'Dallas Buyers Club' concept metastasizes

Though it may sound like a spin-off of the Oscar-nominated movie Dallas Buyers Club, this PBS News Hour report about the black market in prescription drugs out of Mexico really has more to do with inflated pharmaceutical prices and the failure of states like Texas to expand Medicaid under Obamacare. The story opens:

In borderland Texas, a widespread lack of health insurance is linked to poverty and high rates of diseases such as diabetes, obesity and high blood pressure.

Cheaper prescription drugs to treat these conditions are available across the border in Mexico. But physicians and law enforcement are tracking a relatively new trend — the smuggling of medicine in bulk from Mexico to U.S. patients who no longer feel safe shopping for them in Mexico.

Mexican Pharmacist Jorge Sandoval says people who buy his medicines these days often buy for people they don’t even know.

“There’s a trade in legal prescription medication,” he said in Spanish from his shop in Chihuahua, Mexico, about an hour south of the border. “The trade is generated by people (in both countries) who want to buy medicine at a lower price. People are bringing in ice chests to fill with medicines that they sell to friends and relatives.”

About 24 percent of Texans have no medical insurance, the highest percentage of uninsured in the nation. And although Texas has some of the highest enrollments in the new health care marketplaces created under the Affordable Care Act, the numbers represent a small fraction of the overall uninsured.

That’s one reason why, for years, people have crossed the border for cheaper medicine. The diabetes medicine Metformin is $35 a month here and $15 in Mexico. The blood thinner Coumadin is $60 a month here, $15 there.

But what’s new here is a cottage industry of smugglers buying medicines in bulk to bring back to the U.S.

In the movie Dallas Buyers Club, Matthew McConaughey's character sought out AIDS drugs from Mexico because of approval delays at the FDA. These days, the practice has become more common and generalized, with folks bringing everyday medications into the country illegally because of inflated prices barring access to medication by the uninsured.

When black markets occur for legal commodities - especially ones that don't get you high - it's an indictment of government-sanctioned oligopolies controlling distribution and price. Drug companies on the US side are making a fortune from this over-charging, subsidized by friendly government regulators and now gun wielding law enforcement officers. Don't police have anything better to do than arrest folks for getting legal, prescribed drugs to sick people who need them at a cost they can actually afford?

Criminalizing prescription drug use, distribution: The next frontier for 21st century drug warriors

Should prescription drug abuse be treated primarily as a medical or a criminal justice matter? At the Texas Senate Criminal Justice Committee last week, the answer to that question seemed nearly a faint accompli, with the focus more on tactics and best practices for maximizing prosecutions of doctors and potentially patients. See the Texas Tribune's coverage.

Americans consume 80% of the world's opiates, including 99% of the world's hydrocodone, Dr. Emilie Becker of the Texas Department of State Health Services told the Texas Senate Criminal Justice Committee last week. (Here's the agenda and here's the link to the online video.) In 1990, said Becker, the Center for Disease Control estimated there were  575,000 new opiod users nationally; by 2010 that number had mushroomed to 4.5 million, with the number of drug-related deaths rising with use. She presented this striking chart to the committee, demonstrating that last year, for the first time, drug overdoses eclipsed deaths from firearms and traffic accidents:

'The Police State is Here': Conservative critiques of Big Brother

 These few, disparate items with caught Grits' attention related broadly to limits, or the lack thereof, on government power:

Conservative critiques of Big Brother
A reader forwarded a link to an interesting pair of stories from the Rockwall County News (July 26). See here (pdf) - the articles in question are the second and third ones on the first page, scrolling down, with these headlines:

• Will you be the next peaceful traveler? A scenario and analysis of judicial practice
• The Police State is Here

The second story laments that "So-called fusion centers have popped up in 49 states, amassing files on ordinary Americans for doing the most ordinary of things." These articles interest me not because of their incisiveness - I could quibble with aspects of both of them - but because they portray critiques of the criminal justice system from the perspective of populist conservatism.

