Category Archives: Broken in the USA

guns & gas

Undocumented (Illegal) Immigrants

Undocumented (Illegal) Immigrants

There is a lot of bad information out there about undocumented residents, especially among folks with a specific political agenda. The first is that most are coming across our Southern border. The reality is that most enter either on a seasonal work or tourist visa and decide to stay. I am not advocating opening our borders, but I am advocating a more sensible and efficient method for accepting immigrants.

Other bad information has to do with what legal rights are available to illegals.

Are undocumented immigrants eligible for federal public benefit programs?

Generally no. Undocumented immigrants, including DACA holders, are ineligible to receive most federal public benefits, including means-tested benefits such as Supplemental Nutrition Assistance Program (SNAP, sometimes referred to as food stamps), regular Medicaid, Supplemental Security Income (SSI), and Temporary Assistance for Needy Families (TANF). Undocumented immigrants are ineligible for health care subsidies under the Affordable Care Act (ACA) and are prohibited from purchasing unsubsidized health coverage on ACA exchanges.

Undocumented immigrants may be eligible for a handful of benefits that are deemed necessary to protect life or guarantee safety in dire situations, such as emergency Medicaid, access to treatment in hospital emergency rooms, or access to healthcare and nutrition programs under the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Are legal immigrants eligible for federal public benefit programs?

Only those with lawful permanent resident (LPR) status, but not until they have resided as a legal resident for five years. LPRs – sometimes referred to as green card holders – do not have full access to all public benefit programs and are subject to limitations before being eligible for federal means-tested benefits, including Medicaid, the Children’s Health Insurance Program (CHIP), TANF, SNAP, and SSI. Such limitations include the “five-year bar,” which requires the individual to have maintained LPR status in the U.S. for five years before being eligible for benefits. However, under some federal benefit programs, this requirement can be bypassed when the recipient has worked 40 quarters under a visa. Quarters worked by parents when the immigrant was a dependent child, or by a spouse while married to the immigrant, count towards the immigrant’s 40 quarters.

LPRs are eligible to apply for Medicare and Public/“Section 8” Housing as well, as long as the five-year bar is fulfilled. For LPRs to become eligible for Social Security benefits for both retirement and disability, they are required to have completed 40 quarters of work in addition to having maintained LPR status for five years.

Certain additional categories of immigrants, specifically refugees, asylum seekers, and victims of human trafficking or domestic violence have the same eligibility requirements for federal benefits as LPRs. Individuals on non-immigrant and temporary visa holders are ineligible for benefits.

How much do legal immigrants use federal public benefit programs?

Legal immigrants use federal public benefit programs at lower rates than U.S.-born citizens. As recently as 2013, the rate at which non-citizens have used public benefit programs was less than that of U.S.-born citizens. For example, 32.5 percent of native-born citizen adults receive SNAP benefits compared to 25.4 percent of naturalized citizen adults and 29 percent of noncitizen adults. In addition to immigrants’ lower rate of SNAP usage, they also receive lower benefit values, costing the program less.

How much do immigrants contribute to support public benefits programs?

Both documented and undocumented immigrants pay more into public benefit programs than they take out. According to Institute on Taxation and Economic Policy, undocumented immigrants contribute an estimated $11.74 billion to state and local economies each year. However, undocumented immigrants are not eligible for many of the federal or state benefits that their tax dollars help fund.

Additionally, a few states have completed studies demonstrating that immigrants pay more in taxes than they receive in government services and benefits. A study in Arizona found that the state’s immigrants generate $2.4 billion in tax revenue per year, which more than offsets the $1.4 billion in their use of benefit programs. Another study in Florida estimated that, on a per capita basis, immigrants in the state pay nearly $1,500 more in taxes per capita than they receive in public benefits.

Do undocumented children have access to a public education?

Yes. In accordance with the Supreme Court ruling in Plyer v. Doe, all immigrant children, regardless of status, have access to a public education and are eligible to attend public schools for grades K-12. Undocumented immigrants are also eligible for the Head Start program as it is not considered a federal public benefit program – any child who is otherwise eligible, regardless of their or their parents’ immigration status, may enroll in Head Start.

Facts that should Matter

Facts that should Matter

I am not naïve enough to suggest that “facts” carry the day with regard to decision making or election outcomes. My experience suggests that emotions and belief systems are more powerful factors. Regardless I think that there are numerous, problematic facts about our country that should matter to patriots.

Legal Issues:

Facts: The USA has 4.2 % of the world’s population but incarcerates 19.2% of all the worlds inmates.

