictions on one of the country’s most powerful industries.

Even more remarkable is that the majority decision was written by Chief Justice John Roberts, a former corporate lawyer thought to be firmly in the anti-regulatory camp.

What made the healthcare case so unusual is that, strictly speaking, none of the parties were overtly opposing the provisions of the ACA regulating the heinous practices of the private insurance industry, such as discriminatory pricing, denial of coverage to those with “pre-existing conditions” and cancellation of coverage after a subscriber gets seriously ill. Both the oral arguments and the written opinions were filled with pro-regulation comments by normally laissez-faire-minded Justices.

Opponents of the law chose instead to focus their attack on the constitutionality of the individual mandate, which was at the heart of the deal the Obama Administration and Congressional Democrats made with the insurance industry under which the companies agreed not to fight the regulations in exchange for which they were guaranteed millions of new compulsory customers paying subsidized premiums.

Thanks to the defection of the Chief Justice based on a narrow interpretation of the mandate, the stratagem of the anti-healthcare reform camp turned out to be a colossal miscalculation. It also looks like the insurance companies have been snookered about the extent to which they will benefit from the law.

It will be of some consolation to conservatives that the Roberts opinion contains a strident rejection of the idea that Congress was justified in imposing the individual mandate through its constitutional power to regulate interstate commerce. The Chief Justice devotes many pages of his decision to a recitation of the argument that the mandate was in this sense an overreach, in the course of which he even reprises the broccoli analogy used by Justice Scalia during the hearings on the case.

Yet he then pivots and embraces, along with the Court’s four liberal justices, the secondary argument that the mandate was justified as an exercise of the taxing power of Congress, the tax being the financial penalties contained in the ACA for those without coverage who refuse to purchase individual policies.

What’s interesting is that in order to depict the penalties as a legitimate tax, Roberts has to argue that they are not overly punitive. In doing so, he writes that “for most Americans the amount due will be far less than the price of insurance, and, by statute, it can never be more. It may often be a reasonable financial decision to make the payment rather than purchase insurance.”

Roberts is thus highlighting one of the rarely discussed features of the ACA’s individual mandate: the penalties for disobeying it are far from draconian. Overheated rhetoric by the Right notwithstanding, no one will ever be thrown in jail for not having health coverage, nor will the penalties drive anyone into penury. In fact, it is not clear that the requirement will ever be enforced to any significant extent.

Moreover, any penalties that are collected will go to the Treasury, not to the private insurers missing out on premium payments from scofflaws. If enough of the defiantly uninsured realize the relatively low risks of non-compliance, the individual mandate may not create as many new customers as the insurance industry had hoped.

Of course, the ACA will create new customers from among the ranks of the uninsured who want coverage but have not been able to afford it without the subsidies the law will create. But many of these will be families who will make significant use of the coverage, as opposed to the young invincibles who never go to the doctor. In other words, the industry will end up with more of the less profitable end of the market.

Reading the Roberts opinion, one gets the impression that he was grasping for a way to uphold the ACA and rise above the unalloyed conservative partisanship that has tainted the recent history of the Court. While history may look kindly on his decision, in the shorter term he is bound to become a whipping boy for disappointed opponents of healthcare reform. Back in the 1960s rightwing fringe groups campaigned to have then-Chief Justice Earl Warren impeached for his supposedly pro-Communist rulings. Calls to “Impeach John Roberts” are already emerging from Red State America.

Whatever the Roberts legacy turns out to be, the bigger question is what will become of the U.S. healthcare system. It is encouraging that the most egregious insurance company behavior will be outlawed, but who knows what other tricks the industry will devise to torment its customers. The uproar over the ACA does not change the fact that the only real solution is to take the profit out of health coverage.

Will Big Pharma Remain Above the Law?

The recent announcement that a corporation agreed to pay $1.6 billion to settle regulatory violations would normally be considered significant news, but because the company involved was a drugmaker there was not much of a stir. That’s because Abbott Laboratories is only the latest in a series of pharmaceutical producers to pay nine- and ten-figure amounts to settle charges that they engaged in illegal marketing practices.

Abbott’s deal with federal and state prosecutors involves Depakote, which was approved by the Food and Drug Administration to treat seizures but which Abbott was charged with promoting for unauthorized uses such as schizophrenia and for controlling agitation in elderly dementia patients. The company admitted that for eight years it maintained a specialized sales force to market Depakote to nursing homes for the latter unauthorized use. In other words, it systematically violated FDA rules and encouraged doctors and nursing homes to use the drug in potentially unsafe ways.

