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Hepatitis C, a Miracle Cure and Gilead’s Plan

Hepatitis C, a Miracle Cure and Gilead's PlanGilead aims to eradicate hepatitis C from the planet and has enlisted an entire nation as its demonstration lab.    In return, the Republic of Georgia has gotten the best possible price on Harvoni (ledipasvir-sofosbuvir), the company’s hepatitis C drug that lists at $1,150 a pill in the U.S.

The Black Sea nation wedged between Turkey and Russia does not pay a penny (or “tetri”) to Gilead as part of a five-year Hepatitis C Elimination Program launched in April with technical support from the U.S. Centers for Disease Control and Prevention (CDC).

Gilead donated an initial 5,000 courses of Sovaldi (sofosbuvir) and, this fall, began supplying Harvoni, which it began donating at a rate of 20,000 courses annually this fall upon its approval by Georgia.

The Georgian government is funding other costs associated with the program, such as screening, administration and monitoring.  Harvoni is a once-daily tablet while patients must use Sovaldi with other medications.

With just a population of five million, Georgia has the world’s third highest prevalence of HCV infection, exceeded only by Mongolia and Egypt.   As many as seven percent of the nation’s adults carry the virus, a blood infection which can destroy the liver.  Worldwide, HCV infects an estimated 130 – 150 million people and killed 700,000 in 2013.

By the end of August, the Georgians had completed a population based prevalence survey, registered 10,564 patients in the program, started treatment on 3,022 and recorded cures for 122 of 125 patients completing a 12-week regimen.  Some estimates place the total number of Georgians infected at 200,000.

Progress but Obstacles

Despite this early progress, the Georgians are facing obstacles inherent in the complexity of the disease and the variety of current therapies, including interferon, multiple anti-virals, Sovaldi and Harvoni.  These obstacles will hinder eradication there or anywhere else – as noted by “Alexandre,” a Georgian HCV patient interviewed by Georgia Today.

“I try not to worry,” said Alexandre, “My biggest concern is that our infectionists lack experience with hepatitis C management.  The disease emerged in the 80’s and despite a large number of variations in the treatment formula, it needs high professional experience.”

The virus, discovered in 1989, has six different genotypes, the prevalence of which varies from nation to nation.  Genotype 1 is most common in the United States at 75% of those infected.  In Georgia, genotype 1 drops to 43%, accompanied by genotype 2 at 20% and genotype 3 at 37%.

Disease progression by patient also differs, from spontaneous disappearance or easy treatment of the virus, to chronic hepatitis, cirrhosis, cancer and/or decompensated liver disease requiring a liver transplant.  Patients can also vary by age, comorbidities (e.g. heart disease, HIV), treatment history, risk factors and disease stage.  Hepatitis C can also be associated with heavy alcohol use, toxins, some medications, and certain medical conditions.

As a result, selecting the right treatment alternative typically requires – even in the United States — a specialist to type the virus, assess the patient, avoid harmful drug-drug interactions and monitor for potential side effects.  “Alexandre,” for example, suffered an allergic reaction from a prescribed adjunctive medication, ribavirin.  Patients must also strictly adhere to their medications or risk full recovery.

In the United States, the National Institutes of Health (NIH) is conducting a clinical trial in Washington, DC, to assess the effectiveness of treating hepatitis C with Harvoni in community clinics led by primary care physicians, nurse practitioners, and physician assistants.  Based on trials conducted by specialist teams, the Food and Drug Administration (FDA) approved Harvoni in October 2014, but only for genotype 1; approval for genotypes 4, 5 and 6 came in November 2015.

Miracle Cure for Hepatitis C

However, a solution for the specialist bottleneck is on the way — the first all oral, single tablet chronic HCV regimen for every genotype, simple to use regardless of prior treatment, disease stage or anti-viral resistance.  Potential side effects are modest, most commonly fatigue, nausea and headache.  “This is what a miracle looks like,” enthused one hepatitis C activist on Twitter.

Groundbreaking results from clinical studies of Gilead’s sofosbuvir (Sovaldi) – velpatasvir (SOF/VEL) combination recently appeared in the New England Journal of Medicine here, here and here, and in the Annals of Internal Medicine here and here.

The new drug is on approval fast tracks in both the U.S. and Europe.  The FDA has assigned SOF/VEL a Breakthrough Therapy designation as an investigational medicine that may offer major advances in treatment over existing options.  It has also set a PDUFA approval target date of June 28, 2016.  Meanwhile, the European Medicines Agency (EMA) has granted SOF/VEL Accelerated Assessment.

