A pharmacist's look at the supermarket and beyond

If You Will Recall…

The continuing barrage of recalls of losartan and other ARBs is causing quite a bit of trouble in the pharmacy world, with millions of dollars in recalled products and untold man-hours dealing with the logistics of a Class One recall. Although the latest round of recalls have been “voluntary” recalls initiated by the manufacturers, each recall that I have seen is being treated as a Class One recall by pharmacies.

In addition to scaring the bejeezus out of patients with letters and phone calls, news alerts, and the inevitable spread of misinformation, which I guess we call “Fake News” now, the recalls continue to roll out. Anyway, I thought I should dig into this. Back when I was fat and ugly, I was on losartan for a time and although I don’t plan on being that fat or ugly again, I still want to know the facts.

The FDA recently unveiled new testing methods for the three nitrosamines of most concern, NMBA, NDEA, and NDMA. The FDA has “acceptable” limits for these three suspected carcinogens set at less than 100 nanograms per day. A nanogram is a billionth of a gram! The FDA states, “The acceptable intake is a daily exposure to a compound such as NDMA, NDEA, or NMBA that approximates a 1:100,000 cancer risk after 70 years exposure.” That’s one cancer for every 100,000 patients exposed for 70 years! Note that most carcinogens take decades to have apparent effect.

The thing is, these nitrosamines are not exclusive to pharmaceuticals. They are in our food, water and air too! For this discussion, I will try to focus on the three N-nitrosamines named above. These are notoriously found in cured meats, notably in super delicious crispy bacon (sigh), beer, (sigh), and even our water supply (double sigh). Before this gets too gloomy, here are some bright spots: Microwave cooking of bacon likely creates fewer nitrosamines, and most beer makers have adopted newer malt drying methods that reduce the amount of nitrosamines in their product.

NMDA has been studied most extensively of the three and has been demonstrated in factory discharges (constraints on which have recently been relaxed by the current administration), and detected in diesel exhaust. My point is that we have been and continue to be exposed to these chemicals. Even the FDA seems to acknowledge reality as it now “is temporarily not objecting to losartan with NMBA below 9.82 ppm remaining on the market,” which is considerably higher than the recall benchmark of 0.96 ppm.

With all that in mind, feel free to make your own decision based on this knowledge and after consulting your health care providers. Our current level of medical knowledge allows us to live longer. For many, that means cancer will appear eventually, if we live long enough. For others, it never appears at all. Until we unravel all the mysteries of life, death, and cancer, we are all left to make our own choices and live with the consequences.

Keep up with drug recalls here at this FDA page.

Sweet Nightmare

Diabetics are in the news as insulin prices soar to levels that many cannot afford. Patients are rationing themselves to the point of death. Still many in Congress have been brainwashed to believe that not only do we have the best healthcare system in the world, drugs companies are doing everything they can to lower prices on critical drugs like insulin.

Many of my pharmacy colleagues may not remember the names Banting and Best from the University of Toronto who had worked with dogs (under the forbearance of Professor John Macleod) to demonstrate that a pancreatic extract could alleviate morbidity and mortality in dogs without a pancreas. By 1922 they tried a purified version on a 14-year-old boy with a degree of success (the first injection resulted in minimal effect and a sterile abscess at the injection site). Further purification by a University of Toronto biochemist named Collip yielded a better product. Once word spread through the scientific community the improvements came fast and furious. Soon commercial products from beef and pork took over the market.

You can Google the details of further development as well as I so I’ll simply say that from that first bold trial until 1978 when the first recombinant DNA human insulin was produced by Genentech. Genentech signed an agreement with the Eli Lilly company to commercialize the product and in 1982 Humulin N and Humulin R hit the US market. These products and subsequent new types of rDNA insulins were paralleled with products from a Danish company Novo Nordisk. Normally this would be undiluted great news for diabetics, who suffered from a variety of side effects from the beef and pork products. But…

In 1923, Macleod and Banting won and shared the Nobel Prize with Best and Collip. They also obtained the patent for insulin which they sold for $1 each to the University of Toronto, saying that such a life-saving drug should be as widely available as possible, perhaps fearing what commercialization would do to the availability of their discovery. The University grant right to Lilly and other companies to produce insulin royalty free and to obtain new patents on any improvements they might develop. Insulin had left the realms of science, academia, and altruism and been naively cast into capitalism. And now, for the scientists, their worst nightmares have come true and are beyond anything they could have imagined.

