Despite increased attention to the reach and gravity of mental illness, there is no secret of the limited supply relative to the demand for affordable and quality treatment options. Indeed, given rising costs and great distances to find services, an estimated 45% of the mentally ill receive no treatment, with 40% of those with schizophrenia and 51% of those with severe bipolar disorder receiving no treatment. 

As further recent evidence of the shortfalls of mental health care, Oklahoma announced on March 25, 2016 that the state will face $13 million in cuts to mental health care. The Oklahoma Department of Mental Health and Substance Abuse Services had already announced earlier this year $9.8 million in cuts, bringing the total to $22.9 million in cuts announced in 2016 alone. Accounting for federally matched funds, the Agency has said that it is effectively down $40 million, leading to over 73,000 Oklahomans facing reduced services.

In prior instances of major cuts to mental health services in Oklahoma, the state saw marked increases in the rate of suicide, and there are anticipated to be impacts on both private providers and the inmate populations. $7 million of these cuts are to private community-based providers of mental health services, and there are to be reductions in reimbursement rates for inpatient and residential treatment programs.  

This is particularly salient because Oklahoma is one of the states with the highest rates of serious mental illness (those in most need of urgent treatment), with a national rate of serious mental illness among adults of 4.0% while Oklahoma's rate is 5.24%, outranked only by West Virginia (5.48%). Moreover, with a national average of 18.2% of any mental illness, Oklahoma's rate of 21.88% is outranked only by Utah. An estimated 57% of the Oklahoma prison population suffers from a mental illness or exhibit symptoms of mental illness, and while Oklahoma outpaces almost every state in rates of mental illness, it also spends less per capita on services than do most states (only Arkansas, Idaho, Texas, and Puerto Rico spend less per capita). Needless to say, these newly-announced cuts will only amplify this disparity. Oklahoma also ranks as having the 11th highest poverty rate in the United States, an issue particularly salient given that money is a frequent barrier to treatment. Thus, this is a particularly dangerous context in which to be seeing funds reduced. 

​The realities of governance are such that policies are the product of partisan bargaining, and that some services need to be cut in order to make ends meet. However, when we consider that the long-term ramifications of untreated mental illness -- especially untreated serious mental illness -- range from homelessness to addiction to incarceration, it is incumbent upon us to remind lawmakers that cuts to mental health services may necessitate distribution of more funds toward prisons, crime control, and substance abuse treatment (mental health and substance abuse often co-occur), not to mention managing higher costs for treatment of medical conditions given the greater prevalence of physical illness in the medically ill population. Thinking more proactively toward preventive care, both medical and mental health, may aid states in managing these various illnesses and avoid the more costly interventions when it may be too late. 

 One takeaway from the last few election cycles is that the Republican Party has not done an effective job of reaching out to women voters, particularly salient given that they currently make up just over half the population and are more likely than men to turn out to vote. We can point to a number of explanations for this difficulty in reaching out to such a key demographic group, from pro-life stances that in some cases go as far as opposing family planning services and access to preventive care, and the politicization of more basic policies such as equal pay for equal work, largely supported by the Democrats and opposed by Republicans. From "binders full of women" to adding Palin to McCain's ticket in hopes that women's solidarity would trump policy preferences, the Republicans have made a number of moves that have not served them well. 

The so-called "war on women" is particularly salient this year given that the Democratic Party's presumptive nominee is Hillary Clinton, and Donald Trump has not been known for his sensitive comments toward women, quite notably in his battles with Fox News' Megyn Kelly, who may or may not have had "blood coming out of her wherever." Indeed, Huffington has even catalogued hard-to-believe things that Trump has said about women, from marginalizing the importance of sexual assault in the military, referring to breastfeeding as "disgusting," to characterizing women as a "manipulative" sex, to speaking often to the importance of looks in politics and entertainment. Trump's latest attack on Cruz's wife only adds not only to the GOP's struggle to garner the support of women, but also to the animosity between the two main remaining Republican presidential candidates. 

