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“The Bank Always Gets Paid,” Mr. Potter

I met Lynn while working with Alan Collinge of the Student Loan Justice Organization. She too has been working with Alan to call attention to the plight of students who took loans out to pay for college and the mishandling by servicers of them.

The first story is of an older man who took out a Parent Plus Loan for his daughter, who has since died, and he is paying off the loan through garnished Social Security checks.

The second story is a time table and it is long. A younger person takes out a student loan for $10,000, graduates with a Bachelors degree, encounters many issues along the way, and works in the type of work which does not pay as well as many. The $10,000 debt turns into $30,000 over time. This is a well detailed story as told by Lynn a CPA. I plan to send this story to a few people I know to make a point. Monica’s story is one of most detailed accounts of student loan mischief and as close to fraud I have read. It is typical of what students face today.

Obama took the student loan lending business away from commercial interests and kept it within the government. The only problem, he left the servicing of the loans to commercial interests, who are in it for the money, and prey on unknowing teenagers trying to go to college, and eventually a living. These loans have greater profitability in default and are impossible to escape unless a person is disabled or dead.

Lynn Petrovich, CPA: In 2016, I prepared the return for an 80-year-old man who came into the tax clinic. He handed me his W-2 form which reported wages of $500 and a Social Security statement. He needed to file a tax return to obtain a refund of federal and state withholding reported on the W-2. While reviewing his Social Security statement, I noticed one-third of it was garnished. When I questioned him about this, he became very solemn, put his head down, and explained it was for an education loan taken out for his daughter “some time ago” to help her attend college. She had since died. Piecing together what he told me, I figured he took out a federal Parent Plus loan, had defaulted (before, during, or after his daughter’s illness and death), and didn’t know what to do. The default resulted in the garnishment of his Social Security, most likely without end for the rest of his life. There is not even an accounting of what is taken each year.

Monica’s Story

Between 1984 and 1987 Monica took out $10,000 in student loans. Over the next 30 years she made payments totaling over $24,000, yet she still owes more than $3,000 on her loans.

I first met Monica at a tax clinic in the early 2000s. As a CPA, I had been volunteering my time preparing tax returns pro bono on Saturdays during tax season. Monica and dozens of other taxpayers were waiting patiently to have their taxes prepared at this free clinic located at the Jersey Shore.

When it was her turn, Monica brought her completed interview/intake form to my workstation. I looked over the information she had provided and asked a few follow-up questions, including if she had any student loan debt.

She shifted in her seat and explained that she took out $10,000 in student loans when she was in college in the 1980s. She said that she has been doing her best to repay the loans since graduating but wasn’t really sure about how much she had repaid, how much of the principal she has knocked down, or how much she still owed. As a single person who rented, Monica needed all of the deductions to which she was entitled, so I encouraged her to get some specifics about her loans. She agreed to come back the following week with her student loan interest amount.

I’ve prepared Monica’s taxes many times since that first meeting in the early 2000s. Each year, she provided statements from her loan servicers which reported student loan interest received. During the 2017 tax season, while preparing her return, I discovered that she was still paying down the original student loan debt she’d taken out 30-plus years earlier.

How could that be?

My curiosity piqued, and I asked Monica if I could perform a review of her student loan debt. A week later, she handed me a large and overflowing manila folder containing 30 years’ worth of payments, loan documents, and servicer statements.

I dove into it with passion.

The following is a narrative on what I found (below narrative is summary recap of events by date, numbers are rounded):

1984 -1987: Origination of Student Loans

Monica attended a large public university outside New Jersey, graduating in the spring of 1987. In order to pay for tuition, housing, and other college costs, Monica obtained four (4) Federal Stafford FFEL loans for $2,500 each. All of the loans were fully subsidized.

What are FFEL Loans?

The Federal Family Education Loan program (FFEL) was a student loan program in which commercial bankers issued student loans directly to borrowers or colleges. FFEL loans are what the accounting industry calls “cash cows,” a type of business investment which rewards investors beyond risk (initial investment costs) with liberal guaranteed payments and profitability. FFEL loans are 100% guaranteed by the government, including subsidized interest rates, and administrative costs (special allowance payments).

FFEL loans issued for qualified educational expenses began to earn interest from the date the loan was distributed to the borrower or school (date of origination). While the borrower is in college, interest accruing on subsidized FFEL loans is paid by the government directly to the lender. Since this interest is paid by the government, the borrower is only responsible for repaying the original principal balance upon graduation.

The FFEL program was terminated by President Obama effective July 2010. Federal student loans are now issued directly by the government to borrowers (or colleges) and are a part of the Direct Loan program.

December 1987: Graduation, Repayment Begins

Monica graduated from college in the spring of 1987. Once her six-month grace period expired, her FFEL loans entered repayment.

Overview of Monica’s student loan debt in 1987:

Term of note: 10 years, 120 monthly payments
Monthly payment: $127.00
Interest Rate: 9%
Principal: $10,000 (because interest while attending college was paid to the lender by the government)
Interest over loan term: $5,238.00.
Total repayment: $15,238.00
Grace period: 6 months
Repayment to begin: December 1987

Over the next two years, Monica made consistent monthly payments of $127 directly to the commercial bank in New Jersey which originated the FFEL loans.

1989: Monica Gets a New Loan Servicer

November 1989; the commercial bank notified Monica that the servicing of her loans was being transferred to the Student Loan Servicing Center (SLSC), effective January 1990. The principal loan balance at the servicing transfer date was $8,706.

The commercial bank reported student loan interest received for 1989 was $746.33.

1990 – 1992: Negotiating New Terms in Hard Times

Despite working two jobs, full-time for a local nonprofit during the day and waitressing at the local bar at night, Monica had problems meeting her repayment obligations. She fell behind on the $127 monthly payments and approached her servicer for help.

July 1991; Monica signed a new note with SLSC (replacing her original loan note) for 90 monthly payments of her loans at 9% interest. Her new monthly payments were $136. The principal at note date was $8,148 plus accrued interest of $368 (for periods when she was unable to make payments interest was still being charged). With the interest capitalized (added to principal), her new principal balance totaled $8,516 ($8,148 plus $368).

1993 – 1995: Struggles and Forbearance

Over the next three years, Monica continued to work at least two and sometimes three jobs. Despite her hard work, she still struggled to make her loan payments. During these years, Monica’s housing and transportation costs accounted for more than 50% of her income. She had very little left for discretionary purchases and the payment of student loan debt.