“This drug regimen changes the standard of care in treating patients with HCV. We can now cure almost everyone with a very simple treatment,” explained Dr. Jordan Feld, MD, MPH, lead author of the NEJM studies, to the Toronto Star.

“Knowing which treatment to use for which patient required expertise, which made it much more difficult for non-specialists to treat hepatitis C.  With the single tablet that is effective for all strains of the virus, it’s hoped that family doctors, internists and nurses will step in to treat hepatitis C,” he added.

“There are some who believe that the future is a one-size-fits-all single pill, such that a primary care doctor could prescribe it without having to be concerned about genotype, viral load, or complications,” concurred Ronald Sokol, MD, of University of Colorado School of Medicine and Children’s Hospital Colorado during a liver disease conference in November 2015.

Weighing in, too, were two key CDC leaders via a NEJM editorial:  John Ward, MD, Director of the Viral Hepatitis Program and Jonathan Mermin, MD, MPH, Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP).  They said sofosbuvir–velpatasvir regimen could simplify HCV management, “paving the way for simple ‘test and cure’ strategies appropriate for primary care and other settings, such as addiction-treatment programs.”

In noting that this new medicine removes significant clinical obstacles to hepatitis C eradication on a global scale, Ward and Mermin are very concerned that financial and access barriers could be thwarting:

“The availability of simple, safe, and curative regimens creates opportunities for improving the health of the millions of patients living with HCV infection. At a population level, the effect of HCV medications will be determined by affordability and equitable access to HCV testing, care, and treatment. Only through these improvements can our focus be directed to what matters most: reducing the morbidity and mortality associated with HCV infection, stopping HCV transmission, and ultimately eliminating HCV as a public health threat in the United States and worldwide.”

Pricing the Miracle Cure

How do you price a new miracle cure for hepatitis C, serving both shareholders and patients?   Gilead likely is still working the problem, deploying a process much like the one it used to price Sovaldi.  The U.S. Senate Finance Committee revealed the process in a December 2015 report, which the Wall Street Journal described as providing “perhaps the most transparent look ever into pricing decisions in the modern drug business.”

Aside revenue maximizing accusations and price gouging insinuations by Sens. Ron Wyden (D-OR) and Chuck Grassley (R-IA), Gilead actually deployed a very deliberate pricing process.  It calculated the value added by Sovaldi compared to existing treatments and balanced that with forecast of patient “starts” (volume), potential payer access restrictions and clinical obstacles like the specialist bottleneck.

Then, amidst U.S. market competition and payer resistance for 2015 sales, it discounted both Solvadi and Harvoni by an average of 46% to an estimated $643 per tablet for Sovaldi and $536 per tablet for Harvoni.

In Europe, Gilead negotiated a $536 per tablet price for Sovaldi with both Germany and France, although the deal with France includes volume incentives.  Globally, list and negotiated prices tracked a nation’s ability to pay, as measured by gross domestic product, gross national income and health expenditure per capita.

Meanwhile, Gilead has signed licensing agreements with 11 Indian generic manufacturers to produce and distribute generics for Sovaldi and Harvoni in 101 developing countries.  In addition, it has signed agreements with three companies in Egypt and Pakistan for local distribution within those countries.

In May 2015, Médecins Sans Frontières/Doctors Without Borders (MSF) reported that one of the Indian generics makers was charging $189 per 28-day-supply bottle, or $567 for a full 12-week treatment course of sofosbuvir (Sovaldi).  However, it is unhappy with Gilead’s generic licensing strategy, saying that it prohibits licensees from selling in 50 middle-income countries and excludes additional generics makers who want licenses.

Setting the Stage for Launch

Notably, Gilead has already included its breakthrough SOF/VEL combination drug in these generic licensing arrangements, anticipating approvals from the FDA, EMA and regulatory bodies elsewhere.  Alluding to SOF/VEL and its forthcoming launch, MSF notes, “People living with HCV and governments around the world have high expectations.”

However, MSF suggests governments do not have to wait for “patent and regulatory barriers” to come down, especially in middle-income countries.  To secure access to affordable treatment, MSF advises:

“Through measures taken at the domestic level, or through collective engagement at the international level, low-cost generic medicines – which cost a fraction of the high prices charged by Gilead – could be provided.”

