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| Posted by: Tree
- [3533298] Mon, Apr 14, 2008, 15:46
we are coming a truly frightening point in our nation's history in regards to taking care of ourselves, and each other.
to me, it is a vile, vile tragedy that we have people in this country who are uninsured, and can't afford simple health care that would prolong their life - and i'm not talking about living past 100, i'm talking about living into a reasonable old age.
but, it's only going to get worse if we don't change the course. As prescription drug prices spiral even more out of control, even those who are insured are struggling to afford necessary medicines they need to SAVE their lives... |
| | | 1 | J-Bar
ID: 292552222
Tue, Apr 15, 2008, 00:03
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most of the top 12 drugs in tier 4 were not being highly used 5 yrs ago and therefore insurance could absorb the cost for the few but as these more exotic and expensive drugs became approved and more widely used the companies had to adjust the tiers.
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| | | 2 | Madman
ID: 230542010
Tue, Apr 15, 2008, 09:22
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This is one of those big issues that no one is seriously talking about, and cuts across the political spectrum. No one has been able to develop a reasonable solution ...
Notice that Steinwand has coverage through the federal government's FEP plan, but got stuck with Tier 4. Canadian provinces are jacking up deductibles and copays or reducing coverage, as well (British Columbia has a $2000 *deductible* for drug coverage, for example).
To make matters worse (from a financing perspective), companies like Pfizer are shutting down their chemical research facilities and focusing on biologics, which have, for all practical purposes, a perpetual intellectual patent. Genentech is infamous for jacking up the dosages in their clinical trials (think Avastin trials for breast cancer ... IIRC) for chemo drugs that they already think might work. This creates a situation where the clinically proven dosage is much larger than what many think is actually required.
The efficacy of many of these drugs is also coming into question. How much should we pay to extend life an average of 3 months? Under what circumstances?
But we shouldn't delude ourselves into pretending that this is solely about end of life cancer care. Sprycel (mentioned in the article), Gleevec, Copaxone, etc., can be maintenance drugs. We don't even know the effective life for many of these multi-thousand dollar drugs.
In theory, Sprycel can compete against Gleevec. But there's no evidence for price pressure that I've seen yet.
To complete the logical conundrum, pharmacy companies do need a massive return per drug to research relatively rare diseases.
I'm a bit surprised it's taken this long for someone to complain about the Tier 4 idea and part D. Remember that Part D has a government "catastrophic reinsurance" for expensive individuals. This catastrophic reinsurance, however, still requires a 15% contribution from the plan and a 5% contribution from the individual.
With a progrma like part D, it does come down to money and political pull. The government has a limited budget. To make the design poltically popular, they have to lower catastrophic coverage thresholds. This costs lots of money, so they erase some of the coverage above the threshold. Which sucks if you get in a situation where you really need these items.
Notably, there isn't even catastrophic coverage in Medicare (medical side), for the same political reasons (it was passed with bipartisan support in the late 1980s, and was so unpopular they had to reverse it).
Meanwhile, private insurers are stuck in the competitive conundrum mentioned in the article. This conundrum is subject to the *exact same* pressures that the government programs are subject to. Namely, it can get so expensive to actually provide catastrophic care, that some private plans are experimenting with doing away with it on drug coverage. Ultimately, the $$ has to come from somewhere, or people have to use less services, or prices have to be lower. And many biologics are unlike chemical-based drugs, in that they actually do have substantive production costs. Not to mention the difficulty financing good and effective clinical trials, government oversight, etc.
And in some ways the private side is worse, since these are identifiable illnesses. This means that if you lose your HIPAA creditable coverage, you're only recourse is the generally crappy state high-risk pool (if you live in a state that guarantees access to insurance).
If anyone has a solution, I'm all ears.
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| | | 3 | biliruben
ID: 33258140
Tue, Apr 15, 2008, 14:17
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I don't have a solution, but I can see a few places we could improve the system by lowering costs.
- Negotiate with drug companies, and harness competitive forces where possible.
- Ban marketing directly to the consumer.
- Cap profit margins. Last time I looked at this sector, (admittedly many years ago) their margins were north of 25%; much higher than any other sector except maybe energy. Make them route excess profits into drugs for rare diseases.