November 1994; SLSC accelerated the loan due to nonpayment. The principal balance at acceleration was $7,325 plus accrued interest of $375. The interest was capitalized, bringing the principal balance to $7,700.

Monica requested forbearance. Forbearance allows student loan debtors to pause their payments for a short period of time. While payments are not due, the interest on the loan generally continues to accrue. As a result, the balance due will be greater after forbearance. SLSC agreed to grant a six-month forbearance, giving Monica a little bit of breathing room.

January 1995; Monica signed a new note with SLSC. Under the new deal, Monica would be required to pay 63 monthly payments of $154 at 9% interest. The principal of the note at signing was $7,325 plus accrued interest of $495, which came to a grand total of $7,820. Monica would begin payments in April 1995.

1996 – 1998: Increased Cost of Living Leads to Default

Over the next two years Monica did her best to make payments each and every month. Cost of living and transportation increased, continuing to swallow more than half of her monthly income. Monica skipped or delayed payments on her $154 plan.

August 1997 – ten years after graduation – Monica’s FFEL loans had been purchased by the NJ Higher Education Student Assistance Authority (NJHESAA). SLSC (the loan servicer) denied a request for economic hardship relief forbearance allowing the forbearance period to be interest free. Principal balance in August 1997 was $5,187.

[The NJ Higher Education Student Assistance Authority is a State agency which administers NJ CLASS loans (private student loan debt* originated through the sale of bonds to investors) and, as investments, maintains large quantities of purchased FFEL loans in their portfolio. As of 6/30/17, NJHESAA’s FFEL-owned loans totaled almost $2 billion].

*The Federal Reserve categorizes any loan that is not a Title IV loan as private. Title IV refers to the Higher Education Act of 1965 and amendments.

September 1997, after SLSC granted forbearance through April 1998, Monica signed another note with SLSC. The terms of the new note included 38 monthly payments of $173 at an interest rate of 9%. Principal balance was $5,187 plus accrued interest of $520 which was capitalized, bringing repayment of principal to $5,708. Payments were to begin May 1998.

1999 – 2003: Default and Rehabilitation

Over the next 2 years, Monica struggled to make the increased loan payments. Originally her monthly payment was $127 and a decade later, the monthly student loan commitment had jumped to $173. Working 60 hours a week, Monica’s yearly income rarely exceeded $25,000. In addition to struggling to keep up with the rising cost of living, Monica endured a series of medical catastrophes, fell behind on her payments, and defaulted in early 2000. NJHESSA told Monica she had to “rehabilitate” the loans.


Default of federal loans occurs when payment has not been made (or acknowledged by the lender) for more than 270 calendar days. Default causes the loan to be subject to higher interest rates, collection, and late fees. Collection costs for Monica’s loans were 18.5%.


A process where the borrower must bring the loans current by making consecutive monthly payments over no less than a 10-month period. Most often payments are determined by calculating 15% of borrower’s discretionary income, are not applied to the principal, and are used to pay for collection costs, fees, and interest.

Late 2000; Monica enters the rehabilitation program. After a year, she was notified by the guarantor, NJHESAA (who owned the FFEL loans), her rehabilitation was completed, and the loans had been referred to Sallie Mae for servicing. Principal at completion of rehabilitation was $5,282 plus accrued interest of $338 plus collection and late/collection fees of $1,076 (both of which were capitalized) brought the new loan principal balance to $6,697.

Monica signed a note with Sallie Mae for 104 monthly payments at $86.

February 2003; Monica continued struggling to make payments on the latest note. She was still working on paying off medical debt and dental work. Housing and transportation costs exceeded 60% of income. She requested and was granted a forbearance of 12 months.

2004 – 2007: Request for Consolidation

Early 2004; Monica’s forbearance ends. Housing and transportation costs still accounted for more than 60% of Monica’s income, and she was still paying off medical debt. Adding to this burden, she encountered large veterinary bills for her dog. Monica could not keep up with the new payment plan and was delinquent.

2006; Monica contacted NJHESAA and requested to have her loans consolidated. She completed the Direct Loan Consolidation application complete with loan detail, personal information, and references and submitted it to the Direct Loan Consolidation center. If the loan consolidation were approved, Monica’s loans would only be subject to 8% interest. She received a postcard informing her that her application had been received on 06/22/2006. Loan balance at June 2006 was $9,436. 18 years after graduation, her principal balance was almost as much as the original loan amount of $10,000.

There is no evidence her application for loan consolidation was ever processed and/or approved. If Monica’s loans had been consolidated, they would no longer be the cash cow FFEL-guaranteed loans were and may have been a deterrent to consolidation by the loan holders.

February 2007; Monica was notified by NJHESAA that her loans had again defaulted. They threatened garnishment of her wages. Monica agreed to a voluntary repayment arrangement of $112 a month over a 10-month period which required direct deduction of the payments from her bank account.

NJHESAA Form 1098-E for 2007 reported “defaulted FFELP loan” interest received of $972.87.

2008 – 2010: Struggling to Find a Solution

March 2008: After completing the second rehabilitation** program of her loans and 20 years after graduating from college; Monica entered into another repayment agreement with loan servicer AES, agreeing to monthly loan payments of $95.

[**According to studentaid.ed, prior to 2008, defaulted federal loans could only enter rehabilitation once. After receiving the notice from NJHESSA reporting her loans in default and threatening wage garnishment, Monica “volunteered” to make 12 monthly payments of $112].

NJHESAA Form 1098-E for 2008 reported “defaulted FFELP loan” interest received of $633.48.

2008 and 2010, Monica attempted to make monthly payments of $95. She was granted several periods of forbearance. In September 2010, AES notified Monica that her most recent forbearance had ended.

NJHESAA Form 1098-E for 2009 reported “defaulted FFELP loan” interest received of $580.77.

September 2010; Principal balance was $6,211, accrued interest of $1,000 (during forbearance) was capitalized, and resulted in new a principal balance of $7,209. Housing and transportation costs continued to hover around 55% to 65% of income. Old and new medical and dental bills exceeded $1,000.

NJHESAA form 1099-E for 2010 reported “defaulted FFELP loan” interest received of $225.86.

2011 – 2016:

Monica’s income stabilized a bit, and she was able to make monthly payments of $95.