Already, another group, Initiative for Medicines, Access & Knowledge, is challenging Gilead patents or patent applications in China, Argentina, Brazil, Russia and Ukraine.

The Republic of Georgia is among the 50 middle-income countries MSF wants included in Gilead’s voluntary licensing program – “or else.”  Rather than expand its licensing program to these countries, Gilead reveals a different strategy with its Georgian demonstration project – one of engagement with these nation’s governments coupled with financial assistance from multilateral organizations.

“We will take the Georgia data to other countries around the world to really make the case that investment can fundamentally change the disease over time,” explained Gregg Alton, Gilead’s executive vice president, corporate and medical affairs.   “Gilead cannot cure hepatitis C globally on our backs alone.”

Launching the Miracle Cure

Just another pharmaceutical product launch, SOF/VEL will not be.  Instead, look for Gilead to announce a global campaign to eradicate hepatitis C, answering the global call of patients, health systems, governments, multilateral organizations and even the Economist newspaper.

Photographs will show generics produced and ready to ship, videos will document compelling patient stories in Georgia, agreements will chart the expansion of Georgia-like demonstrations and support from multilateral organizations.  Perhaps, even MSF and Gilead leaders will stand together at the press conference.

In the U.S. and the developed world, shifting to a primary care screen and treat model, removing the specialist bottleneck, should provide an increase in patient starts justifying list and negotiated prices much lower than those of Sovaldi and Harvoni.

Watch, too, for the rollout of education campaigns to increase screening and diagnosis, and special initiatives in prisons and among substance abusers, recognizing that about half of all those with HCV have yet to be diagnosed.  Again, at the press conference, expect representatives from government, medical societies and the big pharmacy benefit managers to stand with Gilead.

Stay tuned!

Express Scripts 2020: Back to the Future?

Express Scripts

The clocks are ticking for Express Scripts.  Having achieved formidable “size and scale,” how will the nation’s largest pharmacy benefit manager synchronize with value-based health care?  With each day, between the medical and pharmacy benefits, the time to value is diverging.

Time to Value

Under fee for service, the time to value is relatively short for both benefits.  The physician bills soon after an encounter.  Similarly, the patient (for the most part) uses her pharmacy benefit to get her prescription, after which Express Scripts pays the pharmacy, collects a rebate (on a brand) and bills its client.

In value-based health care, the time to value lengthens to include outcomes and, as a result, expands to include many more inputs.  As Michael Porter explained, using the Institute of Medicine as his source, “Because care activities are interdependent, value for patients is often revealed only over time and is manifested in longer-term outcomes.” According to Porter, “The only way to accurately measure value, then, is to track patient outcomes and costs longitudinally.”

Value Based Health Care

By 2020, 75% of commercial payments will be through value-based arrangements, if the Health Care Transformation Task Force — a coalition of providers, payers, purchasers and patients – has its way. In 2014, 38% of payments to hospitals were value-oriented, compared to 10% for specialists and 24% primary care physicians in the outpatient setting, reported Catalyst for Payment Reform.

Meanwhile, the Centers for Medicare and Medicaid Services (CMS) wants 30% of Medicare payments in alternative payment models by the end of 2016 and 50% by the end of 2018.  The percentage stood at 20%.  Alternative payment models include Accountable Care Organizations (ACOs), advanced primary care medical home models, bundled payments for episodes of care, and integrated care.

Great Value from Express Scripts

To be sure, Express Scripts has added substantial value to the pharmacy benefit transaction.  It led the conversion to generic drugs, most notably and unprecedentedly when it moved against Pfizer’s Lipitor with simvastatin (generic Zocor) in 2006.  Now, Express Scripts’ drug exclusion announcements are routine events and its public campaign against high priced specialty drugs compelling.  The company has also narrowed retail networks and, for nearly a year, excluded Walgreens.

For years, Express Scripts has mined its mountain of data for insights and it pioneered the application of behavioral economics to the pharmacy benefit, in an effort called “consumerology.”   The company now has its own research laboratory, to which Medco’s Therapeutic Resource Centers and RationalMed program have been important additions.  Using these assets, the company has driven drug costs down, promoted greater use of lower cost drugs and achieved stronger adherence to drug regimens.

Better adherence can indeed lead to improved outcomes, thus increasing Express Scripts time to value, as demonstrated by its ScreenRx® program.  However, the company’s value proposition remains tethered to the pharmacy benefit transaction, instead of the ultimate clinical outcomes of value based health care.  At most, its contribution to those outcomes can be inferred, but not routinely measurable — yet.