BY 1941, Lilly, and 2 other insulin distributors were found in violation of the Sherman Antitrust Act for conspiring to arbitrarily fix insulin prices. They all took a plea of “no contest” and each company was fined $5,000 and each corporate officer $1,500. Today those old animal derived products are gone from the market (beef in 1998, pork in 2006). That sort of thing has gone dead silent as today’s insulin all seem to sport exorbitantly high prices within a few dollars of each other. Quite a coincidence!

I find it amazing that from the launch of rDNA insulin in 1982 to today that all we have managed to do is create more expensive insulin!

There are only three companies in the U.S. insulin market: Eli Lilly and Co., Novo Nordisk, and Sanofi (HQ in Paris).

For fiscal year 2018, the CEO of Lilly was compensated well over $15 million dollars. All told the CEO and leadership took home over $41 million. That’s for 6 individuals.

Things are different in Denmark: At Novo Nordisk, the most compensated executive makes $700,000, annually, and the lowest compensated makes $50,000.

Meanwhile , Sanofi sales took a hit and it’s CEO took a hit: The CEO’s pay package was slashed by 25% in 2018 to €7.28 million ($8.2 million).

To me, $700k seems a healthy income for anybody and keeps company income disparity at a more reasonable level of 14:1 versus Lilly’s 314:1.

This has been a long-winded way to get to my points.

  • Insulin must be affordable. If it takes Medicare for all or a reasonable national health plan, then I’m for it.
  • I feel that income disparity is as big a problem as inequitable taxation.
  • Healthcare should not be a commodity provided at exorbitant profit.
  • I realize that statesmanship is virtually dead. We must return civility and rationality to the national psyche and integrity to our government.
  • Learn. Speak. Vote.

Sedatussin, Ferengi, and Fragrances

I thought I would do a blast from the past for Pharmacists Month and take a look at a prescription from 1924 for a cough preparation called Sedatussin.

I picked this Rx from my collection because it it for a proprietary product. Most Rxs from 1924 are true Rxs or “recipes,” much like this one:
Sedatussin was marketed by Eli Lilly and Company beginning in 1909, advertised as free from alcohol and narcotics, which made it very different from many of the cough syrups on the market in the early twentieth century.
It contained cephaeline, a plant alkaloid more recently found in syrup of ipecac, which is used to induce vomiting. It was thought to be an expectorant back then. Today we use guaifenesin, which is of dubious effectiveness also, and even it did work would require doses approaching emesis inducing levels.
Another ingredient in Sedatussin is tincture Sanguinaria, from the bloodroot flowering plant. Used by Native Americans as an emetic, various tinctures appeared in the US Dispensary until the mid 1900’s. It is probably most notable for being listed by the FDA in 2010 as one of 187 “Fake cancer cures that consumers should avoid.” In fact, oral use of bloodroot preps have been linked to oral cancers.
As with many other cough syrups in the 1920’s, Syrup of Squill has many reported uses, from “heart tonic” to cough remedy, to an emetic, and even in some cultures as an abortifacient! We get squill from the bulb of the squill plantand has since been deemed unsafe for causing GI problems, rashes, cardiac dysrhythmias, and seizures. Syrup of Squill gained modest notoriety when it made an appearance on Star Trek:Deep Space Nine as a breakfast syrup valued by Klingons and price-manipulated by the Ferengi!
Sedatussin also had Syrup Tolu, derived from the sap of South American balsam trees. It still is in use today in some “natural” cough syrups, again as an expectorant, but it is valued in the perfume industry for its spicy, warm scent, likely due to the cinnamyl esters present.

I find exploring the evolution of pharmacy practice by taking a closer look at past products and ingredients quite a bit of fun since you never know where the journey will take you!