2017 – 30 Years After College Graduation

January 2017; A statement issued by loan servicer AES reported principal balance at $3,208.



January 2017 According to servicer statements and after thirty years after college graduation, Monica still owed over $3,000 on her original student loans. Along the way, she’d made over $24,000 in payments. The loans were not consolidated, although she tried to do so to lock in a lower interest rate.

Her New Jersey refunds were levied for over a decade and seized by NJHESAA. Additionally, her tenant homestead rebates were also seized. Total amount of income tax refunds or homestead rebates taken by NJHESAA, exceeded $1,000.

Student loan payments are applied as follows:
1. First to late charges, fees, and collection costs,
2. Second to outstanding interest, and
3. Last to reduce principal.

During forbearance; interest does not stop accruing when payments were not made and if payments are less than the amount to pay accrued interest, the principal balance increases. When a borrower is seeking forbearance for FFEL subsidized loans claiming economic hardship, application must be made and approved by the loan servicer. Monica made application for economic hardship in 2007 but it was denied by the servicer.

Student loan borrowers should be aware of the daily interest cost of their loans. This is important because if payment is made for less than the daily amount, principal will never be reduced. At the beginning of Monica’s repayment journey in 1987, her daily interest cost on the 4 FFEL loans with a principal balance of $10,000 at 9% was $2.50 per day. She needed to pay at least $75 ($2.50 times 30 days) per month in order to satisfy the interest accrued and due before payment would be applied to principal. The daily interest rate decreases with each payment, assuming interest has first been fully satisfied.

Federal student loans are exempt from most consumer protections (Fair Debt Collections Act, Truth in Lending, Statute of Limitations), are excluded, for the most part, from oversight by the Consumer Financial Protection Bureau, and are dischargeable in bankruptcy only under the most dire of circumstances (you have to meet the Brunner test proving harm and undue hardship). Collection costs are punitive, enormous, and add to the principal.

Like most students entering college right after high school, Monica was a teenager when she signed her student loan contracts. It is apparent she had no idea what kind of indenture she’d “agreed to.” This can be said for the majority of student loan borrowers. Financial education at the high school level is seriously lacking, if existent at all. Student loans are originated between borrower (student) and lender without much scrutiny, oversight, awareness, or repayment considerations. Politicians in Congress made this possible.

Over the past decade, through both pro bono and paid tax preparation work; I’ve seen many student loan borrowers like Monica struggle to make ends meet and have tried to understand what is happening with their student loans. I’ve watched as refundable credits in the thousands of dollars have been seized by federal and state agencies year after year to pay for student loan debt. Many low-income taxpayers who took out debt decades ago and who have tried to pay this debt back, find – with accrued interest and collection fees – they owe much more than the original loan amount. Those who qualify for tax credits earned for dependents, education, or economic qualifications (refundable child tax credit, education, and earned income tax credits), never see the refunds which could have helped with housing, utilities, and child care. Instead the money is siphoned off into a vat of pots to pay for bloated collection costs, fees, interest, and most likely never touching principal. It is a cycle that can last decades, is rarely broken, and often without any reconciliation of seized funds.

This past tax season I prepared the return for an 80-year-old man who came into the tax clinic. He handed me his W-2 form which reported wages of $500 and a Social Security statement. He needed to file a tax return to obtain a refund of federal and state withholding reported on the W-2. While reviewing his Social Security statement, I noticed one-third of it was garnished. When I questioned him about this, he became very solemn, put his head down, and explained it was for an education loan taken out for his daughter “some time ago” to help her attend college. She had since died. Piecing together what he told me, I figured he took out a federal Parent Plus loan, had defaulted (before, during, or after his daughter’s illness and death) and didn’t know what to do. The default resulted in the garnishment of his Social Security, most likely without end for the rest of his life. There isn’t even an accounting of what is taken each year.

Without basic consumer protections, financial education, understanding, or advocacy, and absent the ability to discharge in bankruptcy, the contracts Monica and other borrowers enter to secure loans to help fund higher education are heavily lopsided in favor of lenders, investors, and loan servicers.

I question, as required by the basic principles of contract law, whether there is even a meeting of the minds between borrower and lender. Additionally, there seems to be some amount of unconscionable favor on behalf of one party over the other.

Student loan debt has topped $1.3 Trillion. By entering into these cumbersome, confusing, complicated, non-transparent contracts, the US has been devouring its citizens- young and – old in a cruel system of endless servitude.


Original principal 10,000
Interest added to principal 5,173
Collection fees added to principal 2,225
Revised principal increase over 30 years 17,398
Principal paid 14,370
Principal balance January 2017 3,028

Total paid over 30 years Dec 1987 thru Jan 2017
Paid toward principal 14,370
Paid toward interest 9,710

Lynn Petrovich, CPA
Copyright 2018

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Impacts of Temperature

As taken from the comments section. EMichael’s commentary on temperature and its impact.


“Air conditioning has changed demographics, too. It’s hard to imagine the rise of cities like Dubai or Singapore without it.

As residential units spread rapidly across America in the second half of the 20th century, the population in the “sun belt” – the warmer south of the country, from Florida to California – boomed from 28% of Americans to 40%.

As retirees in particular moved from north to south, they also changed the region’s political balance. The author Steven Johnson has plausibly argued that air conditioning elected Ronald Reagan.

Reagan came to power in 1980, a time when America used more than half the world’s air conditioning.

Emerging economies have since caught up quickly: China will soon become the global leader. The proportion of air-conditioned homes in Chinese cities jumped from under a tenth to more than two-thirds in just 10 years.

In countries like India, Brazil and Indonesia, the market for air conditioners is expanding at double-digit rates. And there’s plenty more room for growth: 11 of the world’s 30 largest cities are in the tropics.

The boom in air conditioning is good news for many reasons.

Studies show that it lowers mortality during heat waves. Heat makes prison inmates fractious – air conditioning pays for itself by reducing fights.

When the temperature exceeds 21C or 22C in exam halls, students start to score lower in math tests.

In offices, air conditioning makes us more productive: according to one early study, it made US government typists do 24% more work.

Economists have since confirmed that relationship between productivity and keeping cool.

William Nordhaus divided the world into cells, by lines of latitude and longitude, and plotted each one’s climate, output and population. The hotter the average temperature, he found, the less productive the people.