Trump's charge: his wife Melania (a retired model) is more attractive than Heidi Cruz (depicted unflatteringly), with the caption, "The images are worth a thousand words." This was in conjunction with allegations that Cruz had cheated on his wife. Admittedly, it is not uncommon for the families of presidential and vice presidential candidates to be "vetted" as well as the candidates themselves. 1992 saw numerous GOP attacks leveraged at Hillary Clinton and Tipper Gore, characterizing them as "radical feminists" with women not actually wanting to be liberated from their home/kitchen. Tipper Gore was challenged for her campaign against violent and sexually explicit lyrics on record albums. The Palin family came under extensive scrutiny as well in the 2008 election cycle, showing that it is not solely a partisan matter. 

Trump's comments may not be surprising to those who have followed him closely, and his transparency in the way of discussing the importance of image over substance (resulting in a 70% unfavorable rating of Trump among women, with even a 39% unfavorable rating among Republican women). They also allow Cruz an opportunity to defend women, because while women do vote more Democratic (52 vs. 36% according to a 2015 Pew study), Republicans cannot win the election without some women on their side. Cruz retorted that spouses and children should be off bounds with respect to partisan attacks. What remains to be seen is to what extent he will stick with that language moving forward. Will we see a resurgence of Bill Clinton's extramarital affair(s)? Will we see other personal attacks? Is it only personal when it is personal to them? 

While Trump's comments certainly underscore his continued assaults on women (and many others), for example, his characterization of Hillary Clinton as "very shrill," it would be hard to construe Cruz's defense as much more than defending his wife. Cruz, after all, has opposed abortion even in cases of rape and incest, and opposes the provision of plan B. And while abortion is only one of many issues of gender (in)equality at play, Cruz has also expressed that equal pay for equal work is already law, and voted against the Paycheck Fairness Act. That Cruz defended his wife as beautiful and a wonderful wife and mother should not be mistaken for a position in favor of women more generally. Whether Cruz stands by his charge that the families of candidates should be off grounds for personal attacks remains to be seen. 

If there's anything that you take away from reading my blog, I hope that the importance of persisting underinsurance in America is one of them. Chelsea Clinton recently spoke out about this, raising the possibility that Hillary Clinton might use the tool of executive order to help curb healthcare costs for those who are unable to afford to use their health care, specifically working to reduce out-of-pocket maximums: "And, kind of figuring out whether she could do that through executive action, or she would need to do that through tax credits working with Congress. She thinks either of those will help slove the challenge of kind of the crushing costs that still exist for too many people, who even are part of the Affordable Care Act and buying insurance." This was consistent with Clinton's health reform plan in the 1990s, though that we know to have been unsuccessful.  

This raises an important question: What is the best way for a president to achieve this end consistent with the party platform and campaign goals (not to mention many public preferences)? There are a number of options. One is to work with Congress to push for amendments to the Affordable Care Act (ACA) in ways that reduce healthcare costs. The challenge here is that both chambers of Congress are controlled by the Republican Party. It is unlikely that the partisan control of the House of Representatives will change with the November elections. The Democrats have a chance at reclaiming the Senate, but it's a toss-up -- the Democrats may take the Senate, but it may only see a leftward lean in the Senate median with a de facto need for supermajoritarian support in order to pass legislation of any significance. And amendments to the Affordable Care Act would absolutely fit the bill. The result is that there will be a political environment not ripe for major policy change, with potentially only incremental progress to be expected given tendencies toward obstructionism. In fact, partisan voting extends even to non-political but also to procedural votes. In short, Congress isn't likely to move much unless the Democrats take the Senate, and even then there will be marked potential for opposition obstruction. 

Another option is to work with states to incentivize improving upon the federal plan. For example, we find marked variation in air and water quality standards in the states, with California standards being particularly higher. We might envision states opting into add-on plans that cap out-of-pocket maximums and deductibles, two of the plan costs that constitute massive barriers to individuals being able to use the plans by which they nominally are covered. 