Drug Payment Models

Take the pay-for-outcomes vs. pay-for-performance conversation now underway between Express Scripts and some drug manufacturers.   For its newly approved heart failure drug Entresto, Novartis proposed an initial discount with a performance bonus if it successfully lowered hospitalization rates in patients suffering from the condition.  The company said Entresto does a better job of preventing heart failure deaths and hospitalizations than lower cost alternatives already on the market.

Express Scripts was not buying it.  Instead, the company countered with an indication-based model, emphasizing its “elegance.”  It would differentiate pricing for specific cancer drugs based on how well they work against different types of tumors.

“Unlike the outcomes-based rebate systems that have been tried by others in the past, our model won’t require plans to reconcile payments long after-the-fact based on downstream health outcomes of a specific patient,” responded Express Scripts.

However, a leading pioneer of outcomes-based rebate systems has been Cigna, which Express Scripts client Anthem is set to acquire. Cigna’s arrangements have involved Merck’s diabetes drug Januvia (sitagliptin), the EMD Serono multiple sclerosis drug Rebif (interferon beta-1a) and, recently, Gilead’s hepatitis C drug Harvoni (ledipasvir/sofosbuvir).  Cigna based the Harvoni contract on elimination of the disease.

Hepatitis C

Arguably, disease elimination would reduce high cost liver transplants – a significant and valuable outcome.  Presumably, that is why Cigna, Anthem, Aetna, Humana and United Healthcare – with their longer, medical benefit time to value equation — all contracted with Gilead for Harvoni. They did so exclusively, presumably for better discounts.  Prime Therapeutics, owned by a number of Blue Cross plans contracted for both Harvoni and AbbVie’s Viekira Pak.

Meanwhile, Express Scripts contracted exclusively and presumably at a deep discount with AbbVie for Viekira Pak, excluding Harvoni from its 2015 formulary.  Viekira Pak is a four pill a day regimen to Harvoni’s one pill, with similar effectiveness and different safety profiles.  The latter comes from a review by Advera Health Analytics, which analyzes real world outcomes data.

Payer Cost

Advera Executive Vice President, Jim Davis, argued that exclusive deals emphasize the payer trend of focusing on immediate savings rather than overall outcomes, total cost of care and most importantly patient safety.

He echoed findings of a 2014 survey by the consulting firm EY that found “payers are highly focused on immediate cost containment, which means that the longer-view approach that emphasizes outcomes and keeping total costs down is irrelevant to payers.”

Express Scripts clearly is not alone in its short-term focus on controlling immediate costs.  However, it alone of the major PBM’s has the shortest time to value horizon because its “center of gravity” remains the pharmacy benefit transaction.

Competitor Time to Value

Both Caremark and EnvisionRx are subsidiaries of providers CVS and RiteAid respectively.  CVS recently inked a big data deal with IBM’s Watson cloud to predict patient health and RiteAid is pursuing innovative care initiatives with EnvisionRx.  OptumRx, and now Catamaran, are part of UnitedHealth Group, which concentrates on linking “demographic, lab, pharmaceutical, behavioral and medical treatment data.”

Synchronizing Express Scripts

Often offered in answer to the question of how Express Scripts will synchronize with value-based health care is a merger or other arrangement with Walgreens mirroring CVS/Caremark.  That may be part of a solution, but it will not be the entire or sufficient answer.

Also not the answer, but still important, Express Scripts should remain independent and continue to leverage its size and scale to lower drug prices.  Ironically, its assault on Giliad’s Solvadi and Harvoni, and then its exclusive contract with AbbVie, lowered Giliad’s prices, benefiting Express Scripts’ competitors.

Anthem Contract

It is through Express Scripts’ relationship with Anthem that the PBM can extend its time to value horizon and synchronize with value based health care.

Key will be the creation of a new, outcomes-focused collaborative thrust involving Anthem’s HealthCore, which is conducting real world evidence research with drug manufacturers, Cigna and its innovative payment models and the Lab at Express Scripts.  The only alternatives would be losing the Anthem business or relegation to functional role, much like Medco’s with UnitedHealth Group, the pending 2013 loss of which led to Express Scripts’ acquisition of Medco in 2012.