According to Geoffrey Heal and Jisung Park, a hotter-than-average year is bad for productivity in hot countries, but good in cold ones. They conclude that human productivity peaks at between 18C and 22C.”

How air conditioning changed the world

And the math on the study of Nordhaus is way, way beyond my pay grade.
Geography and macroeconomics: New data and new findings

Abstract: The linkage between economic activity and geography is obvious: Populations cluster mainly on coasts and rarely on ice sheets. Past studies of the relationships between economic activity and geography have been hampered by limited spatial data on economic activity. The present study introduces data on global economic activity, the G-Econ database, which measures economic activity for all large countries, measured at a 1° latitude by 1° longitude scale. The methodologies for the study are described. Three applications of the data are investigated.

First, the puzzling “climate-output reversal” is detected, whereby the relationship between temperature and output is negative when measured on a per capita basis and strongly positive on a per area basis.

Second, the database allows better resolution of the impact of geographic attributes on African poverty, finding geography is an important source of income differences relative to high-income regions.

Finally, we use the G-Econ data to provide estimates of the economic impact of greenhouse warming, with larger estimates of warming damages than past studies.

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Opioids, the Quiet Killer

There are no loud guns shots in the middle of the night. No screams for help or sounds of cars speeding away. No police sirens or flashing lights. It is pretty quiet when someone ODs on Opioids unless someone finds them before it is too late.

As I wrote earlier; “From 2006 to 2015, pharmaceutical companies spent $880 million in lobbying state and federal legislatures and contributing to campaigns to prevent laws restricting Opioid prescriptions. Opioid manufacturer lobbying expenditures has outstripped those such as STOPPNow advocating for greater controls on Opioids and prescriptions by 200 times at the state level.”

In comparison, only the NRA and its gun lobbying efforts in legislatures displays a similar capability to oppose and defeat any and all laws for bullet-spewing-weapons laws the same as the Opioid industry efforts to block legislation. Legislators pay attention when either industry or lobby calls on them.

Any particular article advocating greater regulation of Opioids or reporting of Opioid dangers on medical blogs such as Medscape, centers such as Public Integrity, news agencies such as Associated Press are met with a resistance (if they still have a comments section) the same as what is found on sites when they advocate for greater “gun control.” The evidence is overwhelming that there is an opioid epidemic in the nation resulting from usage and is similar to the epidemic of injury and deaths resulting from guns. Quietly, the industry and their lobbyists work the legislatures to stymie any effort to control opioids.

Latest Findings by the CDC

Today, Medscape reported:

Emergency department (ED) visits for suspected opioid overdoses rose by 30% throughout the U.S. in a year, according to the CDC.

“All five regions of the U.S. saw significant increases during this time period,” said Anne Schuchat, MD, acting CDC director, in a CDC tele-briefing Tuesday.

If you come back later to Medscape article, you will see the comments section flooded with what appears to be an organized opposition to what supported facts MedScape presents and consequently any and all suggested Opioid control. Many of the posters appear to be the same ones time and time again. It is pretty apparent the pharma industry is attuned to any medical backed article going up advocating for Opioid control.

The analysis backing the increase in Opioid ER visits can be found in a new CDC Vital Signs report. The basis of its findings are from ~91 million ED visits in 52 jurisdictions in 45 states from July 2016 to September 2017. The data is reported in the CDC’s National Syndromic Surveillance Program (NSSP) Biosense Platform. The 142,557 visits to the ER reported as suspected opioid overdose cases equate to a 29.7% increase from the previous 1-year period.

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Trump’s I coulda

Terry talking to his Brother Charly: “You shoulda looked out for me a little bit. You shoulda taken care of me, just a little bit, so I wouldn’t have to take them dives for the short-end money…I coulda had class. I coulda been a contender. I coulda been somebody, instead of a bum, which is what I am.:” “On The Water Front”

Coulda Trump rush faster than a walk to the Green? “I coulda had class. I coulda been a hero if I had rushed in there. I coulda been somebody instead of a bum, which I am.”

Trump’s Coulda: “You don’t know until you’re tested but I think I really believe I’d run in there even if I didn’t have a weapon and I think most of the people in this room would have done that, too,”

Bone Spur’s the Deputy coulda: “They really weren’t exactly Medal of Honor winners,”

Trump’s critique on the news arming teachers: “When the press covered it, the headline was ‘Trump wants all teachers to have guns, Trump wants teachers to have guns.’”

Trump on highly trained good guys with guns coulda: “I don’t want teachers to have guns. I want highly-trained people that have a natural talent, like hitting a baseball or hitting a golf ball or putting.”

Trump’s critique of people who really have to work coulda: “How come some people always make the four-footer, and some people, under pressure, can’t even take their club back?”

Mr. Trump will always be other “people coulda” and will go down as an “I coulda been” a great president in the history of presidents.

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Big Pharma Influence in State, Federal Government, and Everyday Life

How Pharma Influences Legislation They Do Not Like

From 2006 to 2015, pharmaceutical companies spent $880 million in lobbying state and federal legislatures and contributing to campaigns to prevent laws restricting Opioid prescriptions. Their lobbying expenditures has outstripped those advocating for greater controls on prescriptions by 200 times giving them greater influence at the state level.

In 2015, 227 million prescriptions were written for opioids such as OxyContin, Vicodin, and Fentanyl. This was enough prescriptions to give nine of ten adults a bottle of pills. With its aggressive lobbying, the pharmaceutical industry maintains the “status quo of aggressive prescribing of opioids and reaping enormous profits” according to Dr. Andrew Kolodny of Physicians for Responsible Opioid Prescribing.

Opioids are used to interact with the receptors (protein molecule that receive chemical signals from outside a cell causing a cellular/tissue response) in the body. They work with sites in the brain and nervous system known as opioid receptors to stop pain messages from reaching the brain effectively telling you to not feel pain. Opioids are used to counter pain from injuries, surgery, and chronic pain.

While campaigning for a law limiting the initial prescription quantity of an Opioid, Jennifer Weiss-Burke came to realize the strength of the pharmaceutical lobby in New Mexico. Her son Cameron was sent home with a bottle of Percocet to combat and dull the pain from a broken collar bone. A few years later, Cameron died of a heroin over dose.