- Assign 10-fold damages for frivolous lawsuits intended to impede generics entering the market. Again, increasing competition is good.
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| | | 4 | biliruben
ID: 33258140
Tue, Apr 15, 2008, 14:19
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Oh yeah - stop giving away gratis drug research paid for in our public universities, usually paid for by federal grants.
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| | | 5 | Madman
ID: 14139157
Tue, Apr 15, 2008, 22:39
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- Ban marketing directly to the consumer.
Here's an idea I threw around at work a couple years ago ... make it *illegal* for a regulated insurance company to cover any drug marketed direct to consumers.
Clinically effective drugs can be marketed successfully to physicians (although this has its own problems). Any drug that requires direct marketing to consumers is, virtually by definition, a personal lifestyle choice. Personal choices should not result in socialized costs (which is what insurance really is).
This idea is a pipe-dream, since many state legislatures *require* and most federal programs provide coverage for popular but medically questionable drugs. Nonetheless, I wonder if an argument about making insurance coverage illegal is deft enough to provide political protection, since you wouldn't appear to be attacking the drug companies or access to popularized med's, just attacking the mechanism to acquire them.
And if that doesn't work, I'll go with you. DTC advertising is a recent experiment that has proven to be quite the failure. Within the current regulatory framework, DTC simply doesn't work.
Regardless, this doesn't address the impending biologic problem addressed by Tree's article. On that topic, I'll just mention that we need to overhaul our certification processes, definitions of generics, and patent laws for pharmaceuticals. There are some decent ideas out there, although I'm still not sure I see a good solution.
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| | | 6 | Perm Dude
ID: 420241913
Tue, Apr 15, 2008, 22:50
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The only think DTC advertising does is raise the price of the drugs to cover the advertising costs.
Excerpt for the grins that come about because of the possibility of having a Viagra Bowl in college football, I can't see any real plus in DTC ads.
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| | | 7 | Madman
ID: 230542010
Wed, Apr 16, 2008, 08:39
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The only think DTC advertising does is raise the price of the drugs to cover the advertising costs.
I think we're advertising on the same side here, but there are a variety of impacts of DTC advertising.
1) increased pressure on physicians to prescribe not what's in the patient's best interest but what they saw on TV,
2) Overuse of physician office-visits for trivial cases of "I want some of that" logic,
3) Branding. The same drug, but branded, can capture 500% of the revenue or more. "Insurance" companies run scared to exclude them from formularies or charger higher copays to help steer to equivalently good but cheaper drugs. This effect is especially pernicious in the anti-depressant and sleep-disorder categories, where I'm suspicious that the placebo effect somehow is at work ...
4) Legal liability issues ... the fear of insurance companies mentioned in (3) also presents a legal liability issue with formulary design, generic-substitute patterns, prior auth's, etc.
5) Cheaper TV. (HA!)
I'm all for a free market, and I think they should be free to advertise and try to brand their product. Even if it is meaningless.
However, if they do so, then the cost of their products shouldn't be socialized. The least-interference mechanism I can think of is to make that rule-of-thumb law.
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| | | 8 | Frick
ID: 23117516
Wed, Apr 16, 2008, 08:56
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I question the wisdom of capping profit margins.
The drugs that make a large amount of money pay for all of the research and development of drugs and ideas that don't make it. Drug companies have a fairly high risk/reward nature. There is no certainty that an idea will work and a huge amount of money will be spent with the possibility of no recovery? Do we want to create an incentive for drug companies not to do research into new medications?
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| | | 9 | GoatLocker
Leader
ID: 060151121
Fri, Apr 18, 2008, 13:00
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For those interested in more info on this.
Here is a follow-up artlice on the government employee side of this.
Dozens of federal health plans require high payments for specialty drugs
Scary stuff, especially after just getting the pre-info prior to our annual benefits choices.
Lots of new things they appear to be adding that are heading in similar directions to this.