Facts: Our population is less than 65% of the EU, but we incarcerate almost five times as many inmates.

Facts: The direct annual “reported” direct cost of operating our prisons is just under $85 Billion or $40,000 per inmate. There are numerous indirect costs that occur as a result of a high incarceration rate which can arguably double this cost to the taxpayer.

Facts: We have over 1.3 million lawyers, that’s a lawyer for every 244 for every man, woman & child and ranks 2nd among all the world’s countries in lawyers per capita.

Fact: The average time on death row, prior to execution is eight years.

Facts: The intentional homicide rate in our country is 5 per 100,000. The majority of these murders are committed by either friends or family of the victim.

Fact: Our homicide rate is three times that of the average for the EU countries.

Facts: The USA has 298 police officers per capita while the average for the EU is 314. It is interesting to note that the five Scandinavian countries average only 180.

Fact: There have been 237 deaths from Mass Shootings (incidents with over 4 deaths) in the last five years.

Comments: Given the facts what are our elected representatives doing to lower the homicide rate and the unfair cost in both lives and money to our residents?

Sustainability Issues:

Fact: Our planet has a limited amount of resources to provide sustainability for our residents. Such things as food, water, materials to support manufacturing and the list goes on.

Fact: Experts that study this issue estimate that we have the ability sustain a range of 3.5 to 5 billion people at a reasonable standard of living.

Fact: Our current populations stand at just under 7.6 billion.

Fact: It took tens of thousands of years to reach a population of 3.8 billion and only 50 years to add another 3.8 billion.

Fact: If the current trend continues, we will reach a population of 10 billion by 2050.

Fact: Some good news is that the experts predict that growth will decline and top out at about 11 billion by the end of this century.

The not good news is that there will be far fewer young people to support retirement programs for the aging and we will have too many people for our resources to support. The prognosis is a significant decrease in the standard of living and likely more violence as groups vie to control the resources that are available.

RX Ricing

RX Pricing

 In several prior posts, I have compared what we pay in our country for prescription drugs to other countries. With the advent of such Apps as Good RX and Single Care I have been confused. Why is there such a wide range of prices for the same item? My suspicion is that “cash” payers are paying a price that is more related to the actual cost and some pharmacies only quote the price is paying with insurance. If true, doe this mean that the Insurance providers are paying far too much? If so, what impact does this have on insurance premiums and the overall cost of healthcare in the US?


In the process of researching this subject I found the following article. It is rather long, but worth the read,

 Medication pricing: So this is how it works

Publish date: February 1, 2018 By  Dinah Miller, MD

In my last column, I looked at the tremendous variation in prices among pharmacies for two psychotropic medications, aripiprazole and modafinil. The cash price variation could be as much as 45 times more from one pharmacy to the next, which I found to be both outrageous and incomprehensible.

To learn more about pharmaceutical pricing, I contacted Doug Hirsch, the cofounder of GoodRx, a firm based in Santa Monica, Calif., that offers deep discounts on some medications. The company sends discount cards to physicians’ offices – call me if you need some, I have many boxes of GoodRx cards – and has a website ( and an app. It advertises that it is about transparency, and if you’ve ever tried the company’s site or app, the service it offers is remarkable and simple to use.


You plug in the medication you’re interested in, include the dose and quantity you’d like, and add your ZIP code, then a list of pharmacies with the GoodRx discounted prices is generated for easy comparison shopping. It tells you how far each pharmacy is from your current location and provides the discount codes; the phone, fax, and hours of operation for the pharmacy; and a link to a map with driving directions. And if driving to multiple pharmacies to get the best price on multiple medications seems too difficult, in what is just short of miraculous technology, the app allows people to enter in all their medications and shows the comparative prices for the bundle. In short, GoodRx is to medication pricing what Trivago is to hotel rates. The technology is impressive, and it’s worth noting that the founders of GoodRx previously worked in top positions at Facebook.

I approached Mr. Hirsch with two simple questions. The company offers “up to 90% discount” on the cash price of medications through its app, website, or discount card – all of which can be gotten for free. I wanted to know 1) Who pays for this difference in the medication cost, and 2) How does the company, with 95 employees, make any money? Mr. Hirsch was gracious enough (and patient enough!) to spend the next hour walking me through the steps of medication pricing. It was a lively conversation, so let me share with you what I have learned.