Jennifer Weiss-Burke had lobbied the New Mexico legislature to limit “initial” pain-killing opioid prescriptions to seven days outside of the needs of chronic pain patients. The bill died in the New Mexico legislature. There was no open discussion of its merits, suggested improvements, proposed compromises, or discussed safeguards to protect those using Opioids for chronic pain. Instead, the Pharmaceutical Lobbyists privately called on each legislator to discuss why they should oppose the bill Weiss-Burke was advocating.

One of the manifestations of substance abuse in New Mexico was prescription drug overdose death. It was not a significant problem ten years before; but, it was developing and unidentified as a significant problem. In 2011, Cameron Weiss Burke died of a heroin overdose. Between 1992 and 2013, New Mexico was at or near the top for drug overdose deaths nationwide. In 2013, New Mexico had a drug overdose death rate of ~ 22 per 100,000 ranking third nationally behind West Virginia and Kentucky (CDC). Yet, the New Mexico legislature chose not to react to this plague and take action?

The pharmaceutical industry is profitable and wields influence across both sides of the aisle in
Congress and at the state level. In the past its lobbying efforts paid off with Congress blocking Medicare, Part D, and the ACA from negotiating directly with Pharma on pricing. Just how strong and profitable is pharmaceuticals? As Dr. Perry Wilson explains; “Different chronic diseases have different patterns of price increases. The biggest increase was seen in diabetes care (1993 – 2013) and driven largely by the rising prices of pharmaceuticals” of which the cost of manufacturing did not increase. Now Secretary of HHS, Alex Azar as the CEO of Eli Lilly raised the price of the century old drug Humalog used to treat diabetes by 345% taking it from $2,657.88 per year to $9,172.80 per year.

With greater profitability comes the ability to employ lobbyists who can call on state and congressional legislators. The Opioid industry, associated companies, and their allies have contributed to many candidates at state-level offices and employ an army of lobbyists covering the 50 state legislatures. From 2006 to 2015, the Pain Care Forum, a loose coalition of drugmakers, trade groups and dozens of nonprofits supported by industry funding, spent $740 million to stop laws governing the prescription of opioids. Up from 2016, the pharmaceutical and health products industry spent a record $78 million in 2016.

Because of their lobbying strength in Congress and states, laws and regulations are skewed to benefit the pharmaceutical industry. Medicare, Part D, and the ACA are blocked from negotiating directly with Pharma while insurance companies are too small to take on Pharma and often resort to using Medicare pricing plus a markup. With the appointment of nominee for HHS secretary Alex Azar, the environment for lower pharmaceutical costs by allowing Part D, Medicare, and the ACA to negotiate directly looks dim.

What If They Like a Piece of Legislation?

The pharmaceutical industry can block state legislation by lobbying. If they like a piece of legislation, they can also lobby for it. Fifty-eight pharmaceutical and 26 biotech companies spent $192 million to push the 21st Century Cures Act bill through Congress in 2016. The bill potentially saves drug and device companies $billions in bringing products to market. The Food and Drug Administration will have new authority and tools to speed up approvals and shortcut the process.

– Medical schools, hospitals, and doctors will see increased research dollars coming from a $4.8 billion windfall to the NIH biomedical research organization subject to annual appropriations. “60 schools, 36 hospitals, and several dozen groups representing physician organizations” spent $120 million in lobbying efforts.

– Over two years, $1 billion in state grants will be spent to address Opioid abuse and addiction most of it going to treatment. Mental health and Research got a boost with $millions for old and new programs. Mental health, psychology, and psychiatry groups spent $1.8 million in lobbying disclosures including the 21st Century Cures bill.

– Specialty disease and patient advocacy groups supported the legislation and lobbied Congress. Many of these groups get a portion of their funding from drug and device companies. The bill includes more patient input in the drug development and approval process. The passage of the bill shows off the clout of such groups in their spending of $6.4 million in lobbying.

– More than a dozen computer, software and telecom companies also kicked in for Cures Act lobbying totaling $35 Million in lobbying on the Cures Act as well as other legislation. It will benefit hospitals and groups requiring new technology and programs.

– Funding for the giveaways? The ACA lost $3.5 billion or 30% of its funding taken from its Prevention and Public Health Fund established to promote the prevention of Alzheimer’s disease, hospital acquired infections, chronic illnesses and other ailments.

The bill does nothing to address the rising cost of pharmaceuticals. It promotes unproven and unsafe drug and device approvals which groups such as Public Citizen, Consumer Safety Org., The Associated Press, The Center for Public Integrity, and the National Center for Health Research fought against. The bill leaves the FDA under funded with a miserly boost of $500 million through 2026 to take care of the additional priorities imposed upon the FDA.

And The Politics?

Michigan Representative Fred Upton’s sponsored 21st Century Cures which will save drug and device companies $billions in bringing products to market by short circuiting FDA testing. The Food and Drug Administration will have new authority and tools to bypass studies and speed up approvals. Translated what this means is; the bill allows the FDA to approve new uses, or indications, for existing drugs without rigorous clinical trials and tests now being conducted following proven practices. This would include not taking randomized samples to prove the new drugs are safe and effective. Instead, the FDA could rely on “real world evidence,” which includes observations, safety and side-effect claims, and other data not subject to rigorous analysis. According to Public Citizen’s Michael Carome this a much lower level of evidenced and proven usage.

No friend to the ACA, Michigan Representative Fred Upton sabotaged the ACA Rick Corridor Program and continues to weaken it by taking $3.5 billion or 30 percent of the funding from the Prevention and Public Health Fund to fund the 21st Century Cures Act, a continuation of the Republican attack on the ACA. Since 2000, Representative Fred Upton has received pharmaceutical contributions in excess of $1 million according to Open Secrets Org.

Besides weakening the testing of new pharmaceuticals, the 21st Century Cures does “nothing” to fight the rising cost of pharmaceuticals. Henry Azar took Eli Lilly’s Humalog diabetes drug and increased the pricing of it from $2,657.88 per year to $9,172.80 per year. After acquiring Vimovo, Horizon Pharma increased the price of it from $138 to $2,979 per 60-pill bottle. This is not the end of the story with Horizon. They will sell to customers at a much lower price and bill insurance at the higher price. Turing Pharmaceuticals Martin Shkreli bought the rights to the 62 year old drug Daraprim and immediately increased the price for it from $13.50 to $750 a pill. The same as other drugs, EpiPens will also rise and fall in price at the discretion of its manufacturer with little regard for actual cost.