Which then brings us to changing health policy by way of executive order, which are legally binding orders given by the President of the United States. The challenge is that the public's view of executive orders tend to low, as Reeves and Rogowski (2015) show. They find that support for the use of executive orders tracks the public's evaluation of the president and the their beliefs in the rule of law (e.g., ensuring civil rights, civil liberties, mechanisms of accountability, etc.). 

So there is a real risk in pursuing policy through this means. When the president works with Congress to achieve progress toward healthcare progress, in the face of obstruction, it becomes relatively easy to point to Congress (in particular, congressional Republicans) as the culprit in precluding movement from the status quo. We are seeing this in the context of the current battle to fill the Supreme Court vacancy held by the late Justice Antonin Scalia. That said, it is easy also for Republicans to say, "You elected Clinton, and what has she accomplished? Vote for us in 2020 and we'll let you decide how you spend your money." But amid a polarized setting, pursuing policy change by way of executive order may be smart, but it would have to work given that there would, in that case, be only one person to blame, using a tool not revered by the American public on principal (a trend that is consistent over time, though with public support for unilateral action higher in those contexts in which Congress fails to act). How Clinton continues this discussion with respect to executive orders (in this context and others) will give us valuable information as to how we can expect her to work with Congress and to what extent she will work toward a stronger presidency, albeit toward responsiveness to public needs by way of unilateral action. 

​Auden’s “Funeral Blues” characterization of funeral perhaps most aptly describes the sense of loss that one feels upon the passing of a loved one: “He was my North, my South, my East and West, My working week and my Sunday rest, My noon, my midnight, my talk, my song; I thought that love would last for ever: I was wrong.” While Auden shows us the devastation of funeral mourning, he does not there address the grappling with the permanence of that person’s passing, the transition to addressing the person forever in the past tense. That was something that hit home markedly at the memorial concert for a friend who tragically died in January at the young age of 30. We heard two hours of people delivering hauntingly beautiful performances of Amy’s music because she couldn’t. There was so much love, so much loss in that room, but so much finality about her never to return to the stage with that “extra dose of awesome,” guitar in hand and mic stand in front of her petite figure as she sang her songs of love and loss. Her music lives on now only through recordings and others’ renditions, which beautiful though they are, still echo her absence, her missingness. And none of us quite know how to grapple with accepting that loss. 

A friend of mine write the song “It’s Gonna Get Better,” a few years before she passed away in January of this year. And in a sense, that’s what so many people tell those who are particularly struggling. It makes for a better line than, “What if this is as good as it gets?” or “You’re right, you probably are fucked.” But to many in crisis or near that point, those words can feel hollow unless sung by Fleetwood Mac and with the accompanying Bill Clinton associations (“don’t stop thinking about tomorrow… it’ll be better than before, yesterday’s gone…”). When sadness turns to heartbreak (or as per my earlier writing, “sadness squared” or “sadness to the nth power), the things that we know are no longer the same as the things that we believe, and that disconnect can at times be a confusing one to make sense of. Part of therapy, or self-development more informally, is reducing that disconnect between knowing and believing, because with believing comes the faith in better days to come.
 
Knowing comes from the mind, which is the first to go when depression hits (and it can hit hard). It is cerebral, and not from the heart. It is the rational part of us that makes us erroneously think that we can talk ourselves out of the depression that consumes us, that makes us beat ourselves up for failing to intellectualize out of depression. It is the first battle that we lose, and we do not know what to make of that loss as we shrink into identifying as the Salieri’s of the world.
 
Believing is to be more advanced in one’s grieving or trauma processing. It is actually understanding the possibility of a difference between today and tomorrow, between tomorrow and week or month from now. As my friend sang, “It’s just a few days of pain and that’s all.” That is believing, understanding that that is potentially all through which she, we, must grit our teeth and bear the pain. But in the moment, when heartbreak becomes all-consuming, belief becomes hard to come by. It is when some turn to faith, which Springsteen calls out to in hopes that it be rewarded. Faith is a belief in the absence of evidence, either supportive or contrary, but its religious connotations pose obvious challenges to a number of non-religious people. Faith does not work for us all, and so we are left with the dichotomy between understanding and belief, treading a line in processing events, understanding the potential for progress to be slow, but to know that eventually, somehow, we do eventually heal if we give ourselves the time on this earth to. Not all of us do. Some inject, take pills, drink, jump, because they have not crossed over to the land of belief. Patience is a virtue not easily embraced, but in this case allows us the time to thrive in this important transition in healing, in accepting, in moving on even if our loved ones cannot. It is what allows us to understand and believe that it’s gonna get better. 

