HEALTH CARE/Joan Retsinas

Scroogian Tale of BiDil

The tale of Scrooge and Tiny Tim revolves around an individual's moral compass. Scrooge amassed a fortune on the labor -- call it productivity -- of beleaguered Bob Cratchit. Focusing on the bottom line, Scrooge didn't see the desperate straits of the Cratchits. He didn't care that Tiny Tim, their crippled (Dickens' word) young son, was moribund. Enter the three ghosts. Poof! Scrooge underwent the epiphany that zillions of readers have cheered: he looked beyond the bottom line to the people whose suffering under-girded his success. At the end, Scrooge treated the Cratchits to at a bountiful feast. And readers knew that Tiny Tim would live.

This is a story of hope, with a reassuring formula. An individual's miserliness breeds suffering. The solution? Reform the individual. A reborn Scrooge ("I feel like a baby!") sheds his miserliness. And the suffering ceases.

Would that the genesis of suffering lay solely within the moral bearings of an individual -- and that sparking a moral rebirth within an individual would -- poof! -- write a happy ending to a sad tale.

When Scrooge is a system, not a person, the tale ends differently.

In this holiday season, our freewheeling, capitalist system -- the one that has given us astounding prosperity -- has also given us a tale of miserliness.

The tale of the drug BiDil begins with a scientific discovery. In clinical trials, researchers found that African Americans, who are disproportionately prone to congestive heart failure, responded well to this pill.

The reasons for the racially-marked impact were not obvious; but the statistics were sufficiently convincing to spur the manufacturer, NitroMed, to seek FDA approval. In January 2005 BiDil went on the market. As the first drug earmarked for one racial group, the approval drew press coverage.

Roughly 750,000 African-Americans suffer from congestive heart failure.

Analysts expected a substantial swathe of them to start taking the drug. The cost was high (as much as $2,700 annually); but the patients most likely to benefit from BiDil are elderly, poor, and African American -- sociologically speaking, the trifecta of discrimination in America. These patients were often covered by state Medicaid insurance. And states generally picked up the tab for BiDil. After all, states negotiated with drug manufacturers for low prices. And states' Medicaid constituency is comprised of poor patients.

At this point the tale, while not an especially happy one, was promising. Medicaid could not change the plight of its patients; but it could help a number of them with failing hearts live longer.

Enter systemic government reform. Enter the ferociously competitive corporate megaliths battling for market share. Enter Medicare Part D.

Medicare Part D encompassed all the people who had been enrolled in Medicaid. States could stop paying for drugs for their elderly, poor, minority patients. These patients, like everybody else over age 65, would be enrolled in one of the assorted private-sector plans of Medicare Part D. At first glance, this seems an improvement. Programs run for the entire population generally give better service than those run expressly for a disadvantaged segment.

But this new Medicare add-on incorporated the plusses -- and the pitfalls -- of a competitive market. The plans looked at BiDil and saw its cost. Did people really need that drug? Some experts suggested that a patient could get the same benefit by chopping up generic pills and combining them. (Other experts criticized this self-help alchemy.) Medicaid had footed the bill, but Medicaid negotiated for cheaper prices with manufacturers. For Medicare Part D, the federal rules barred plans from negotiating. What the drug companies charged, was what the plans had to pay.

So the plans did the kind of cost-benefit analysis that drives capitalism. On the one hand, some patients -- a small subset of the total subscriber-pool -- might improve with BiDil. On the other hand, the rise in costs might spike premiums for everybody else. The plans needed to stay competitive to stay in this market. Plans' mandate is to enrich their shareholders.

So Medicare Part D plans made the decision that a pre-Ghost Scrooge would have understood: they excluded BiDil from their formularies. Patients could chop up different generic drugs -- or do without. Sylvia Pagan Westphal reports in the Wall Street Journal that 1% of the affected patient-population takes BiDil.

When Scrooge is a system, not a person, there is no quick redemption via ghostly visitations. The plans are economic vehicles, not people. Compassion is not a corporate virtue.

If this tale is to have a happy ending, the federal government must intervene. It will have to unshackle plans, letting them negotiate directly with manufacturers, not just for BiDil, but for all drugs. It will have to prod the plans into expanding their formularies.

In this season of hope, I hope that the administration will write that concluding chapter to this tale.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, December 1, 2006

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