Abbott follows in the footsteps of other industry violators:

In November 2011 GlaxoSmithKline agreed to pay $3 billion to settle various federal investigations, including one involving the illegal marketing of its diabetes drug Avandia.
In September 2010 Novartis agreed to pay $422 million to settle charges that it had illegally marketed its anti-seizure medication Trileptal and five other drugs.
In April 2010 AstraZeneca agreed to pay $520 million to settle charges relating to the marketing of its schizophrenia drug Seroquel.
In September 2009 Pfizer agreed to pay $2.3 billion to settle charges stemming from the illegal promotion of its anti-inflammatory drug Bextra prior to its being taken off the market entirely because of concerns that it was unsafe for any use.
In January 2009 Eli Lilly agreed the pay $1.4 billion—then the largest individual corporate criminal fine in the history of the U.S. Justice Department—for illegal marketing of its anti-psychotic drug Zyprexa.

The wave of off-label marketing settlements began in 2004, when Pfizer agreed to pay $430 million to resolve criminal and civil charges brought against Warner-Lambert (which Pfizer had acquired four years earlier) for providing financial inducements and otherwise encouraging doctors to prescribe its epilepsy drug Neurontin for other unapproved uses.

Soon just about every drugmaker of significance ended up reaching one of these agreements with prosecutors and shelled out what appeared to be hefty penalties. In fact, the amounts were modest in comparison to the potential revenue the companies could rake in by selling the drugs for uses far beyond what the FDA review process had deemed safe. A 2009 investigation by David Evans of Bloomberg noted that the $2.3 billion penalty Pfizer paid in connection with Bextra was only 14 percent of the $16.8 billion in revenue it had enjoyed from that drug over the previous seven years.

The company’s 2004 settlement should have been a deterrent against further off-label marketing, but, according to Bloomberg, Pfizer went right on doing it. Seeking maximum sales, regardless of restrictions set by the FDA, was an ingrained part of the company’s modus operandi. When the 2009 settlement was announced, John Kopchinski, a former Pfizer sales rep turned whistleblower, was quoted as saying: “The whole culture of Pfizer is driven by sales, and if you didn’t sell drugs illegally, you were not seen as a team player.”

Compared to other forms of corporate misconduct, such as securities violations, the drug companies are much more likely to have to admit to criminal violations in the off-label marketing cases. And the penalties are far larger than those imposed for most environmental and labor violations.

Yet these seemingly harsher enforcement practices appear not to have been very effective in putting an end to the illegal activity. In fact, the willingness of the drug industry to flout the drug safety laws raises serious questions about the effectiveness of FDA regulations and the federal criminal justice system in general. If a group of companies know that they can repeatedly break the rules and face consequences that fall far short of the potential gains from the illegal behavior, enforcement has little meaning.

What makes the situation even more outrageous is that off-label market is just one of numerous ways that the drug industry regularly violates the law—whether by defrauding federal programs such as Medicare or by covering up safety risks related to the approved uses of certain drugs.

The one thing that makes drug industry executives a bit nervous is that federal prosecutors have begun to show interest in reviving what is known as the responsible corporate officer doctrine, a provision of U.S. food and drug laws that could be used to hold executives personally and criminally responsible for violations. So far, the doctrine has been applied to only a few small fish. But if Big Pharma CEOs start appearing in perp walks, the industry may finally realize it is not above the law.

Are Free Market Ideologues and Big Business Heading for a Divorce?

Conservatives are feeling smug. The recently completed Supreme Court oral arguments on the healthcare law were replete with skepticism about the powers of the federal government and glorification of personal liberty, though what was being celebrated was the dubious right of a person to be uninsured against the risk of a catastrophic medical event.

We’ve come to assume that modern conservatism is a stalking horse for an expansion of corporate power. Yet were the interests of big business really being served by the evisceration of the Patient Protection and Affordable Care Act?

First, in their desire to invalidate the individual mandate to purchase coverage, lawyers opposing the law and conservative justices went out of their way to distinguish it from what they had to admit were the valid powers of Congress to impose taxes and regulate commerce. Nary a negative word was said about the provisions of the act that impose dramatic new restrictions on the health insurance industry relating to pricing and the denial of coverage to those with pre-existing conditions. Although the justices seemed more inclined to throw out the entire law than to simply carve out the individual mandate, they suggested they would have no problem if Congress subsequently passed new legislation that reinstated the regulations without the hated mandate.

What the justices downplayed is that the Affordable Care Act was a grand bargain with the health insurance industry in which it acceded to the new regulations in exchange for being guaranteed a vast new pool of customers whose premium payments would be heavily subsidized by the federal government. The Right has gotten so carried away with its denunciations of the Act as a government takeover that it has forgotten it is really an enormous boon to private insurers.

One member of the court who chose not to ignore this was Justice Ginsburg, who during the second day of the hearings said she found it “very odd” that the opponents of the law were conceding that the government had every right to take over entire portions of the healthcare insurance market, as with Medicare, but rejected an arrangement designed to “preserve private insurers.”