Unabashedly opportunistic though it is, the tragic attacks in Brussels gives Clinton an opportunity for her foreign policy experience to shine, showing herself the most competent candidate from among both fields to navigate the complexities of this international attack and helping nations to coalesce toward a solution. This is not a traditional "women's issue," which is to Clinton's advantage in a sense because she cannot be marginalized as caring primarily about such issues as women's rights and social programs (areas in which she also shines politically), but also national defense and security, which are issues in which the Republican Party tends to dominate more and which have been more "owned" by the Republican Party. 

Accounts of unfavorables on both sides of the political aisle have been documented, and part of the dissatisfaction that the Democratic voters have had with Clinton is her more moderate approaches to policymaking. In truth, her policies vary only marginally from those of Sanders, but she has the more pragmatic and admittedly less "sexy" approaches to these political problems -- wear and tear in the Senate and other offices have given her realistic expectations -- which Sanders supporters have ben keen to characterize as being less progressive.

There are a few realities with which they must both contend and one that only Clinton must  contend. First, making radical changes at the national level may founder, leaving the Democratic Party highly vulnerable in taking the fall in the 2018 midterm elections. But that would be an unlikely scenario to arise because it is contingent upon even getting to the implementation stage. Which brings us to the second problem. Having a likely still divided government  scenario (the Democrats will assuredly move the Senate median to the left, but not necessarily enough to gain control) requires some measure of compromise and conciliation which is hampered by designation as a self-described socialist, and by the stubborn promotion of positions too far to the left and too uncompromising to garner needed moderate Republicans' support. 

The Clinton-specific challenge is that of being a woman operating in a man's world, and thus needing to appear stronger, tougher, more in command, and let's face it, deal with slanders that our culture rightly abhors in the racial context and yet somehow accepts in the analogous cases where gender is concerned. Such is consistent with years of American history, with African Americans gaining suffrage far earlier than did women of any color. And concessions to emotion by women immediately confirm biases that women "may not have what it takes" to be the leader of the free world. There is no question that if Nancy Pelosi cried publicly as much a did John Boehner, we would not have heard the end of it. Boehner got a free pass, except for his name of course. 

Part of what we are seeing in Hillary is her effort to play this man's game, but until we change the gender dynamics of the United States, it will be a necessary evil, and a necessary condition for winning elected office not to mention prevailing in bargaining conditions upon electoral success. In a wonderful "West Wing" episode titled "Let Bartlett Be Bartlett," in which the main players choose to set loose the progressive Jed Bartlett with whom they had all fallen in love in the primary campaign. Hopefully one day we will be able to "Let Hillary be Hillary," but as long as she and her staff know well, you have to play the rules of the game in order to get in the door and begin to win the real fights. In the meantime, I hope that the Democratic voters have the patience to let her show her true colors as a bona fide progressive and champion of rights as Madame President. We just need to elect her first. 

Ironically writing while being treated in the American healthcare system (I like to think of it as "field work" on American hospitals and insurance... as any politician can tell you, it's all about the framing), this article from the American Journal of Managed Care speaks directly to my previous post on the prevalence of underinsurance in American health care:

"Today’s health insurance marketplace is brimming with 17 million newly insured individuals, including those covered directly by the Medicaid expansion or the marketplace provisions of the Affordable Care Act (ACA) and those newly enrolled in an employer plan. Although the expansion of insurance coverage is a good thing for access and population health, specific features of the ACA coverage expansion have contributed to the rising number of underinsured individuals, defined by the Commonwealth Fund as people who have out-of-pocket healthcare expenses (eg, co-pays, coinsurance, deductibles) that account for 10% or more of their income, or at least 5% among those with lower incomes. Individuals with rare diseases, chronic conditions, or costly illnesses like cancer, who rely on specialty drugs, are even more likely to become underinsured, and this underinsured population is growing. A 2015 issue brief on the 2014 Commonwealth Fund Biennial Health Insurance Survey revealed that 23% of adults aged 19 to 64 were underinsured—that’s almost twice the 2013 rate. Our experience at the Patient Access Network (PAN) Foundation, an independent, national charitable organization that assists federally and commercially insured individuals living with chronic, critical, and rare diseases with the out-of-pocket costs for their prescribed medications, coincides with this finding. We have seen steady growth in patients’ need for financial assistance with the out-of-pocket costs of their medical treatments. In 2013, we assisted 99,271 patients, and in 2015, we assisted 364,385 patients—a 267% increase in just 2 years. Further, the amount of assistance PAN provides to individual patients has nearly doubled in the last 2 years."

The Patient Access Network (PAN) is an independent 501(c)(3) organization committed to addressing these very challenges of underinsurance, particularly in those with rare and chronic diseases that require that they draw heavily on their insurance benefits as well as their bank balances to cover the remainder. (Interesting, though somewhat distressing note on this: Hospitals have taken to running credit checks on patients' ability and likelihood of paying their hospital bills. While such credit checks are supposedly for informational purposes and not used to make decisions whether or how to treat a given patient -- they are obligated to provide treatment -- it adds an interesting level of transparency to the monetary aspect of healthcare provision in the United States). $0.95 of every dollar donated to PAN goes directly toward helping helping patients to afford needed medical care. This is not a Democrat issue or a Republican issue. It is a human issue. If you're in the camp of voters dissatisfied with options in both parties, consider donating here instead. I can almost ​guarantee karmic rewards.

In the interest of full disclosure, my (strong) personal preference is for Hillary Clinton to be the next President of the United States (#ImWIthHer). But even absent this personal preference, at this point in the campaign there are innumerable reasons for Sanders to concede to Clinton in the race to the White House and not merely in the individual states in which she outshines him (sometimes very modestly as in Missouri, other places much more dominantly such as in Virginia). 

Whether or not you like superdelegates (definition: an unelected delegate free to support any candidate for the presidential nomination at the party's national convention), they change the delegate math in a way that makes the nomination virtually unattainable for Sanders. While one needs 2,382 of the 4,763 delegates in order to win the Democratic nomination, Clinton currently has 1,119 to Sanders' 813. But among superdelegates, Clinton currently has 467 to Sanders' 27, making the delegate gap much larger. To be clear, this is not a case in which the superdelegates are going against the preferences of the rest of the delegate population. Clinton leads in both subgroups. But the superdelegate differential reinforces the upward climb that Sanders would face, an upward climb that is moving steadily from challenging to futile. 

And yet he still has ample support, and there are arguments of representation in American politics that can be made in support of his continuing to represent those preferences (which admittedly from a policy standpoint differ only minimally from the preferences of Clinton, who emphasizes experience and pragmatism in implementation of a similar core agenda). There are also cases in which candidates can serve important roles to put on the agenda issue items that mainstream candidates will not, but maybe should at least think more critically about, or promote some dialogue in the media and among the voters themselves. Kucinich's campaign in 2004 serves as a salient recent example. And despite apparent determination to take the nomination battle to the convention, we have seen some rhetoric from Sanders that echoes the inclination to put issues on the agenda, to force discussion of issues, as opposed to battling for those ideas to be put into practice. 