Rice and More

I am long overdue to get this blog out of the pharmacy for a while and out into the aisles.
While shopping recently, I noticed something interesting when looking for convenient rice. Good old Uncle Ben offered a variety of pouches that promised a variety of rice dishes that would be ready in 90 seconds. “Deal,” I thought.
Then I read the ingredients. The best bet is Whole Grain Brown Rice with ingredients listed as “water, whole grain parboiled brown rice, canola oil and/or sunflower.” Nice and simple and low sodium too. No wonder it claims to support a healthy heart.
It was pretty close between the Jasmine and Basmati versions, with 10mg and 15mg sodium respectively, and a few added vitamins.
Then things get pretty strange. With the flavored versions and “medleys” things like wheat gluten, corn starch, corn syrup, soy, milk products, xanthan gum and more. There is even pork gelatin in the cheddar broccoli variety!
The biggest disappointment was the Long Grain and Wild variety with “23 herbs and seasonings.” Uh oh. Not only is soy, corn, wheat and yeast protein added, we find salt and sea salt, bumping the sodium to a less friendly 590mg. I could not find 23 herbs and seasonings listed. There was sugar though.
Compared to other offerings in the “center store” aisles where processed foods reign supreme, most of these choices are not too bad if you are not concerned about surprise gluten in a rice product or hidden pork, for examples. It goes to show, though, how it pays to read the labels. I will give Uncle Ben credit for truly reflecting the differences in these products in their labeling, although stating that it is an excellent source of niacin, thiamine, and folate when these are added ingredients all but one of the varieties is pushing the envelope a little. If I was grading on a curve, I guess I would give this product line a B with an A for the simple whole grain brown rice option.
And they are from Mars!

Metrics? We Don’t Need Stinking Metrics!

We all know that retail pharmacy or health care in general can be a difficult and often thankless job. I received this letter in the mail and it made me happy!
grateful letter
The gratitude was well received by myself and staff. Eventually I began to think about metrics. Pharmacists and techs spend hours every day dealing with undecipherable prescriptions, impossible billing, and a wide assortment of barriers to good pharmacy care. As pharmacists we dole out free advice on a regular basis to patients that are usually appreciative. Patients will talk to us about anything.
On the same day that I received this letter, I had a man in his 40’s wondering why his doctor ordered Prozac for him when he was not depressed, just dissatisfied with the quality, quantity, and duration of his erections. He broached the subject and responded to one of my counseling questions by saying, “I think I’d be OK with a group of half naked cheerleaders.” That’s when the conversation moved to a more discreet level.
Later, a student pharmacist asked for my assistance counseling a young woman who wanted help selecting a prenatal vitamin. Turns out she was trying to get pregnant, and after explaining the benefits of a prenatal product and other healthy options, she took the conversation to a deeper level. After discussing underwear choices for her husband, she volunteered information about her tipped uterus and asked, “are there any positions that might compensate for that?” I was tempted to tell her the joke about positional gender selection, but my professionalism vetoed that idea. In case you are wondering, missionary and girl on top are the top two recommendations.

All three of these interactions are wonderful and meaningful experiences for the people involved. They do not, however, have an effect on our metrics, which, increasingly, is how our job performance is measured. We are constantly bombarded with data that is presented as helpful information to make the job easier as we gain effectiveness. Yet our “Percent Effective” measure looks only at the labor hours (and minutes) gained for the tasks that are required to fill prescriptions. The bottom line is that the biggest chunk of data demands that we fill a prescription using about 8 minutes of labor. And, there is time built into that to allow for counseling, regulatory compliance, inventory control etc., but at the end of the day it’s how many Rxs were filled with the labor permitted.

You can easily see that the scenario that Jay describes in the letter would have taken much more than 8 minutes to complete. Multiple people were involved and it required several faxes and two phone calls to the prescriber, calls to the patient, and multiple attempts to successfully bill the claim for the product. The forty-something with problems “down there” and I had a ten minute conversation exploring possible causes and solutions for his dilemma, which included the recommendation that he should keep his lust for cheerleaders as a fantasy. The young mother-to-be was another lengthy discussion that started out looking at vitamins and evolved into a frank discussion of the physiology of fertility.

All three of these examples had great outcomes and yet only one prescription was picked up by the patient, the testing strips for Jay. The other guy did not get the Prozac prescription, effectively making all the labor to fill it wasted, and created more labor to return it to stock. The soon-to-be-mom bought a prenatal supplement and left with several helpful ideas for conception strategies. In my judgement, all three of these were big wins for myself, my staff that were involved, and the student pharmacist that gained perspective on the delivery of very personal, even intimate counseling.

If we are lucky the patients will do one of those ubiquitous satisfaction surveys and we will get a second of recognition that way. Our metrics will suffer though, and that is a price that I am willing to pay. My patients know that they are not numbers to me. My whole team works hard to establish a solid rapport with each patient and from that grows the trust and mutual respect that lets our pharmacy thrive despite intense competition.