Cliff
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| | | 10 | Boxman
ID: 571114225
Sun, Apr 20, 2008, 06:59
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Health insurance is not a right, it is a priviledge. Frick's #8 pretty much sums up my position. I don't think the left has realized the dangers of price caps or margin caps. All they want is the bullet point for the campaign presentation. Then of course anyone who isn't for socialized health care is evil and wants to exterminate the poor, according to them anyway.
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| | | 11 | sarge33rd
ID: 76442923
Sun, Apr 20, 2008, 09:16
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How odd (was it really?), that a non-partisan discourse was underway, until a certain someone injected their bias view and blames only 1 side of the aisle?
Box..it isnt a right-v-left issue. Its purely a matter of economics. As for it not being a "right"...The right to life, liberty and the pursuit of happiness...could be interpreted to include a right to life-sustaining health care.
I encountered multiple Srs (back in the 80s when I ran my Ins Agency), who were spending 50% or more of their monthly income, on prescription drugs. HBP meds, Diabetes, and a host of other fairly "common" ailments which befall the aged in our population with a much greater frequency than the youth. Something has to give, and like most others here..I really dont know "what" that something is.
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| | | 12 | Tree
ID: 511251614
Sun, Apr 20, 2008, 10:16
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if you live in one of the most industrialized, wealthiest nations in the world, expecting a level of health care that can keep you healthy into an older age, is certainly a right.
this isnt a right vs. left issue. this is an issue of taking care of our own people as they get older, as we get older ourselves.
if we allow an entire generation to get older without taking care of them, the burden on society as a whole if they are NOT reasonably healthy will be even more than if they are.
i'd like to think of myself as a better person than the kind that has no problems with seeing an entire generation of americans - millions of them - wandering the streets in their older ages, sick and frail, because they cannot afford simple things like housing and medical care.
do i think capping profits is fair? well, not in a true capitalistic society. but, i also believe that our capitalism has run unchecked, and not enough is being done to "give back".
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| | | 13 | Boxman
ID: 571114225
Sun, Apr 20, 2008, 11:43
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Sarge, I suppose you have no biases. Bullshit. Again you lie. Perhaps you missed it, but Mith had asked for an elevation of respect around here and I'm trying to honor that for those who do so in kind. Tree has followed his lead, to me anyway, and I am trying to speak with him with more respect.
Until you stop acting like an a$$hole, I will treat you like one.
Back to better conversation and more inteligent conversation.
Tree: this isnt a right vs. left issue. this is an issue of taking care of our own people as they get older, as we get older ourselves.
I am in full agreement with you. This is more important than your or my partisan turf. What I'm perceiving here though is that you think I want or hope to have the elderly walking the streets destitute. That is far from the case.
Here's how I see things. The government has failed us with their promises of retirement and medical coverage. We are facing a huge liability with Social Security and Medicare and we can't afford it without mammoth tax increases. Like you, I don't have all the answers. I certainly have ideas, but I don't pretend to know it all.
I don't view government as the answer to problems, more often than not, they are the causation of problems. What I'd love to see are Americans who are taxed less that use that income to purchase health insurance on their own. This will create a competitive market where companies will try and provide better services for the consumers dollar or they'll go bust.
I see the government like how I see companies. Not all companies are good at everything. That's why Coca-Cola makes soda and not computers. Our government just isn't good at providing sustainable safety nets at affordable (taxes) levels with good rates of return for their customers. It's just not a core competency that we have. For various reasons that I'm sure both sides can be blamed for, government just fails us with it.
Therefore, I see no reason to grant the government more ability in the form of dollars to do something that they cannot do. It would be like paying me to build you a house.
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| | | 14 | sarge33rd
ID: 76442923
Sun, Apr 20, 2008, 11:54
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I don't think the left has realized the dangers of price caps or margin caps. All they want is the bullet point for the campaign presentation. Then of course anyone who isn't for socialized health care is evil and wants to exterminate the poor, according to them anyway.
That was you...right?
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| | | 15 | Seattle Zen
ID: 29241823
Sun, Apr 20, 2008, 12:14
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Our government just isn't good at providing sustainable safety nets at affordable (taxes) levels with good rates of return for their customers. It's just not a core competency that we have. For various reasons that I'm sure both sides can be blamed for, government just fails us with it.