The problem is, when treating the race as hotly contested (and it is being hotly contested in a number of states, though keep in mind that New York has not yet voted), Sanders is -- as does any candidate -- making a number of attacks on Clinton. It has been argued that his becoming an "attack dog" is the only winning strategy he would have left in order to succeed. And that is certainly his right given that she is his opponent. But given the high probability that she will indeed win the nomination, battles on the nuances of policy and personal attacks leveraged among Democrats become ammunition come the general election. Sanders is in effect writing attack ads for the Republicans or shortening the amount of time they need to do on opposition research. And that isn't for the good of the Democratic Party. (Indeed, it has not gone unnoticed that some are attracted to both Sanders and Trump given their anti-establishment rhetoric, in addition to going after Hillary on the issues on which the GOP will be focusing going into the November general election). What it shows is that, like any human and particularly like any politician, he has self-interest and is acting on it, even to the detriment of the policies that he so vigorously defends. 

Sanders has come much farther than many (even he) thought possible, and it was going to be a difficult road no matter what (not aided by his being a self-proclaimed Socialist, which is a label unlikely to play well among Blue Dog Democrats, independents, and moderate Republicans feeling that their party's candidates are out of step... also not aided by his failure to garner support among key Democratic constituencies such as the African American community, or the fact that he does not hail from a key state). He should feel proud of what he has accomplished, both in delegate counts and in promoting discussion of a progressive vision of what America can and should be. But that is where is should end, lest he help facilitate a change in presidential partisan control and in turn the (potentially far) rightward direction of American social, economic, and foreign policy.

We all know the phrase. It isn't easy being green. Kermit was a wise frog. But maybe it's not so hard after all. Don't lose hope, Kermit (and other similarly-woed frogs of the world).

When we talk about the environment, we often create for ourselves a dichotomy between economics and environmental protection. And there is some merit in that. We impose oil taxes to increase the cleanliness (such as it is) and to incentivize reduced consumption. Green alternatives for products can be more expensive. Not everyone can afford a Prius as opposed to an older, less fuel-efficient model.

But there is also so much opportunity for job creation and innovation when we fully commit ourselves to environmental protection in ways that go beyond images of polar bears in melting ice or taking the bus instead of driving (if your city of residence has such infrastructure in place). And even as other nations have outpaced us on health care and education and certain technologies, Americans pride themselves on their innovation, tenacity, finding pathbreaking alternatives to the status quo.

There are few policies as ripe for innovation as environmental policy. From wind and solar technologies to finding new sources of alternative energy that we have not even yet considered, there are innumerable opportunities for those with scientific skills and craftsmanship to think outside the box, or better yet, beyond the box. Finding affordable ways to manufacture products sustainably provides other such opportunities to bring new ideas and visions to the table, some of which may well fail, but some of which may allow us some meaningful breakthroughs so that we can collectively work to leave the planet better than how we found it (or at least not considerably worse).

There inevitably are costs of compliance with environmental regulations, and some small businesses may feel the pinch. But if possible, it would behoove us all, especially amid the policy rhetoric of the coming months of the presidential election to set aside the false dichotomy of economic security versus environmental protection. Without a planet with breathable air and drinkable water, the economic impacts may begin to pale in comparison. With economic investment in hiring smart people to develop ways to limit our environmental impact, we can have both. The ball is in our court.

​Episode 1 of Season 2 of Last Week Tonight with John Oliver took on the important relationship between doctors and the pharmaceutical industry, encouraging his viewers to look up their doctors’ relationships with the industries (meals, speaking events, “thought leader” status) through the website http://openpaymentsdata.cms.gov. And as an avid fan of John Oliver (I do indeed profess my belief to Our Lady of Perpetual Exemption) and as a citizen interested both personally and professionally in interest group influence in our legal and medical systems, I spent a lot of time on there. This is an issue of immense magnitude: Americans spent $329.2 billion on prescription drugs in 2013, and few of us understand the science underlying them or the rationale behind the prescription unless particularly inquisitive. I looked up all of my doctors over the years (sadly, there have been many) and took satisfaction out of knowing that my favorite ones had little to no connection to pharmaceutical companies (and confirmed that it was not merely due to the policies of the hospitals with which they were affiliated). One of my doctors, for whom I have utmost regard, took a speaking fee but he is heavily engaged in research as well as clinical work, and thus it seemed well within reason, and the others’ contributions were meals totaling less than $200 (sometimes less than $50) in a given year. Not exactly big-time influence, but I was primed to keep on the lookout.
 
