The new Alzheimer’s drug that could break Medicare

“Medicare’s inability to determine the price it pays for aducanumab is a uniquely American problem compared to health systems in the rest of the developed world. Countries like Australia and the United Kingdom have independent boards that evaluate a new drug’s effectiveness and set a price based on that estimated value. The US pharma industry says the US system is important for encouraging innovation, and companies have made amazing breakthroughs, such as the hepatitis-C drugs that effectively cure that disease.

But, as the standards for approving have sometimes seemed to slip in recent years, the chances of the FDA approving very expensive drugs with only marginal benefits have risen.

“We don’t require prices to reflect the value of treatment, period,” Dusetzina said. “Companies can price their drugs as high as they want. Companies can also get drugs approved with little evidence.”

So Biogen is planning to charge $56,000 annually for aducanumab. ICER, which evaluates the estimated value of new drugs, estimates, based on the clinical evidence, that it’s worth more like $8,000; perhaps as little as $2,500 or as much as $23,100. Regardless, the price announced after Biogen secured FDA approval “far exceeds even this optimistic scenario,” ICER concluded.”

Colombia’s protests are a product of its post-peace-deal reality

“Colombia is the second most unequal country in an already unequal Latin America region. Even as its economy has grown in recent decades, the poorest slice of the population is not seeing those benefits, and many lower- and middle-income earners struggle to pay for basic services.”

“unrest that has convulsed Colombia for more than a month. A tax reform bill proposed by right-wing President Ivan Duque sparked protests in late April, with thousands responding to a call from national labor unions to push against the measure.
The government defended the proposed tax increase as a much-needed measure to repair the economy after fallout from the coronavirus. Those who opposed the legislation saw it as putting another burden on middle-class and poorer families who are already in a precarious position, also because of the coronavirus.”

“Columbia recently emerged from decades of internal armed conflict, the culmination of an imperfect and still not fully realized peace process. But this helped excise the civil war as the dominant political issue.”

“The Colombian National Police is very much linked to the military; though a distinctive branch, it falls under the oversight of the Ministry of Defense. The force itself was shaped by the conflict in Colombia, with officers often fighting “on the front lines, wielding tanks and helicopters as they battled guerrilla fighters and destroyed drug labs,” according to the New York Times.

Critics have said the country’s national police needs to reform, moving from a focus on training for battle to one of public safety.”

““They are treating the protesters as they used to treat the guerrillas, as subversives, because that’s the type of public force that is the police,” Restrepo said. “The military and security forces that we have, that was never reformed.””

“The government has also alleged that some of the violence and chaos is the work of guerrillas, including the vestiges of the FARC, as well as drug traffickers who have infiltrated the protests. At the end of May, when protests had stretched on for a full month, Duque deployed the military to Cali, saying the increased capacity would help in the areas that have seen “acts of vandalism, violence and low-intensity urban terrorism.” Officials have also said hundreds of police officers have been injured, including by armed civilians.

Restrepo said the government is trying to bring the FARC guerrillas and Colombia’s conflict back to the center of the agenda “to justify the militarization of the police and the techniques that they’re using, the violence [and] brutality that they’re using.” In other words, when it works politically, go back to the us-versus-them paradigm.

This has further enraged protesters who see their legitimate grievances being ignored and their anger recast.”

“Experts told me it would be a mistake to say all protesters, or even all blockades in cities like Cali, are associated with criminal elements. “That being said, you’re having this context of social protests embedded in a city, in a country where, of course, there are some powerful criminal organizations and guerrilla groups,” the Universidad Icesi’s Albarracín said. At least some of those groups will take advantage of the disorder — and the front lines are already so chaotic and disorganized, it’s hard to know who’s who.”

“Protests are happening across Colombia, in cities including Cali, Bogotá, and Medellin. But this is not a fully unified movement. Up close, the protests all look very different, with diverse and often localized grievances — and not all of the demands are aligned.”

Biden plans to reverse Trump’s Alaska policy. Here’s why it matters.

“the Biden administration revealed plans to reinstate environmental protections preventing logging and mining in Alaska’s Tongass National Forest, which the Trump administration had discarded. The 17 million acres in southeastern Alaska — the largest national forest in the US — have been a political battleground for over two decades, bouncing back and forth between the interests of logging industries and climate activists.

In 2001, President Bill Clinton finalized the “roadless rule,” which prohibited road construction on 60 million acres of forested land across the US and heavily restricted commercial logging and mining. But in October of 2020, then-President Donald Trump reversed these protections when he made the Tongass Forest exempt from the rule, doing what many developers and politicians in Alaska had been calling for since the Clinton era.”