You are simply wrong and yes, you do seem to want to have the elderly walk destitute through the streets.
You are a broken record and your "let the market solve it" is sophomoric. Seriously, anyone in high school can see the problem with your "no taxes, no services" program. The poor become destitute. Private charity will not make up the difference.
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| | | 16 | GoatLocker
Leader
ID: 060151121
Sun, Apr 20, 2008, 12:29
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Not wanting to take the thread down the dirt road, but Frick already spoke to this.
Capping profit margins will only stop Researdh and Development (R&D).
From the Defense side, I can give you some rough ideas.
In the service Areas, Return on Sales (ROS) is going to run 5-8%.
And I'm going to try as hard as possible to be at 8%, but it is tough with some of the Small Business requirements that are mandatory.
In the Systems Areas, I can get an ROS of up to 25-27%.
This allows me to have Money to do R&D.
Its all just the nature of the beast.
Cliff
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| | | 17 | Madman
ID: 14139157
Sun, Apr 20, 2008, 17:40
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Goat ... interesting that most of those plans are Humana plans ... Also interesting to note that Obama's written a letter to the OMB asking what's up ... weird, since he's a big supporter of the FEHBP model and wants to spread that to all Americans, you would think he would already know what's up.
As to the profits ... I'll vote with Goat and Box, etc. An accounting/incentive nightmare ... plus, it doesn't make a heck of a lot of sense if you think about it ... you preserve the patent rules that give them monopoly rights, then cap their profits from the drug? That seems like an end-around solution for what may be the problem: patent rights.
To this end, there are versions of congressional bills that talk about patent rules for biologic drugs ... but I haven't seen any that deal with this problem comprehensively. We'll also need to consider FDA reform, and perhaps a reform of our entire prescription/doctor model before it is all said and done.
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| | | 18 | Boxman
ID: 571114225
Sun, Apr 20, 2008, 18:00
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That seems like an end-around solution for what may be the problem: patent rights.
That's an excellent point Madman. I'm patent ignorant. What is the patent length of a pharma product? Do they differ at all from others?
Yet if we hasten the ability to make generics, won't big pharma just up the pricing to make up their R&D costs in a shorter time span?
Tommy Thompson didn't contribute much in the primaries, but he did add some facts about health care.
On Issues.Org
We got to completely transform the health care system, make it a wellness system, and make it a prevention system.
We have 125 million Americans that have one or more chronic illnesses. In order to change this we have to educate the American people about tobacco, about diabetes, about cardiovascular and about obesity. You do that, you'll be able to change health care.
25% of Americans use 2/3 of the cost of health care. If you manage those diseases, you can reduce that down to 50% and save lots of money.
information technology--electronic medical records, a patient bill of rights, and be able to have ePrescribing, and if you do that, you're going to be able to save billions of dollars.
If you just go paperless, you will save 10% of the cost of health care.
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| | | 19 | Frick
ID: 23117516
Mon, Apr 21, 2008, 16:44
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I don't think you can look at this as just a US issue. Many countries piggyback on the US when it comes to drug costs. Other countries put a cap on the cost of medications, but the drug companies can maximize their profits by selling there, if they can pass along the R&D and approval costs on to other users, mainly the US.
My wife has been battling an illness and one of the meds prescribed wasn't fully covered because it was so new. She took it 1 month, but the $200 deductible (for 2 weeks) and the limited effectiveness prompter her to speak to the doctor and switched to an older cheaper medicine (it also happened to work better for her).
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| | | 20 | James K Polk
ID: 5010361213
Mon, Nov 17, 2008, 11:43
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Curious if Madman, biliruben, etc., have looked at Bobby Jindal's proposal for health care reform.
The details remain a bit sketchy, but the basic idea seems to be that he'll move Medicaid patients -- and a fair number of the uninsured -- into managed care plans that would receive a fixed rate per patient (the rate would vary with health status). That would eliminate the perverse incentives of fee-for-service care, presumably. But in order to ensure high quality outcomes, there would be financial incentives if physicians met certain performance criteria. Here's the Times-Picayune story, and some potential risks highlighted at Wonk Room. Here is Jindal's outline of his proposal (PDF).