Metrics are a tool, a limited tool that will never be able to measure the kind of outcomes that health care providers work for every day. Labor hours should be added to the metrics algorithm that would allow us the time to treat all of our patients the way they deserve. Wouldn’t the loyalty and improved health and happiness of our patients be worth a couple hours of labor per week? After all we give ’em $25 just to transfer a prescription to us from a competitor. We should be playing the long game.

A Prescription Gone Wrong

The national media and social media exploded a local story of a pharmacist refusing to fill an prescription for misoprostol for a woman carrying a dead fetus. It’s difficult to get the exact details of the whole process, which took place over several days, but I think some of the events are evident and worth discussion.

Let’s first be clear that we should not have this opportunity to discuss this specific situation. It should have been a private process involving prescriber, patient and pharmacist, as we expect for each prescription filled. This patient, however, chose to put her uncomfortable and personal experience on social media, Facebook, and from there it migrated to more traditional local and national media. OK, that is your choice. So now anybody who cares to voice an opinion is free to do so and I will take my turn.

The OB/GYN ordered an effective drug that would terminate this nonviable pregnancy. A miscarriage was inevitable and the drug would allow the patient’s medical team to control the process. The prescription was taken to a Walgreens where the pharmacist would not fill the prescription for reasons of strong personal beliefs. The patient attempted to explain the medical reason behind the prescription and the pharmacist was unyielding. Apparently there was significant back and forth discussion between the two with that patient’s 7-year-old child, other pharmacy staff, and other people standing in line listening.

This is where things go careening off the tracks. First, the pharmacist should have recognized the very personal nature of this exchange and taken the patient to a discrete location for a private consultation. Most pharmacies have a consultation room and if not can find a private space. Retail pharmacies prominently display a large HIPAA sign that explain patient privacy protections. The dilemma for retail pharmacies is that the area where patients pick up their prescriptions is not private. Oh, we may have a little plastic divider shield, but if you look at most retail pharmacies there is little barrier between the pharmacist and patient at the counter and the patients waiting in line to be next or even in the waiting area. Do patients in this situation implicitly give up their privacy rights simply by being there willingly? To me, this particular situation was handled poorly by the pharmacist and the patient, but the pharmacist, as the professional, failed to act professionally in respect to patient privacy. Yes, the patient chose to discuss the details in this setting and then further on social media. At the pharmacy counter, however, the pharmacy staff should realize the obligation for discretion and act upon it. I have asked hundreds of patients to join me in our consultation room or another private space to discuss sensitive issues. Most pharmacists I know would do the same.

The moral objection to filling a prescription is supported in most pharmacy organizations and each of them that I have seen advise the pharmacist to provide another means for the patient to acquire the medication. This did eventually happen and there is some disagreement as to why it took from Thursday to Saturday for the Rx to be filled and picked up. One side claims that there were other pharmacists in the pharmacy the day the Rx was first presented and they were not asked if they would fill the prescription, while others say that the pharmacist did transfer the Rx to another Walgreens that would fill the Rx and it was the patient that delayed picking it up. Some of the latter have claimed that on Friday the patient was too busy giving interviews to TV news outlets and playing the victim card. Perhaps there is some truth to both sides. I will let the Arizona State Board Of Pharmacy complete their investigation and trust they will come closer to the truth better than any individual possibly might.

Pharmacists are presented with medical dilemmas every day. I have refused to fill many prescriptions. Some of those have been fraudulent, some have been presented by obvious drug seekers using multiple doctors or other schemes, and others were instances where I considered the health and safety of the patient in jeopardy. I personally believe that is the scope of our practice. We should fill all legitimate prescriptions unless the physical or mental health or safety of the patient would be put at risk. I do not believe that we should be making religious or moral judgements when assessing the appropriateness of a particular drug for a particular patient.

This particular drug had been identified in the pharmacist’s mind as a drug used for inducing an abortion and therefore would not dispense it. Any other use of the drug was apparently disregarded. I believe we are scientists, not priests. There are plenty of opportunities for pharmacists to apply religious or moral judgment on patients based on the prescriptions that they ask us to fill. Is this birth control Rx for a 16-year-old appropriate? Is that too young for sex? Is it better to provide contraception rather than risk a future abortion if she is sexually active? Oh wait, those questions are moot because the patient is taking the medication to control disfiguring acne, or to lessen her disabling dysmenorrhea. Do you refuse to fill HIV drugs because you consider HIV the “gay plague” and God intends gay people to suffer the consequences of their “choice?” Is it right for a pharmacist to work in an establishment that sells tobacco, liquor and sex toys? Each of us must decide our own morality, and we are free to express our opinions, but we have no right to impose them on others.