“While politicians paint a picture of an oppressive federal government that would deny normal Alaskans access to “jobs and prosperity,” the narrative rings a bit hollow when set against actual feedback from the public. In 2019, the US Forest Service released a summary of over 140,000 comments on the “roadless rule” from the public which overwhelmingly supported the restrictions on forest development. In fact, one of the main points of rationale as to why the public thinks the “roadless rule” should remain was that it is vital to the tourism and fishing industries.”

“In addition to providing jobs, as the United States’ largest national forest, the Tongass plays a significant ecological role in absorbing carbon produced in the US. According to National Geographic, the temperate rainforest absorbs approximately 8 percent of the pollution produced in the US. “While tropical rainforests are the lungs of the planet, the Tongass is the lungs of North America,” Dominick DellaSala, chief scientist with the Earth Island Institute’s Wild Heritage project, told the Washington Post. In fact, the United States Geological Survey recently estimated that if no trees were lost through logging and the land were left unmanaged in the Tongass, its carbon storage could increase by up to 27 percent by the end of the century.

The Tongass is also home to a thriving wildlife population, but Trump’s reversal of the “roadless rule” put this in danger. On land, the state of Alaska is home to 95 percent of America’s brown bear population, and the Tongass specifically contains the highest concentration of brown bears on the planet, while the forest’s 17,000 miles of clean freshwater provide optimal spawning conditions for wild salmon. Due to its high populations, the Tongass is sometimes called a “salmon forest” and, as it produces $60 million of wild salmon annually, this name is not far-fetched. But, if not for the “roadless rule,” this might have changed. Logging around a stream causes runoff like silt or dirt into the water, which can smother developing eggs, while dams, often used to maneuver logs down waterways, disorient the fish and disrupt their natural migratory patterns”

“While this is a loss that can affect any Alaskan, to Alaskan Natives, losing wild salmon and the forests that house them means much more than a declining food source. Twenty-three percent of the region’s population comes from the Tlingit, Haida, and Tsimshian tribes, who have been fighting for recognition and for better treatment of their ancestral land which includes the expansive Tongass Forest.”

Call it authoritarianism

“Blocking an inquiry into the January 6 attack on the Capitol, embracing Trump’s “Big Lie” that the election was stolen, making it easier for partisans to tamper with the process of counting votes: These are not the actions of a party committed to the basic idea of open, representative government.

It’s common to call this GOP behavior “anti-democratic,” but the description can only go so far. It tells us what they’re moving America away from, but not where they want to take it. The term “minority rule” is closer, but euphemistic; it puts the Republican actions in the same category as a Supreme Court ruling, countermajoritarian moves inside a democratic framework rather than something fundamentally opposed to it.

It’s worth being clear about this: The GOP has become an authoritarian party pushing an authoritarian policy agenda.”

“When people think of authoritarian governments, they typically think of police states and 20th-century totalitarianism. But “authoritarianism” is actually a broad term, encompassing very different governments united mostly by the fact that they do not transfer power through free and fair elections.”

“competitive authoritarian systems survive in part by convincing citizens that they are living in a democracy. That’s how they maintain their legitimacy and prevent popular uprisings. As such, they do not conduct the kind of obvious sham elections held in places like Bashar al-Assad’s Syria (he won the 2021 contest with 95 percent of the “vote”).

In competitive authoritarianism, the opposition does have some ability to win a bit of power through, well, competition — even if the scope of their possible victories are limited.

It’s a tricky balance for the regime to pull off: rigging elections enough to maintain power indefinitely while still permitting enough democracy that citizens don’t rise up in outrage. Many competitive authoritarian regimes have collapsed under the stress, either transitioning to democracy (like Taiwan) or forcefully repressing the opposition and becoming a more traditional autocracy (like Belarus).”

“Happily, the United States still passes the most basic test of whether a system is democratic: whether the public can vote out its leaders. But it is hard to deny that the Republican Party has begun chipping away at that baseline principle, using the flaws in our political system to entrench their power.”

Trump’s lies about the 2020 election are endangering America’s election workers

“In a speech on voting rights delivered on Friday, Attorney General Merrick Garland warned that “the dramatic increase in menacing and violent threats against all manner of state and local election workers” is a threat to the country’s democracy.

Garland is right to be concerned. A new survey released by the Brennan Center for Justice found that 17 percent of local election officials in the United States have faced threats because of their job. The same survey, which was released alongside a larger report by Brennan and the Bipartisan Policy Center on threats to America’s elections, found that nearly a third of these officials — 32 percent — have “felt unsafe because of [their] job as a local election official.”

The survey was conducted by Benenson Strategy Group, and it included interviews with 233 election officials “from across the country.”

The Brennan Center’s survey quantifies a phenomenon that appears to have emerged from former President Donald Trump’s conduct during the 2020 election, and his subsequent defeat in that election. Just hours before Garland pledged to prosecute individuals who target election officials in that same speech, Reuters published a long article cataloging some of the threats faced by election administrators and their families.”