In the December 15, 2015 JAMA publication, an article (Industry-financed Clinical Trials on the Rise as the Number of NIH-funded Trials Falls) by Stephan Ehrhardt, MD, MPH1; Lawrence J. Appel, MD, MPH2; Curtis L. Meinert, PhD suggests a growing influence of clinical trials conducted by companies with a vested interest in the outcome and a dilution of the impact of government-funded trials. “The number of newly registered trials doubled from 9,321 in 2006 to 18,400 in 2014 (Table 1). The number of industry-funded trials increased by 1965 (43%). Concurrently, the number of NIH-funded trials decreased by 328 (24%).”

While results from NIH-funded clinical trials are more apt to provide the basis for prevention and treatment recommendations; industry-backed studies can produce biased results leading to an increased concern for patient safety. Such was the case with Johnson & Johnson and Bayer’s anticoagulant Xarelto. Data was withheld during its industry-sponsored trial that would have deemed it less safe than traditional warfarin. It was approved without an antidote to bleeding complications in 2011. Thousands of Xarelto lawsuits have been filed against the manufacturer because of the medication’s severe internal bleeding complications.

NIH trials are down by 24% and commercial trials are up 43% many (71%) of which were also foreign funded. Funding for the NIH has fallen 14% since 2006 when adjusted for inflation and will decrease more as adequate funding has not been provided for the 21st Century Cures Act.

In a letter to Democrats Reid and Pelosi from various organizations, it was asked the 21st Century Cure Act be delayed until such time as rising prescription prices are addressed. “ Moving forward with this legislation now would be a missed opportunity to address unaffordable prescription drug prices. There is no justification for moving forward with legislation providing substantial benefits to the drug industry without achieving something in return.”

Again, pharmaceutical company lobbying Congress plus efforts by people such as Michigan’s Representative Fred Upton, has helped the industry reap substantial government sponsored benefits with little reciprocation in lower pricing. Michigan Representative Fred Upton was also the recipient of $597,000 from the Pharmaceutical/Healthcare Industry from 2014 into 2018. The initial bill was started in 2014.

With the 21st Century Cures Act underfunding of the NIH, increased commercial funding of clinical trials, and the relaxing of the need for clinical trials; can the pharmaceutical industry be counted on to be diligent in its testing of new products using “a lower level of evidence than the gold standard, which is randomized controlled trials” (Public Citizen’s Michael Carome)?

It appears the provisions of the 21st Century Cures Act are another stepping stone leading to the erosion of the ability of the FDA to certify the safety of new drugs and their manufacture which began in 1992 with the Prescription Drug User Fee Act (PDUFA). This allowed pharmaceutical companies to pay user fees to the agency in exchange for speedier reviews of their products. The new fees comprise 42% of the FDA’s budget today having grown from 8.5% in 1997. Companies would not be paying these fees if there were not a return for the cost in the market.

One might not think this would increase the danger the safety of new drugs; however, the 10-month time limit assessed does have its negative results. “For every 10 month of reduced review time, there is a correlated 18% increase in serious adverse reactions, 11% increase in hospitalizations, and 7% increase in deaths related to an approved drug.”

How Pharma Avoids Following the Law and the Penalties

The cost of doing business in pharmaceuticals includes paying the fines resulting from getting caught promoting drugs improperly or illegally. There are many prescriptions being written for Opioids for which there are alternate treatment strategies. When challenged, the industry and spokes people are quick to react to any calling for different strategies or limitations of usage.

For example, in 2001 Pfizer’s was ready to put Bextra on the market as a new class of painkillers known as Cox-2 inhibitors, supposedly safer than generic drugs, many times more expensive as ibuprofen, and translating into higher profits. Late in 2001, the FDA placed a qualifier on the use of Bextra for patients with extreme pain. The FDA found it was not safe for people with a risk of heart attacks or strokes and limited the usage of Bextra to people with arthritis and menstrual cramps.

This did not stop Pfizer and its partner Pharmacia from marketing Bextra as safe to use up to a 40 mg dosage. The same as what many healthcare insurance companies do with using doctors for approval of prescription, the companies hired expert doctors. Except these doctors in sales were to call on and convince other doctors (customers) of the safety of Bextra. After all, who argues with a doctor of medicine? Pfizer and its soon to be owned partner pushed the envelope with their claims of safe usage.

In the end what prevented Pfizer from a severe punishment was its size and the many other Pfizer drugs sold to and used by Medicare, Medicaid, and more then likely the VA. “Any company convicted of a major health care fraud is automatically excluded from Medicare and Medicaid. Convicting Pfizer on Bextra would prevent the company from billing federal health programs for any of its products. It would be a corporate death sentence.” The punishment stopped at fines for the illegal selling of a dangerous drug with Pfizer, again a TBTF or Too Big To Ban scenario? To comply with the law; the newly incorporated Pfizer subsidiary Pharmacia & Upjohn Co. Inc., on the same day prosecutors and Pfizer agreed Pharmacia would plead guilty, was banned from billing Medicare or Medicaid. Pfizer continued to do business as normal. Pharmacia & Upjohn Co. Inc. took the fall not once for Pfizer but twice and Pfizer walked away unscathed except for a fine.

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Healthcare Notes

National Health Spending at $3.5 Trillion in 2017, CMS Says:

CMS is reporting healthcare spending was $3.5 trillion in 2017. National healthcare spending grew by 4.6%, up 3 tenths of 1% from 2016. The increase was blamed on increased spending for Medicare and higher premiums for healthcare insurance. The increase in healthcare premiums can be partially attributed to Republicans blocking the Risk Corridor – Reissuances Programs which eliminated competition through withdrawal of insurance companies and bankruptcy of Coops.

Some contributing factors:

• Spending on physician, clinical care increased 5%, to $698 billion. This is a decline from 5.4% in 2016. High deductible plans have more than likely caused this reduction. Price increases for both were 2.4% and expected to increase in 2018.
• Healthcare spending as a portion of GDP is expected to grow from 17.9% to 19.7% between 2018 and 2026. Much of this will be the result of increased prices for medical supplies and services, income growth, and increased enrollment in Medicare.
• The insured portion of the population is expected to drop to 89.3% from 91.1%.
• Private healthcare insurance spending is expected to have grown at 4.7% in 2017 due to higher deductible plans, employer management of their plans, and an aging baby boomer population.
• Hospital Care is expected to grow at 5.5% annually over the decade. It is expected to be at $1.1 trillion in 2017 or a 4.6% increase over 2016 and similar in growth. Private healthcare insurance payments to hospitals is expected to slow by almost 1%.
• Pharmaceutical spending is expected to increase at a rate of 6.6% annually from 2017 to 2026. “Growth in pharmaceuticals is expected to take a bit of a jump soon, from an estimated 2.9% increase in 2017 to a 6.6% increase in 2018.”