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| | | 21 | Boldwin
ID: 2410291417
Mon, Nov 17, 2008, 14:16
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FWIW Newt Gingerich claims Jindal knows more about fixing healthcare than anyone else in the country.
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| | | 22 | Madman
ID: 43923621
Mon, Nov 17, 2008, 22:31
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JKP -- sounds like California, which has been a resounding disaster (the managed care medicaid approach). The big problem isn't health outcomes, its the fact that the government tightens the screws so tight over time that actual care disappears and/or presents distortions in other markets.
His supply-side initiatives are valid, but would prove unacceptable to the AMA on the national scene.
Dunno. Don't read much innovative in there. Kind of like Obamacare ... a bunch of academic mumbo-jumbo put together under the label of plan.
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| | | 23 | Boldwin
ID: 571021718
Mon, Nov 17, 2008, 23:03
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Hopefully Newt didn't mean, 'knows how to demogogue the healthcare issue better...'. But Newt has always been about substance as far as I can see.
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| | | 24 | biliruben
Leader
ID: 589301110
Tue, Nov 18, 2008, 09:26
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I hadn't read it, but my sense is that if you move patients from Medicaid to managed care, costs will go up. You'll be paying a premium for an extra layer or two of gold-plated bureaucracy.
If you got all the uninsured on the rolls at the same time, it might be worth doing in any case, but I don't see how this would save money. Just move the uninsured onto medicaid, and things would probably turn out cheaper.
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| | | 25 | Madman
ID: 43923621
Tue, Nov 18, 2008, 14:49
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BR -- there's a debate about the efficacy of California's system.
If you move the uninsured onto medicaid, things would definitely turn out to be much cheaper. In fact, it might end up costing the government very, very little to give all of them coverage simultaneously. This is an especially effective tactic when combined with extreme reductions in physician reimbursement, to 20 cents to 30 cents on the dollar compared to Medicare (see NY, CA, etc.). No reason to manage that sort of care, since there won't be much care delivered in the first place.
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| | | 26 | James K Polk
ID: 5910371919
Wed, Nov 19, 2008, 20:52
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So, Daschle as Secretary of HHS. Think Progress talks a bit about his health-care philosophy:
- Expand the Federal Employee Health Benefits Program (FEHBP), or create a group purchasing pool like it: Participants could choose their own provider and would have the security of knowing they could never lose their coverage. Employers could let their employers get coverage through a FEHBP plan only if they enrolled all of their workers, not just ones with health problems. The FEHP pool would also include a government-run insurance program modeled after Medicare and would have tremendous clout to bargain for the lowest prices from providers and push them to improve quality of care.
- Subsidize coverage for those who need it: The government would provide financial help on a sliding scale so nobody has to pay more than a certain percentage of their income for health insurance. Administered as a refundable tax credit, this protection would apply to employer-based health insurance as well as private insurance obtained through the pool.
- Strengthen Medicaid: Simplify and extend Medicaid to cover everyone below a certain income level. The federal government should pick up the tab for this expansion, and ensure that states don’t’ cut off people when the budget gets tight.
- Concentrate on the value of care: Strive to get more for our health care money by promoting research that compares drugs and treatments to determine which ones deliver the best bang for the buck. Daschle also proposes promoting prevention that would reduce the number of chronic conditions.
- Improve health care infrastructure: Adopt health information technology to lower expenses and allows rural residents to connect electronically with medical providers. Increase the number of community health cetners and government-funded clinics that provide basic care for the poor and uninsured.
Anyone read Daschle's book?
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| | | 27 | Razor
ID: 181051618
Wed, Nov 19, 2008, 22:45
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I know about a dozen PhD's in public health, and they were all pretty excited about having Daschle as head of HHS. It will be interesting to see how his healthcare reform proposal differs from what Obama campaigned on.
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| | | 28 | Baldwin
ID: 1110431822
Thu, Nov 20, 2008, 02:36
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My theory is that during a depression Obama can't deliver all his pie in the sky big government, but he will be big on FDR style make-work subsistance pay projects. Maybe habitat-for-humanity on government steroids.
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