Notably, Anthem CEO Joe Swedish told investment analysts during a conference call on his company’s acquisition of Cigna “We do believe there’s significant value and opportunity from a better pharmacy contract.”  Cigna CEO David Cordani, who will serve as COO of the combined company added, regarding Cigna’s PBM business, “We have meaningful optionality relative to the program as it stands, and you should think about that optionality as being preserved and further expanded.”

Back to the Future

In the face of this challenge, Express Scripts would do well to go back to the future, twenty years ago when it launched a visionary effort to link pharmacy and medical claims.  Embodied in a “before-its-time” subsidiary called Practice Patterns Science (PPS), the initiative sought to build clinical data warehouses for health plans that organized all of a patient’s financial medical claims into meaningful, condition-specific, longitudinal episodes of care.”

Express Scripts’ CEO at the time, Barrett Toan, explained, “Having identified an episode of care for a patient, the drug therapy costs for the episode are compared to the associated medical costs.  What we’re finding is, in some cases, the drug costs are helping us control the overall costs.”   He pointed to a $380 reduction in epilepsy medical costs resulting from using a newly approved drug costing just $30 more.   An episode is a time line, which may be long or short depending on the nature of the disease.

Epilogue

With the DeLorean time machine at the ready, enter target destination California and target date April 3, 2015.   Flux capacitor powered, you will arrive in a Federal court where Dr. Douglas Cave won a $12 million patent infringement suit against UnitedHealth Group over the PPS technology.

Cave had been president of PPS and, when Express Scripts shut down the subsidiary.  The company gave him the intellectual property rights, including the disputed patent for physician efficiency measurement.  He now operates Cave Consulting Group in San Mateo, California, and filed an anti-trust suit in July against UnitedHealth Group alleging UHG obtained its patent laws fraudulently and violated anti-trust laws.

High Drug Prices: What Would Donald Trump Say?

Trump_Debate

In a new poll released yesterday, the Kaiser Family Foundation reported that large majorities of Americans, regardless of political party, think drug prices are unreasonably high, drug companies put profits before patients, and government should limit the cost of high priced drugs and negotiate lower prices for Medicare.

However, the same poll found that 76% of Republicans preferred market competition over government regulation to lower drug prices.  In addition, while 74% of Republicans say the government should directly negotiate Medicare drug prices, a smaller number – 56% — believe it can be effective.

Perhaps this explains why Republican candidates for President have not addressed high drug prices, preferring instead to focus on Obamacare repeal, as reported by Politico.  Neither Scott Walker nor Marco Rubio have included drug prices in their Obamacare replacement proposals.

Will Donald Trump take on high drug prices?  If he does, what would he say?  Whatever he says about an issue quickly frames how other Republican candidates and the news media speak about it.  Such is Trump’s dominance of the daily news cycle.   That alone makes the question relevant and the answer useful.

He is also more in tune with the Republican base than the party’s establishment may want to admit, as   political commentator Ezra Klein observed earlier this week.  Trump is the only Republican candidate who opposes cuts in Medicare, Social Security and Medicaid, a long-held position he directly links to making American strong again.

Interviewed on Larry King in 1999, he said, “What’s the purpose of a country if you’re not going to have defense and healthcare.  If you can’t take care of your sick in the country, forget it, it’s all over. I mean, it’s no good.”   He told the Iowa Freedom Summit earlier this year, “I want to make the country rich so that Social Security can be afforded, and Medicare and Medicaid.”

Recently, on Meet the Press, he said, “I want people to be taken care of from a health-care standpoint. But to do that, we have to be strong. I want to save Social Security without cuts. I want a strong country. And to me, conservative means a strong country with very little debt.”

In fact, Trump comes across as a Robin Hood, putting himself on the side of American citizens, taking money from wealthy countries he says rightfully belongs to us, fighting government corruption and stupidity, and expelling illegal aliens (to use his terminology).   He is also a deal maker, exploiting leverage or creating advantage to get what he wants.

What, then, would Donald Trump say about high drug prices?  To answer that question, here is an imagined Meet the Press conversation between host Chuck Todd (imagined) and Donald Trump (imagined).   It suggests Donald Trump could easily take high cost drugs to a place neither the other Republican candidates nor the drug industry want to go.

 

Chuck Todd (Imagined):

Mr. Trump, in a new poll, 70% of Republicans want the government to limit how much pharmaceutical companies can charge for high-cost cancer drugs.  What would you do about the high cost of prescription drugs?