Report: Use, Not Price, Drives State Health Costs

“In healthcare, costs of individual services and products make less of a difference in state-level spending than the overall use of those products and services, a new report indicated.” A report of rising costs at the state level being attributed to use as opposed to the rising cost of healthcare products/pharma, hospital/clinal care, and a service for fees cost model impact cost. As I wrote in answer to this perspective:

“If this is leading to people being the cause of higher costs, this is certainly the first time it is being raised in such a manner. One of the much-maligned factors in the ACA was having, as Congress called it, “skin-in-the game” which spells out in the form of higher copays, deductibles, and no discount to charge master and other pricing till the deductible is paid. It is a drag on usage by those with lower income and not qualifying for Medicaid.

Speaking of which (Medicaid) was expanded in 33 states with 18 states abstaining. Dependent upon what time period this study covers, the increased usage and state costs could be the result of such. Maryland is in a unique situation in that it uses an all payer system to control costs. I do not believe the other states intrude upon healthcare costs the same as there.

So what is the direction of this study, lower usage to control cost? It is already being done with the deductibles, copays, and payment schemes. Limit healthcare to those who can pay? If the current administration has its way, the Medicaid experiment will end. I need to see more of the detail. The article cites 3 years of data which would mean from 2014. Are we going to base rising costs upon the implementation of Medicaid and not look at time periods before 2010?

Healthcare costs are still rising at a faster rate than inflation with only the cost of getting an education beating it out from time to time. Pharma is able to raise pricing whenever they choose with little interference other than the media. Services for fees business model still exists. Hospitals and clinics are in a mad dash to consolidate to bargain better. Non-profit hospitals disappeared a long time ago.

Caring for Ms. L. — Overcoming My Fear of Treating Opioid Use Disorder

New England Journal of Medicine had an article on the human side treatment of opioid addiction by a PCP. This story does not end well for the patient. Feeling normal again is what many work towards and never quite get there. Intermingled are the political interests protecting the commercial interests who spend inordinate amounts of money to influence decisions. Pharmaceutical companies have spent $880 million in lobbying all 50 state legislatures and in state campaign contributions to influence politicians to prevent laws restricting Opioid prescriptions. Their spending has outstripped those advocating for greater controls on prescriptions by 200 times giving them greater influence at the state level.

“Ms. L. always showed up 10 minutes early for her appointments, even though I always ran late. Her granddaughter would rest her cheek against Ms. L.’s chest, squishing one eye shut, and scroll through Ms. L.’s phone while they waited. After reviewing her blood sugars, which Ms. L. recorded assiduously in a dog-eared blue diary, we’d talk about smoking cessation. That was a work in progress. ‘There’s just nothing like a cigarette,’ she’d sigh. “Don’t you ever start,” she’d admonish her granddaughter, kissing the top of her head.

One day, I knew something was wrong the moment I opened the door. Ms. L. was alone. Sweat dotted her lip and forehead. She closed her eyes and looked away, and tears fell onto her lap. ‘I need help,’ she whispered, and it all came out: she had taken a few of the oxycodone pills prescribed for her husband after a leg injury, then a few more from a friend. And like a swimmer pulled into the undertow, she was dragged back into the cold, dark brine of addiction. I tried to hide my shock. I’d known she was in recovery from opioid use disorder (OUD), but it had simply never come up. She hadn’t used in decades.

‘No one can know that I relapsed,’ she said. ‘If my kids find out, they won’t let me see my granddaughter.’ She wanted to try buprenorphine and was frustrated to hear that I could not prescribe it. ‘Why not?’ Annoyed, she rocked in her chair. ‘I just want to feel normal again, and I know you. I don’t want to tell anyone else.’”

Just a few short notes on what I have been reading as of late. If you have some time, please click on the links and read the articles. They are not lengthy. More to come as I finish up.

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The Risk of Opioid Addiction

I have been writing on healthcare for a while now and started to look at various topics with regard to pharmaceuticals. In my researching other topics, I found this particular correspondence to the Editor of the New England Journal of Medicine. Illuminating, if one might call it such? “A 1980 Letter on the Risk of Opioid Addiction

The NEJM published 1980 letter:

Addiction Rare in Patients Treated with Narcotics

Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction. Jane Porter; Herschel Jick; MD Boston Collaborative Drug Surveillance Program, Boston University Medical Center, Waltham, MA.

In a more recent June 1, 2017 letter to the NEJM editor, the authors dealt with the broad based and undocumented assumption in the 1980 letter of Addiction Rare in Patients Treated with Narcotics and the realization of the addiction and deaths of many people using Opioids. “from 1999 through 2015, more than 183,000 deaths from prescription opioids were reported in the United States and millions of Americans are now addicted to opioids.” Signed by four researchers exploring the reasons why Opioid addiction and deaths have risen, one of the conclusions reached was doctors being told “the risk of addiction was low when opioids were prescribed for chronic pain.” Supplementary Appendix.

From the 2017 correspondence to the Editor entitled; “A 1980 Letter on the Risk of Opioid Addiction,” the authors, by utilized bibliometric analysis of data derived from the number of citations of the 1980 letter from the date of its publication until March 30, 2017. The authors analyzed the relationship between the 1980 letter and it’s conclusion(s) with other document’s conclusions citing the 1980 letter. The analysis can be seen in Figure 1.

608 citations of the 1980 letter were identified (Figure 1) of the index publication. Also noted was a sizable increase in citations after the introduction of OxyContin (a long-acting formulation of oxycodone) in 1995. 439 (72.2%) authors of articles cited the 1980 letter as evidence addiction was rare in patients treated with opioids. 491 (80.8%) authors of articles did not note the patients described in the letter were hospitalized at the time they received the prescription and left readers to assume these were out-patients. As an aside to the citation of the letter, some authors grossly misrepresented the 1980 letter’s conclusion(s) in various comments as shown in Section 3, Supplementary Appendix. In comparison to the 1980 letter citations, the researchers also compared the number of times other letters published in the NEJM were cited: “11 other stand-alone letters taken from the same time period were cited at a median of 11 times.” To be redundant, the 1980 letter was cited 608 times.