The postings on this site are my own and don’t necessarily represent the positions, strategies or opinions of The Kroger Company family of stores.

Forget These Products

An elderly lady was at the pharmacy window picking up prescriptions and needed help finding a OTC product. She had been taking something for memory, but could not remember its name. If it wasn’t so sad, it would be funny. The culprit here was Prevagen and I was able to point her in a more reasonable direction. This was made easier by the exorbitant price of Prevagen.

I recently asked a student pharmacist, Thuy “Tina” Ngan Vo, to look into some of the “brain boosting” products that we offer. Although I have posted about Prevagen previously, I felt that her research added new facets to the discussion and bolstered the argument against spending money on these products. I was especially pleased to see Tina take a close look at the “clinical studies” used to market these expensive products. Her original paper is on this site, but I’d like to put my two cents in also.

I’ve already called out Prevagen as snake oil and not worth a dime, let alone more than a buck a pill. The only study that purportedly showed any action at all showed that apoaequorin (active ingredient in Prevagen) infused directly to rat brains may have slowed ischemic cell death. The study was totally funded by the manufacturer, not peer reviewed and the claims of memory enhancement are total bullshit. Though the manufacturer cites many clinical trials, actual peer reviewed trials are non-existent. So, to be clear, when you take a Prevagen pill, any apoaequorin present (if any) will be destroyed by your digestive tract, you may get a peptide or two or some amino acids, but the rest will be tomorrow’s poop. Shame on Quincy Bioscience.

Maybe the patient should try Natrol’s Cognium, that sounds pretty science-y, right? Here we find silk protein hydrolysate. Wow! That sounds impressive! But, digging a little deeper we find more bad science, and in this case a set of six trials by the same author. One published manuscript was retracted due to data fabrication and falsification by the authors. Even the best of these “studies” claims a meager 1.7% improvement in cognition. Save your money!

So maybe one the many herbal supplements would be a good choice. Have a look at Healthy Brain All-Day Focus. This has some vitamins, ginkgo, some roots and other crap (see Tina’s paper) none of which, if present, will help. One ingredient, Rhodiola Rosea root was shown in one study on intern nurses on shift work to actually worsen fatigue! Stop wasting your money! Don’t have a brain fart!

So what can this patient do to help sustain and possibly improve her memory and brain function? As Tina points out, higher homocysteine levels have been associated with Alzheimer’s as well as an increased risk of heart attacks and strokes. Homocysteine is an amino acid that is a by product of protein digestion, particularly methionine, which most of us consume as animal protein. I would suggest this patient start with a reputable B-complex vitamin supplement, with good representation of vitamins B-9 (folic acid), B-6, and B-12, just in case her diet is lacking in these vitamins which help to detoxify homocysteine.

Notice that I said “reputable.” These products are unregulated and what is stated on the label may not truly represent the contents. I look for the US Pharmacopeia symbol to be sure that we have a product that meets scientific standards.

Beyond a good B-Complex supplement, I also recommend:
Try new things that require learning. Make it real, the FTC warns that these brain game apps overstate their usefulness. Working a crossword or finishing a puzzle is good but learning new things is even better.
Be physical. Stay active. Walking is the easiest and requires no special equipment. Swim.
Avoid nicotine. Limit consumption of caffeine and alcohol.
Maintain a healthy blood pressure to avoid strain on your cardiovascular system and avoid accelerated organ damage and strokes.
Besides, ginkgo, there is no proof that vitamin E, ginseng, or mass quantities of fish oil are of much benefit.
Modify your diet to eliminate as many processed foods as possible and limit your consumption of animal protein other than fish. Although there is that worrisome connection between methionine and homocysteine, we do need methionine (it is an essential amino acid) so do not try to completely eliminate if from your diet. Moderation is key.
Socialize to improve your mood and engagement. Love your loved ones and live and act for others when you can.

Not a Scary Movie

He was always willing to help out, covering an extra shift here and there, offering to work till closing alone, and always just so darn helpful. It wasn’t long before I began to notice the dark side, however. The nervous reaction when a pharmacist or tech approached him while he was working alone, escalating offers that would allow him to be alone in the pharmacy, and an underlying sense of dishonesty, all led to suspicions of misbehavior. Then product started disappearing. When alerting management of my suspicions,I was advised not to schedule this pharmacist for coverage shifts any longer, effectively terminating his part-time employment with us. I know now that this was the wrong thing to do. He was never allowed back in that pharmacy.