The public option is now a reality in 3 states

“Washington state first approved its public option in 2019 and made it available to consumers for enrollment in 2020. The state now has a year of experience getting the Cascade Care program up and running, and it’s already starting to tinker with the policy design. It’s also offering lessons for Colorado and Nevada (the other state to pass a public option this year, one week before Colorado).

As these states have drawn up their plans, one thing has become clear: The potential value of a public option is in keeping health care costs in check by keeping rates lower than those of private insurance plans. But it still remains to be seen whether a public option can expand health coverage to more people.”

“None of the states offer a “public” option like the one Congress contemplated in 2009, where the government sets up and administers its own health insurance plan.

“None of them are true public options in that sense,” says Katie Keith, who writes about insurance reform for Health Affairs and consulted with states as they developed public option legislation.

Instead, she compares them with public-private partnerships. States are contracting with private companies to create new insurance options to be overseen, if not run, by the government. States would face practical challenges to doing a “true” public option — namely, building up the financial reserves they’d need to pay out claims — so they’re taking another approach wherein private insurance companies will run the public option under rules set by the government.”

“The plans will be sold on the ACA marketplaces, alongside ACA-compliant private insurance. Only people who are eligible for ACA coverage through the individual and small-group market can sign up”

“How much to pay health care providers is the most important issue for any health insurance plan — those prices dictate the premiums charged to customers — and these states are taking divergent approaches in their calculations.”

“One challenge in trying to set lower provider rates is that doctors and hospitals might simply choose not to accept the public option plan. That was Washington’s experience in its first year: Some hospitals refused to contract with the public plan, and since an adequate provider network isn’t possible without a hospital, the plan has only been available in 19 of the state’s 39 counties.

Washington is trying to correct that issue through recently signed legislation that will, among other things, require hospitals in large systems to participate in at least one public option plan. Nevada and Colorado, having seen Washington’s network-adequacy issues, are setting up their own provider participation requirements from the start.”

How Northern Ireland is complicating Biden’s European agenda

“Brexit happened, and the United Kingdom formally left the European Union. But the UK and EU are still arguing over the deal they both signed on the status of Northern Ireland.

When the United Kingdom voted to leave the European Union in 2016, it created the tricky issue of what to do about the land border between Northern Ireland (which is part of the UK) and the Republic of Ireland (which is an independent country and part of the EU).

It is no ordinary border. During the decades of bloody sectarian conflict in Northern Ireland known as the Troubles, that border was heavily militarized, and it served as both a symbol of the strife and a very real target for nationalist paramilitary groups.

A critical part of the Good Friday Agreement, the 1998 peace process that ended the Troubles, involved increasing cooperation between Northern Ireland and Ireland. That meant softening the border between the two. As a result, the 310-mile border is practically invisible and completely free from checks and physical infrastructure today.

But once the UK and EU split up, that would become the only land border between the UK and Europe. And with the two sides following different trade rules (that was one of the main points of Brexit), there would need to be some kind of checks put back in place to regulate the goods crossing the border.

So you see the problem: Not having any checkpoints or physical border is seen as critical to maintaining the peace. But the UK’s departure from the EU (and its trading rules) made some sort of customs check necessary.

The UK and the EU ultimately coalesced around a plan that carved out a special status for Northern Ireland. It would leave with the UK but follow many of the EU’s rules, thus keeping that land border open. To achieve this, certain goods coming into Northern Ireland from the rest of Great Britain would require checks, just in case they ended up in the EU’s single market. This put a customs border in the Irish Sea — effectively, within the UK.”

“In March, a set of grace periods expired for some provisions, and at the time, the UK just unilaterally extended those deadlines. The EU reminded the UK that, this being a treaty and all, the UK couldn’t just act alone, and so sued them for breaking international law.

Now another set of grace periods is expiring at the end of the month, including a provision related to chilled meats, such as sausages. The UK now needs to start conducting regulatory checks on any chilled meats coming into Northern Ireland from the rest of Great Britain. If the UK doesn’t do them, it would effectively prevent Great Britain from selling its own sausages in Northern Ireland, since those, in theory, might be at risk of entering Ireland, which could mean illicit sausages in the EU single market.

The sausage dilemma is really just the latest fracture between the EU and UK. The EU thinks Boris Johnson’s government isn’t an honest broker and is likely to renege on the protocol once again.

“It’s not about sausages per se, it really is about the fact that an agreement had been entered into, not too long ago,” Irish Taoiseach (prime minister) Micheál Martin said. “If there’s consistent, unilateral deviation from that agreement, that clearly undermines the broader relationship between the European Union and the United Kingdom, which is in nobody’s interest.”

Johnson, meanwhile, says he’s defending the territorial and economic integrity of the UK. His government has accused the EU of failing to do anything to minimize the trade frictions, which may leave them no choice but to get rid of the deal entirely. The problem, of course, is that Johnson himself signed up to the rules that he no longer seems to like very much.”