Medications are made by a pharmaceutical company or, for generics, there may be many manufacturers. The medications are sent to a pharmaceutical distributor, such as McKesson, and it, in turn, sells and delivers the products to pharmacy chains, as well as to smaller, independent pharmacies. The pharmacies pay an acquisition cost for medications then set a price for these medications that are considerably – or even astronomically – higher than the acquisition price. This is the cash retail price, or in medicine, what is called the Usual & Customary (U&C) cost of the medication. The price may be neither usual, customary, nor reasonable, and it’s not the price the pharmacy expects to recoup on sales.

Every major insurance company contracts with a pharmacy benefits manager (for example, Caremark, Express Scripts, and Optum) to negotiate the cost of medications with each major pharmacy chain. Physicians are familiar with PBMs, who intercede by requiring preauthorization procedures for certain medications or by instituting stepwise, fail-first, requirements before they will allow pharmacy benefits toward the purchase of medications. When the PBMs negotiate with the pharmacies, they will negotiate for a discount off the pharmacy’s U&C charge for medication, perhaps a discount as much as 75% or 80%. Mr. Hirsch noted, “The discount is not negotiated on a per-medication basis but as an across-the-board average, so for one medication, the insurance price may be 2% discount from the U&C cost, and on another medicine it may be 95%. There is a dramatic variation, more than you’d ever expect.”

GoodRx gathers prices from many places, including partnerships with a number of PBMs. In addition to providing discounted prices for insured customers, the PBMs also include in their negotiations a slightly less-discounted price for cash-paying patients who present with a GoodRx card or coupon. You might be surprised to learn that discounted prices can often be less than the typical patient copay. For patients with a high deductible, for medications that are not covered at all, or for times when the copay is higher than the cost of the medication, it will often be less expensive for patients to use a GoodRx discount instead of their insurance. And whether patients uses either their insurance or a GoodRx discount, part of the cost of the prescription includes an administrative fee that goes to the PBM. When GoodRx cards are used, the PBM pays GoodRx part of that fee. I hope you are still with me, because this is the part of the conversation where I started telling Mr. Hirsch that I was getting a headache.


You paid how much for that medicine?

I went back to the enormous cost discrepancy that I had discovered a couple of years ago with Provigil (modafinil). Thirty pills cost just under $35 at Costco, while all other pharmacies were charging close to $1,000. Mr. Hirsch explained, “From what I’ve been told, Costco bases their prices on their acquisition costs and then raises them a certain percent. It’s one way to provide a fair price, but that doesn’t mean they always have the lowest price. They are also the only major pharmacy that lists their drug prices on their website.”

I wanted to know what was in it for the PBMs. Why would Express Scripts be motivated to negotiate a discount in price for cash-paying customers outside of the insurance networks, and how did partnering with GoodRx benefit them? The answer, in part, lies with the fact that the website and app allow patients to comparison shop and go to pharmacies with lower prices. If patients use their insurance, the insurance company is paying less; if they don’t use their insurance because they learned the cash cost is less, then the cost burden has shifted from the insurance company entirely to the patient.

What’s in it for the pharmacies? Why would they be willing to accept less money from a patient bearing a discount card? Mr. Hirsch explained, “Pharmacies want to honor their contracts with PBMs, and the U&C prices are set high to enable negotiation so that they still make some profit. Most people couldn’t afford to pay the high U&C, but they can’t lower them for individual cash-pay customers because that would violate their agreements with PBMs, and Medicare and Medicaid, which is a felony. With the GoodRx price, they still make a profit, and people in drugstores buy other items as well.

Dr. Dinah Miller

“I can’t emphasize enough that the pharmacies are very happy to work with us,” Mr. Hirsch went on to say. “They get more patients, and in certain areas, a prescription that costs over $15 may never be picked up. Many pharmacies are frustrated; they want a fair price where they can make a profit, and every year, 200 million prescription orders are left at pharmacies, and the medicines are never picked up. Nonadherence to medication comes at an enormous cost in this country – roughly $300 billion in medical expenses. I started this company because I was trying to figure out a problem with my own medication. We want medications to be affordable.”

GoodRx has 95 employees, and I was still left wondering how they generate income. Mr. Hirsch pinned it down to three sources: the portion of the administration fees the PBMs pay GoodRx, a small amount of advertising, and finally, GoodRx provides technology for the PBMs and charges for this service.

“We started asking how we could gather prices in this bizarre marketplace and address the pricing inefficiencies,” Mr. Hirsch said, “and now I get emails every day expressing gratitude.”

Dr. Miller is coauthor with Annette Hanson, MD, of “Committed: The Battle Over Involuntary Psychiatric Care” (Baltimore: Johns Hopkins University Press, 2016).