Months later he started showing up at the clinic and the pharmacy. He brought treats for the nurses and the pharmacy staff. He tried so hard to ingratiate himself into our good graces. I could still see the dark side, however. The offers to send myself or the staff pharmacist home early and he would close up for us, resumed. Even off the clock! I detected the furtive glances trying to see how much hydrocodone we had on the shelf. I could feel the desperation.

Despite what management had told me, I felt that I must intervene, so I took this young pharmacist to my office and discussed his obvious substance problem. At first he denied it all, of course, but as I expressed empathy and pointed out the obvious addictive behaviors, he told me the whole story. Like many patients with substance abuse disorders, it began with a legitimate prescription for pain management of an acute injury. This pharmacist had be in a grievous accident, involving multiple fractures and significant pain. The slippery slope was too much for him to overcome. In a familiar progression of events, he started augmenting his regular prescriptions with Rxs from other prescribers, taking a tablet or two during his works shifts at one of his three part-time jobs, to eventually stealing entire stock bottles as his addiction took control of his life.

Fortunately, he was able to break the cycle of addiction and get the help he needed. He admitted his addiction to his parents and referred himself to the board of pharmacy and into the PAPA program. All of this happened over a decade ago and that pharmacist is now rehabilitated and working in the profession.

Over the years I have had more opportunities to see the scope of this problem. It has many different faces. A doctor friend whom I played racquetball with on a regular basis, had been ordering a hydrocodone cough syrup at increasing frequency from our pharmacy “for office use,” a former student was caught on tape accessing the narcotic cabinet during non-business hours and removing product, I was asked to go to a pharmacy as quickly as possible because there would be no pharmacist there and arrived in time to see the pharmacist being “perp walked” out of the facility, I was nearly physically assaulted when a call from a technician required me to go and ask the pharmacist for his keys and terminate his employment as he was obviously drunk, and belligerent, on duty. The scary stories are endless.

Most of us enjoy the thrills we get from a scary movie, whether it be an evil clown peeking out of a sewer or mysterious creatures from an upside-down world right next to ours. In real life, not only our patients are affected, the problems of substance abuse permeate our profession. Pharmacists are not unlike our patients and have substance abuse disorders at about the same rate as the general population, somewhere around 12%. The problem is scary and all too real.

This is why I became a part of the Arizona Pharmacy Foundation which provides critical support for the PAPA program as well as providing education for pharmacists and the community to prevent, recognize and understand treatments of substance abuse disorders. It’s rewarding to be a small part of an effective solution.

No to Graham-Cassidy bill

This is what I sent to my Senators:

The Graham-Cassidy bill threatens the health of anyone who is sick, has ever been sick, or who will become sick in the future. This bill is disastrous and will result in coverage being prohibitively expensive for those most in need of it. This bill serves to maximize profits to the corporations that indirectly manipulate health care, at the expense of patients and those of us that provide direct patient care.

The bill would decimate Medicaid, endangering access for millions of Americans. This would have a huge negative impact on low-income individuals and families affected by diabetes and other chronic diseases. Adults with diabetes are disproportionately covered by Medicaid. In Medicaid expansion states, more individuals are being screened for and diagnosed with diabetes than in the states that did not expand. As a pharmacist, I play a key role in helping people manage this insidious disease. Diabetes and its complications can be managed but patients need help to overcome the outrageous drug costs made possible by our Congress. I have had enough of health care executives pulling down multi-million dollar compensation with bonuses that are essentially based on denial of care to those that need it.

I also can see that the strategy of providing block grants will lead to diminished care and programs for special needs patients of all ages, with many good programs that provide pathways for these special people to contribute to society at risk of being eliminated.

I strongly urge you to focus on bipartisan efforts like market stabilization, taking an unbiased look at a modest “safety-net’ Medicare expansion that eventually reaches all Americans, while leaving plenty of viable marketplace options for non-catastrophic coverage. I believe it can be done.

For now, please vote NO on the Graham-Cassidy bill.

I thank you for your service and your desire to do the right thing for your constituents.

I am happy to discuss any facet of health care, because, I believe that through mutual understanding and similar ideals, we may reach a consensus.

(thanks for the form letter seed from American Diabetes Association)

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