The point also came up in an exchange the same day between Justice Kennedy and Solicitor General Donald Verrilli in which Kennedy seemed to acknowledge that Congress would have the right to create a single payer system, and Verrilli responded that it was “a little ironic” that the Act was being criticized because Congress had instead decided to “to rely on market mechanisms and efficiency and a method that has more choice than would the traditional Medicare or Medicaid-type model.”

Of course, there is no guarantee that if the Affordable Care Act is struck down in its entirety, Congress will reinstate the most significant regulations on the insurance industry, much less that it will embrace single payer. But one has to wonder what the industry thinks about the position in which it will be put.

Once they made their deal with the Obama Administration, the big insurers largely stayed on the sidelines as the Right assailed the Act, purportedly in the name of free enterprise. Now those companies seemed to be confused about the law.

In its most recent 10-K filing, giant UnitedHealth Group acknowledges that the new law “may create new or expanding opportunities for business growth” but also warns that it “could materially and adversely affect the manner in which we conduct business and our results of operations, financial position and cash flows.” Its rival Wellpoint expresses the same ambivalence in its 10-K, saying: “As a result of the complexity of the law…we cannot currently estimate the ultimate impact…on our business, cash flows, financial condition and results of operations.”

Yet they seem even more worried about the possibility that the law may be overturned. UnitedHealth writes: “Any partial or complete repeal…could materially and adversely impact our ability to capitalize on the opportunities presented by the Health Reform Legislation or may cause us to incur additional costs of compliance.”

Apart from the insurance companies, there are other major corporate players that have been intending to “capitalize on the opportunities” created by the Affordable Care Act’s infusion of lots more federal money into the medical sector. For example, for-profit hospital operator HCA writes in its 10-K that the Act “may result in a material increase in the number of patients using our facilities who have either private or public program coverage,” though it also worried about intended reductions in payments to Medicare providers. On the issue of partial or complete repeal, it also admits that the impact would be “unclear.”

Healthcare is not the only arena in which corporate interests may be having second thoughts about their direct (as with the Kochs) or indirect encouragement of junkyard dog-style conservatism. Tea party types in Congress recently decided to challenge the continued existence of the Export-Import Bank, an institution that has long been relied on by major companies such as Boeing and General Electric to sell their big-ticket items to foreign customers.

That move features prominently a New York Times front-page story reporting that some business interests are wondering if they made a mistake in heavily supporting the far-right Republicans who seem to call the shots on Capitol Hill these days. The article quotes a spokesman for the Club for Growth, which promotes “economic freedom” as admitting that “free market is not always the same as pro-business.”

Hopefully, those are not the country’s only choices. If we’re lucky, the clash between these two tendencies will open up more space for changes that promote economic and social justice while putting restraints on both the market and the corporations.

Back to the Barricades?

The news that Byron Dorgan and Christopher Dodd will not run for reelection has Democrats fretting that they will lose their 60-vote supermajority in the Senate and will no longer be able to get anything accomplished.

But what have we got to show, with regard to checking corporate abuses, for the past 12 months of Democratic control over the legislative branch as well as the White House? Last year this time, excitement over Obama’s election and the Democratic gains in Congress persuaded many activists that great things could once again happen in Washington. The big business agenda would supposedly no longer reign supreme, and progressives anticipated major legislative gains regarding healthcare coverage, financial regulation, the climate crisis and union organizing.

Now those expectations seem hopelessly naïve. Rather than radical changes, we’ve ended up with a disappointing series of half-measures, quarter-measures, and stalemates.

The biggest frustration is in the healthcare arena. We seem to be on the verge of getting a new system that will expand coverage and curb some of the most egregious insurance industry abuses, but these improvements come at a high cost. The final bill will likely have a strict individual mandate compelling those without coverage to become customers of a bunch of blood-suckers yet a weak employer mandate allowing many companies to avoid providing decent coverage to their workers. It will not seriously regulate insurance rates yet may end up penalizing union workers who gave up wage increases to get more generous benefits. The bill that squeaked through the Senate and is expected to form the basis of the final legislation is so compromised that veteran reformers such as Physicians for a National Health Program have called for its defeat.

After crippling the economy through reckless investments and forcing millions of homeowners into foreclosure, the big banks have largely been treated with deference by Congressional Democrats and the Obama Administration. Nothing has been done to break up institutions deemed too big to fail and thus able to extort massive taxpayer-funded bailouts. Despite loud complaints from bankers used to sumptuous pay packages, the federal government’s restrictions on executive compensation have been pretty indulgent. The bill that passed the House in December creates a new consumer protection agency for financial services, but it is unclear how much power it will have. And the bill lacks aggressive regulation of the exotic financial instruments that helped bring about the crisis. Separate legislation on credit cards that was enacted curbs some of the industry’s most outrageous practices but does nothing about usurious interest rates.