“the protocol has revived tensions in Northern Ireland itself, specifically among the unionist community in Northern Ireland.

The unionists reject any division between Northern Ireland and the rest of the UK (i.e., they support the union between Great Britain and Northern Ireland), and some feel, not totally incorrectly, that they were shunted aside in the Brexit deal. Some unionists are urging the UK to scrap the deal entirely. Northern Ireland saw unrest back in the spring, and there are fears over renewed violence, especially as “marching season” reaches its peak on July 12, when loyalists — extreme unionists — engage in parades and demonstrations.”

“The “sausage wars” may sound silly, but Biden will struggle to create this coalition of democracies to serve as a counterweight to authoritarianism if the EU-UK divorce keeps getting in the way. And it’s just a lot harder to sell the vision that the US and its partners are the ones to trust over China when key members of that group are backing out of agreements or engaging in a trade war.”

What Obamacare achieved — and didn’t

“The Affordable Care Act’s achievements are clear. People who buy insurance in the individual and small-group markets no longer face discrimination for preexisting conditions. Preventive services for Americans with all types of insurance are free. Combine the marketplaces that provide tax subsidies for private coverage and the Medicaid expansions adopted by 38 states (along with a handful of smaller provisions), and the ACA has provided coverage to about 31 million Americans, according to a new estimate from the Biden administration.

After the rocky rollout of HealthCare.gov in 2014 and a few years of soaring premiums, the law’s private marketplaces have stabilized”

“one of the biggest gaps in the ACA itself: Medicaid. The program’s expansion to cover more low-income adults was supposed to be mandatory for all 50 states, a statutory overreach that was scaled back by the Supreme Court, where two liberal justices joined the conservatives to rule that the expansion must be optional.

As a result, 12 states still refuse to expand Medicaid. An estimated 4 million people who would have been covered by the expansion remain uninsured.”

“Some people who purchase private insurance through the law can still face high out-of-pocket costs. Some of the health plans sold on the marketplaces have deductibles as high as $6,000 for an individual or $13,000 for a family — and those are usually the cheapest plans available. Until this year, people who made too much money to qualify for the law’s subsidies had to pay the full cost for their insurance, making it unaffordable for some.”

“one core problem remains: While every other developed country in the world enjoys universal (or near-universal) health coverage, 1 in 10 people living in the United States still don’t have insurance.

That number is lower than it was before 2010, when it was about 17 percent. But it is an embarrassing outlier among our economic peers. Americans also spend more of their own money on their health care than people in almost every other country.”

“America spends more money on health care for worse outcomes than its peer countries, as researchers have noted time and again. On a global index of health care quality and access, the US trails many more socialized systems. Life expectancy has dipped in recent years, ending decades of progress and dropping the US further behind comparable countries.

There is no denying that the high quality of health care available in the United States — for those who can afford it. The US health care industry can undoubtedly be among the most innovative in the world: It was American science that cured hepatitis-C in the last decade. The success of the country’s Covid-19 vaccine development, production and distribution is undeniable.

But prioritizing innovation above all else creates its own problems, leaving US health policy captive to private interests.”

US and Germany have Nord Stream 2 deal, but lack authority to implement it

“A day after the U.S. and Germany announced a deal allowing the completion of the controversial Nord Stream 2 gas pipeline, top officials conceded that neither the White House nor the Chancellery have the authority to implement some of its most crucial components.

As a huge outcry went up from opponents of the Russia-led pipeline project, Chancellor Angela Merkel acknowledged that her agreement with President Joe Biden hardly settled their political disagreements, and that much remained uncertain.

“The agreement with the U.S. government does not cement the differences, but it does not overcome all differences either,” Merkel said at a news conference. “The differences remain.” Of the deal, she added: “It is an attempt between the U.S. government and us to set certain conditions that also have to be implemented.

“I am glad that we have succeeded so far,” Merkel continued. “And we also have a lot of tasks ahead.”

Those tasks are hardly small and include overcoming fierce opposition from some members of the United States Congress, persuading some extremely dubious EU countries to get on board, and convincing Russia to liberalize its energy sector, divest itself of the €9.5 billion pipeline, and pay Ukraine some additional €20 billion through 2034 to make up for the loss of gas transit fees — which the new pipeline would effectively render unnecessary.

While some influential Germans — notably former chancellor and current Nord Stream 2 chairman of the board Gerhard Schröder — have been instrumental in securing the pipeline’s completion, Berlin may have little to no influence over Moscow once construction is done and gas is flowing.

U.S. Senator Jeanne Shaheen, a Democrat on the foreign relations committee who co-authored U.S. sanctions legislation targeting the pipeline, said she was “skeptical” of the deal given that “the key player at the table — Russia — refuses to play by the rules.””