Donald Trump (Imagined):
Repeal Obamacare and replace it with something terrific.  It’s a disaster.  It’s virtually useless and big lie.  Deductibles are through the roof and costs are going up.

 

Chuck Todd (Imagined):

How would repealing Obamacare lower drug costs?  They’re growing faster than other health costs – mainly because of the new specialty drugs – but they still only account for 10% of all health spending.

Donald Trump (Imagined):

Chuck, the drug company lobbyists did a fantastic job when Congress passed Obamacare.  They out-negotiated the President and got a great deal.  They supported Obamacare and agreed to help pay for it.  In return, they got more customers and higher prices.   When I repeal and replace Obamacare, the pharma companies will have to negotiate with me.

 

Chuck Todd (Imagined):

Does that mean you support letting the government directly negotiate with drug companies over the prices it pays for Medicare drugs?

Donald Trump (Imagined):

Medicare is the largest single buyer of prescription drugs.  In business, a best customer gets the best deal.  When I buy televisions for my hotels, which I sadly can’t get in the US but that’s another issue, I use that leverage for a great price.  Yes I’d negotiate better prices with the drug companies.  But, it’d be different, like a business, not as price controls or more regulations in disguise.   You’ll be very pleased, very pleased with how I do it.

 

Chuck Todd (Imagined):

But, what about the cost of drugs not covered by Medicare….these new cancer drugs that cost thousands of dollars.  In fact, the doctors who treat cancer are campaigning for lower prices.

Donald Trump (Imagined):

Chuck, I’ve got a deal where everyone wins.  I love the drug companies.  They’ve made great discoveries and cured many people.  I want the drug companies to create jobs in the US, making new drugs.  That takes money.  They hold almost a half-trillion dollars outside the United States because the taxes on bringing it home are too high.   Bring those dollars home, use them for jobs, discover new cures, keep prices under control and I’ll lower the taxes.

 

Chuck Todd (Imagined): 

Republicans also think Americans should be able to buy prescription drugs imported from Canada, and by a wider margin than Democrats:  75% Republicans vs. 69% Democrats.  What do you think of that?

Donald Trump (Imagined):

The problem is much bigger.  What our pharmaceutical industry accomplishes is tremendous.  It benefits the entire world but prices are highest in the United States.   Per person, we spend twice as much as other wealthy nations.    It’s time other nations paid their fair share.  As you know, rich nations like Saudi Arabia must pay us back for what the Defense Department spends on protecting them.  Canada, the European Union and other wealthy nations should help pay for our National Institutes of Health.  The American taxpayer funds 85% of basic research.  We have to stop subsidizing their health care.

 

Chuck Todd (Imagined)

The drug industry says that it needs to charge high prices because it takes so long to bring a drug to market.  Would you make any changes at the FDA?

Donald Trump (Imagined)

The FDA needs to do a better job on safety, especially after a drug is on the market.  Take vaccines, I don’t think kids should get them all at once.  Spread them out.  It doesn’t hurt anybody other than probably the pharmaceutical companies because they probably make more money putting it into one shot.    I want more approvals and more competition.  That will bring prices down.

 

Chuck Todd (Imagined):

Speaking of health care.  Earlier, you said you would repeal and replace Obamacare.  How would you replace Obamacare?

Donald Trump (Imagined):

I believe in universal healthcare. I believe in whatever it takes to make people well and better.  What’s the purpose of a country if you’re not going to have defense and healthcare?  We can have something far better for the people, and far less expensive, both for the people and for the country.  And believe me there are plans that are so much better for everybody.  And everybody can be covered.  I’m not saying leave 50-percent of the people out.

 

Chuck Todd (Imagined):

How would you pay for it?

Donald Trump (Imagined)

Get tough with the big players like China and OPEC that are ripping us off so we can recapture hundreds of billions of dollars to pay our bills, take care of our people, and get us on a path toward serious debt reduction. We must take care of our own people—we must make our country strong and rich again so that Social Security, Medicare, and Medicaid will no longer be thought of as a problem. We must save these programs through strength, power, and wealth.

 

Chuck Todd (Imagined):

During the debate, you seemed to speak favorably about single payer systems in Scotland and elsewhere.  Do you favor a single payer system in the United States?

Donald Trump (Imagined):

No.   What we need in the United States is free market plan that provides consumer choice, keeps plans portable and affordable and returns authority to the states. We also must break the insurance company monopolies and allow individuals to purchase health insurance across state lines.