As an insomniac, I am often after the miracle drug that will help me to get through more than 4 hours without waking up, and I have tried a number of natural and medication remedies. Yoga. Meditation. Deep breathing. Running in the morning. Running at night. Melatonin. Ambien. Trazodone. Klonopin. Some worked for a little and then stopped working, others didn’t work at all. And then a doctor brought up a new medication to my attention, one that I had not heard of before: Belsomra, which is manufactured by Merck. It cost at least $300 out of pocket but a coupon that he issued to me, the cost was knocked down to $30. (For perspective, Ambien is about $10 with insurance but without such special discounting).
 
I subsequently began to see ads for this new drug on TV, but more importantly saw the next week in this doctor’s waiting office a pharmaceutical representative talking with another patient about, you guessed it, Belsomra. (This particular doctor was not that high ranking when it comes to funds and gifts, but at over $500 and with this particular presence, I was given reason to at least ask for a second opinion from another doctor who expressed suspicion about going on medications that were newly marketed and not tried and true over the years with respect to impact, side effects, etc.). I still gave it a shot (after all, a lot of my favorite products have been sold to me by buying ad time or influence – I posit a direct causal relationship between DSW commercials and my bank balance), but it wasn’t for me. I’m still on my quest for the magic pill. But many others gave this new medication a shot too. Just one month after its February 2015 introduction to the market (admittedly after failing FDA approval at higher doses), physicians were writing approximately 4,000 prescriptions for it a week and huge financial gains as a consequence, in an insomnia market that has been otherwise, ironically, sleepy. Unlike much of the antidepressant market, this drug is in fact novel. In my case, I didn’t like the price tag personally or on principle, and some medical professionals have questioned whether it is indeed more effective than more cost-effective alternative medications (or perhaps better yet, cognitive behavioral therapy).
 
The point here is not that pharmaceutical companies are marketing their products, or that doctors are willing to try new medications when others have failed. The problem is the motivation underlying these influences, with consumer confidence not likely aided by the fact that pharmaceutical companies spend more money on marketing than they do on the medical research itself.
 
The fact of the matter is that there are a lot of medications on the market that chemically are very similar to one another, but that for idiosyncratic reasons may be more effective or problematic for one person than for another. For example, Zoloft, Prozac, Lexapro, Luvox, Celexa, and Paxil are all anti-depressants falling under the category of Selective Serotonin Reuptake Inhibitors, or SSRIs (and not too surprisingly, are manufactured by competing companies, with Prozac manufactured by Eli Lilly & Company, Zoloft manufactured by Pfizer, Lexapro manufactured by Forest Pharmaceuticals, etc). Thus, they all function in a similar way, which is to block receptors in brain cells that reabsorb serotonin so that more serotonin will be made available, potentially reducing the extent of the depression. The major variants are things such as their half-life and the particulars of their binding properties (so in some cases, there can be variation in potency).
 
They also tend to come with similar clusters of side effects, such as gastrointestinal problems, drowsiness, sexual side effects, and weight gain (the last of which is a claim more challenging to make in some cases given the relationship between depression and appetite). For reasons that are not easily explained or well understood, a person may respond better to one than the other despite these functional and chemical similarities.
 
But it is worth thinking critically about what those close similarities mean in real terms from the standpoint of financial gains. Because obviously given the complexity of the mind, it would stand to reason that more diverse options is better than the alternative, right? Maybe in theory, but it doesn’t look like that’s really what we’re getting all the time, which looks more like tweaks than innovations.
 
Because of the way that American patent law is structured, a modest chemical change can justify a new patent (and in turn protect against others producing the same product), and with it a new brand name, new marketing to doctors, and more money for the hot new item on the market. When a patent expires, a tweak can lead to a new set of free samples and ads advising you to ask your doctor of that medication might be right for you. It’s new. We like new. We line up outside for hours for new Apple technologies that we know will become obsolete and incompatible with everything else in two years, but we do it anyway. We try the new restaurant in the neighborhood rather than the tried and true. And some of us like to give a new drug a shot and see if we’ll be among the first to get relief. But on balance, rather than choosing between medications 1 and 2 we’re more often choosing between medications 1.1 and 1.2.
 