The researchers concluded:

a five-sentence letter published in the Journal in 1980 was heavily and uncritically cited as evidence that ‘addiction was rare with long-term opioid therapy.’ Furthermore, they believed the citation pattern contributed to the North American opioid crisis by helping to shape a narrative lessening prescribers’ concerns about the risk of addiction associated with long-term opioid therapy. In 2007, the manufacturer of OxyContin and three senior executives pleaded guilty to federal criminal charges they had misled regulators, doctors, and patients about the risk of addiction associated with the drug. Our findings highlight the potential consequences of inaccurate citation and underscores the need for diligence when citing previously published studies.”

As I have been doing my research on another piece to which this is almost a prelude to it, I have found an overwhelming resistance to any type of control being placed on prescriptions for Opioids of which there are limitations on the number of days a prescription is given for short term pain. The naysayers always go back to the issue of chronic pain.

Whereas one perspective written in the NEJM Reducing the Risks of Relief — The CDC Opioid-Prescribing Guidline comes right out and states; “The few randomized trials to evaluate opioid efficacy for longer than 6 weeks had consistently poor results. In fact, several studies have showed that use of opioids for chronic pain may actually worsen pain and functioning, possibly by potentiating pain perception. A 3-year prospective observational study of more than 69,000 postmenopausal women with recurrent pain conditions showed that patients who had received opioid therapy were less likely to have improvement in pain (odds ratio, 0.42; 95% confidence interval [CI], 0.36 to 0.49) and had worsened function (odds ratio, 1.25; 95% CI, 1.04 to 1.51).”

The resistance to quantity limitations of Opioid prescriptions for non-chronic pain can be felt strongly in both state and federal legislatures by pharmaceutical companies lobbying. In a ten-year period from 2006 to 2015 Pharmaceutical companies have spent $880 million in lobbying all 50 state legislatures and in making campaign contributions in an effort to prevent laws restricting Opioid prescription quantities. In the end, it is just a matter of profits disguised as concern for chronic patient pain care.

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Rene Boucher Plea Bargains

In case you forgot, a neighbor of Senator Rand Paul was charged with assaulting him. And the reason? Rene Boucher was angry by seeing the 55-year-old senator stack brush near Boucher’s property.

An attorney for Boucher did not immediately return a call seeking comment. Boucher faces a maximum of 10 years in prison if convicted, but in the plea agreement federal prosecutors said they would seek a sentence of 21 months in prison. Appears to be excessive.

“Assaulting a member of Congress is an offense we take very seriously,” Josh Minkler, U.S. Attorney for the Southern District of Indiana, said in the statement. “Those who choose to commit such an act will be held accountable.”

I am surprised this does not happen more often as our representatives demonstrate a large degree of arrogance with their constituents.

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Democrats Are Silent Again

I do not understand the silence of the Democrats when it comes to dealing with the issues of this country such as student debt, the attacks by Trump and Republicans on the ACA, the Republican and Trump tax reform plan giving $billions to the 1% of the taxpayers making greater than $500,000 annually, the more recent plan allowing states to invoke job requirements and premiums upon those on Medicaid, etc.

Then there is the latest utterance from the White House, an attack on black and brown immigrants from countries such as Haiti and El Savador.

Trump’s comments do not go unverified by those on both sides of the political spectrum who attended this meeting on immigration between Senators, Representatives, and the President. “Why are we having all these people from shithole countries come here?” The comment made by Trump is also being denied by his supporters.

The real “why” to this issue is the silence of the Democrats when it comes to active and verbally expressed racism by a US President. Democrats who wanted and depended upon support by minorities to put a Democrat in office in Alabama. Democrats who are depending on minorities to turn the corner on Republicans and to reverse everything wrong done to date by this president and the Republicans who hide behind him.

Civil Rights icon and US Representative Elijah Cummings called Trump’s comments the words of expressed bigotry. Others such as Dr. G.S. Potter labeled such words as unsettling stating “bigotry” as used to describe the Trump comment as being too “interpersonal and anyone can be a bigot. Racism is structural. It is structural in the context of white supremacy and racism is white.” Trump’s comment are the words of a racist.

It is time to confront Trump for his words and confront Republicans who knowingly cover up for Trump’s racism and divisiveness and hide behind him. When Trump is gone, the same Republicans; McConnell, Ryan, Pence, Cotton, etc. and the Republican agenda will still exist.

The Democratic party has stood silent against the blatant white nationalism coming out of the White House for too long (Dr. GS Potter). They have continually sought bipartisanship with neo-Confederates and Nazis instead of seeking solidarity with people of color as we fight for our lives against them. The Democrats have continued to use us as bargaining chips, rhetorical talking points, and last-minute voting blocs rather than stand up for their largest and most loyal constituent groups against the GOP.

Their refusal to take a stand against Trump’s most recent racist comments cannot go unchallenged.

This needs to be a turning point for Democrats as voters and as a party. If our leaders can’t say the word “racism,” then they can’t fight it. If they can’t fight racism, they are worthless in a national battle against a network of politically shrewd white supremacists. If they are worthless in battle against white supremacists, they are worthless in battle against Trump and the GOP.

And over the past year, the white-led Democratic party has done nothing if not prove that they are worthless.

The Democrats are depending on black and brown voters to hand them Senate seats in 2018, while blatantly refusing to defend us from the GOP and its attacks on our communities. We can’t afford another term of white Democratic leadership. We can’t afford Senators that use us as bargaining chips for the white middle class. We can’t afford to give our votes to people that refuse to say the word “racist” let alone dig in and do the work necessary to stop racism.

This is a moment for all people of color to stand together and demand that the Democrats, in unity, acknowledge that the President is a racist. It is time that they collectively refuse to seek bipartisanship with neo-Confederates and Nazis. It is time that the party as a whole begins actively fighting the GOP and the Trump administration. And if the white leadership in the party refuses to do that, it is time for them to go.

Democrats Refuse to Call Trump’s Shithole Statement ‘Racist’“, Dr. GS Potter, January 12, 2018

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