The climate bill passed by the House in June not only shunned strict emission limits in favor of the dubious cap-and-trade system, but it would allow many major polluters to avoid paying for their emission allowances for up to 20 years. And the overall emission reductions the bill envisions are far below the level needed to make a substantial dent in global warming.

And then there’s the Employee Free Choice Act, the key priority of the labor movement, which did so much to get Obama and many Democrats elected. The legislation has been in suspended animation for many months as Senate leaders apparently cannot muster enough votes to overcome intransigent opposition not only from Republicans but also from some Dems. EFCA remained stalled even after the AFL-CIO signaled it was open to compromise on the key issue of card-check organizing.

Overall, corporate interests have been remarkably successful over the past year in avoiding serious restraints on their freedom of action. Much of what the Democrats are accomplishing amounts to the appearance of reform. It gives the impression that corporate misbehavior is being addressed but is actually inoculating business against more stringent regulation. In the case of healthcare, the situation is even worse: by turning millions into captive customers, Congress is granting unprecedented power and legitimacy to a discredited industry.

There are plenty of obvious explanations for this dismal performance. It is easy to point to the corrupting effect of corporate campaign contributions and lobbying by former Congressional staffers as well as the pernicious role of conservative Democrats and egomaniacs like Joe Lieberman.

But the progressive movement also deserves some of the blame. The euphoria following the 2008 election gave rise to another bout of the delusion that serious change requires nothing more putting in office a certain number of people with the preferred party designation.

During the 1930s FDR is supposed to have told activists in a private meeting: “I agree with you, I want to do it, now make me do it.” Although that quote has showed up in several blogs over the past year, the underlying message seems to have been lost on many of today’s activists. With the absence of substantial popular pressure, it has been easier for Congressional Democrats to succumb to the siren song of the corporate interests.

Ironically, it has been the woefully ignorant and confused tea party movement—serving as a witting or unwitting stalking horse for the corporate elite—that has lately shown the power of grassroots mobilization. Their positions make no sense, but the tea baggers have made sure that Congressional Republicans maintain a hard-right stance on everything.

Perhaps we will accomplish more if we return to our own barricades.

A Truly Captive Market

parasites The House of Representatives, in a rare embrace of de-privatization, has just passed legislation that would put an industry out of business. If approved by the Senate, the Student Aid and Fiscal Responsibility Act will eliminate the heavily subsidized business of bank origination of federal student loans. Students would get their loans directly from the federal government and would see a huge increase in the Pell Grant program, thanks to the tens of billions of dollars saved by eliminating the subsidies.

Unfortunately, the impulse to abolish a parasitic form of private enterprise has been missing from the official debate on healthcare reform ever since Democratic leaders and the Obama Administration shunned the idea of expanding Medicare eligibility to non-seniors. Now, given the uncertain prospects for a public insurance option (a weak substitute for single payer), we are faced with the possibility that the parasites of the private health insurance industry will not only survive but will be empowered as never before.

While support for the public option has waned, the powers that be in both major parties have never wavered from their endorsement of the individual mandate—the bizarre idea that the solution to the problem of the uninsured is to force them purchase insurance. This implies that being without insurance is a personal shortcoming rather than a social problem. It makes as much sense as saying that the way to help the homeless is to compel them to buy a house.

It is true that the proposals for an individual mandate come with provisions for subsidies, yet as the plan just issued by Senate Finance Committee Chairman Max Baucus illustrates, those subsidies would not extend to many middle-income families, who might find themselves in the absurd position of having to pay penalties to the federal government for failing to buy coverage they cannot afford.

What’s wrong with the imposition of an individual mandate without a public option is more than that of inadequate subsidies. It would amount to an unprecedented move by government to compel residents to become customers of a particular set of corporations. States currently require drivers to obtain insurance for their vehicles from private carriers, but automobile ownership is not compulsory. Adoption of an individual mandate sans public option would make it a condition of being alive for the uninsured to start paying premiums to a private insurance company.

What next? Will the federal government allow the likes of WellPoint and Cigna to put private bill collectors to work harassing “deadbeats” who don’t make their mandatory payments? Since the carriers could not drop these non-paying customers, would the companies be allowed to lock them up in healthcare debtor prisons until a relative takes care of the bill?

Maybe not. But there’s a strong possibility that the furor over unaffordable mandatory coverage would prompt Congress to bring down rates by allowing insurers to offer lower-quality plans. If the public option is jettisoned along with single payer, “reform” may turn out to be nothing more than a way of making millions of Americans pay for the dubious privilege of shifting from the ranks of the uninsured into a captive market of the woefully underinsured.