For example, in 2002, Forest Pharmaceuticals cut Celexa in half and marketed escitolopram, or Lexapro, as the new antidepressant to try.  Was this innovation? Not really. But it was new, and that meant new marketing and money, and as the document “Lexapro Fiscal 2004 Marketing Plan” summoned by the Senate Special Committee on Aging demonstrated, given these chemical similarities to the inexpensive and already available Celexa, Forest Pharmaceuticals’ plan to persuade psychiatrists to prescribe the new drug was through giving them money and food, with even a civil suit about kickbacks to doctors in exchange for prescribing it (which rightly is illegal, or else we would go to MBAs rather than MDs for medical care). And while they did tinker with the molecule and thus legally allow the company to patent the new medication and sell it as a new product, the Food and Drug Administration had not required thorough investigation into its being an advancement on existing treatments. While Celexa and other SSRIs are notably inexpensive, Lexapro garnered $2.3 billion in sales in 2008, at that point selling at about five times the price for a month supply of Prozac (it has since been lowered).   
 
That Lexapro and other medications have some dubious histories attached to their development does not take away from the fact that they may indeed be medically effective and advantageous for a given patient in the eyes of the prescribing physician. But the pharmaceutical industry is an important and complex interaction of economics and public health, and the two can often find themselves at odds with one another, with money holding much of the power and the human side sadly neglected.
 
It is not hard to see why pharmaceutical companies would have a big stake in who holds the political reins in the United States. In the aftermath of Citizens United v. FEC, the Supreme Court controversially held that campaign contributions constitute speech protected by the First Amendment and should be unregulated provided that it is independent of the party or candidate, a holding that has led to increased concern as to the influence of super PACs and other such organizations. As one can find through Open Secrets, pharmaceutical companies have poured millions into campaign contributions, largely though certainly not exclusively to conservatives and Republicans. Moreover, there is a well-known “revolving door” between federal agencies (e.g., the FDA), Congress, and the pharmaceutical industry, thus reinforcing these potentially problematic monetary incentives governing the provision of modern health care in this country.
 
Given this marked influence in drug manufacturing and marketing to doctors and their influence in the government itself, it is important as we evaluate the current presidential candidates the types of pharmaceutical-public health-government relationships that they would reinforce as the next president. Ironically, Donald Trump has referred to pharmaceutical companies as villains and takes a more leftward stance on the drug industry, allowing for the re-importation of cheaper drugs from overseas, though he does support removing barriers to entry into free markets for drug providers offering cheaper products, and it is not altogether clear what that will mean with respect to the multitude of similar drugs with similar effects from competing manufacturers as we see in the case of SSRIs. Cruz’s RESULT Act works to break down barriers to medical innovation by way of allowing Congress to intervene if he FDA is slow to act in adopting certain new medications, but which could mean that in the name of promoting the innovation in which we are lacking, people could be consuming medical products approved with lower standards in other countries or with inadequate evidence of their efficacy. Both Clinton and Sanders have spoken on the importance of reducing the prices of prescription drugs, though Sanders has accused Clinton of being too close for comfort to the pharmaceutical industry.
 
Fixing the system itself is something of high aspirations – worthy aspirations, to be sure, but lofty goals unlikely to be addressed adequately in a conflictual partisan environment. And the manufacturers of medications that can be potentially very beneficial may have valuable information to provide to the physicians confronted with treating those conditions. Thus, there is an important informational value in giving physicians timely access to information about medicines and new treatment options becoming available. The question is whether that informational value is indeed the main mechanism by which they are operating, as opposed to the more nefarious deal-making. Further, we owe it to ourselves as consumers to do the research on what we are being prescribed and why, and to work to promote a culture in which doctors can be freer to practice medicine than business.