Texas let DEA install license plate readers
Speaking of fusion centers and gathering data on ordinary Americans, the national ACLU has launched a research effort to gather information about automatic license plate readers. Their press release mentions:

The Drug Enforcement Administration is planning to install a network of plate readers on major highway systems nationwide. The Department of Homeland Security clocks every car that enters the country. Local and state police departments operate many thousands of ALPR systems nationwide—how many and to what extent, we aren’t sure. Together these programs form a network of data points that can tell the government a lot about our lives.

The Texas Department of Transportation in 2008 rejected a DEA request to install license plate readers on Texas highways, however another recent ACLU blog post stated that "scanners are already in place on 'drug trafficking corridors' in California and Texas." I was unaware that 2008 decision had been reversed. Does data from license plate readers, one wonders, funnel up into so-called "fusion centers"? Who besides DEA has access to this information?

Cops get database with Texans' Rx prescription information
Texas is developing other large databases that a civil libertarian may fear would be uploaded into fusion centers or used by various government entities for reasons unrelated to the purpose for which they were created, particularly a "new state online database of patient prescription drug information." Reported the Fort Worth Star-Telegram, "DPS officials say the database is secure and, beginning this month, available to registered users who provide licensing information, including law enforcers." And if it's available to "law enforcers," why couldn't the data be uploaded to fusion center databases?

On the political economy of the militarization of domestic policing
While we're on the subject of conservative critiques of the criminal justice system, check out this academic article critiquing the "the political economy of the militarization of domestic policing" from the perspective of the Law and Economics movement. Here's a notable passage attributing abuses to the government's near "monopoly" on use of force:

One reason governments are able to effectively exploit their citizens is because they maintain a monopoly, or near monopoly, on military force. It is the concentration of military power, with its weaponry, organizational structure, and tactics that serves as the ultimate tool of government abuse. The threat of violent force raises the cost of deviations from government decree and can be used to repress citizens. As per the paradox of government, this leads to the central concern that while force can, in theory, serve the function of protecting citizens from threats to their person and property, it can also be used by the political elite to undermine the very rights government is tasked with protecting.

Fourth Amendment as a campaign issue
Finally, Grits found it fascinating that legislative efforts to restrict TSA pat downs at airports became a campaign issue in the Texas GOP US Senate runoff, and it seems highly likely the topic will be revived next year when the Texas Legislature meets again. For many years the only time the Fourth Amendment came up in Texas campaigns was when politicians (from both parties) promised to scale back its protections in response to the "war on drugs" and/or the "war on terror." The measure turned out to be immensely popular with the GOP base and perhaps could open the door to more legislation aimed at bolstering Fourth Amendment protections (which couldn't happen soon enough to satisfy this correspondent).

Read more here: http://www.star-telegram.com/2012/08/02/4150020/state-launches-online-database.html#storylink=c

2nd Gregg County death from Methadone withdrawal spurs calls for uniform policy on prescription drugs in jails

Another Gregg County Jail inmate has died after being denied prescribed Methadone - the second such case in six months - raising the question of whether policies on access to prescription drugs should be standardized, the TV station KYTX reported last week.

30-year-old Micah Garner's death is raising new questions about the county's drug policies.

Individual counties have the right to decide which medications are allowed inside their jails and counties around East Texas are handling that decision differently.

The Gregg County Sheriff's Department gave CBS 19 a copy of their drug policies. Medical workers inside the Gregg County Jail have two lists they're working from.

One of them lists drugs that can be administered to inmates. It includes things like allergy and cholesterol medications, even HIV treatments.

The other one contains 26 drugs banned from the jail. It's made up mostly of narcotics and other prescription drugs with the potential to affect an inmate's mood and motor skills.

Methadone, the drug both [Amy} Cowling and Garner were on, is specifically mentioned. The document also says detainees who enter with any of the drugs should have them confiscated.

In Smith County, they do it differently. Instead of a specific written drug policy, a doctor examines the inmate and makes an individual determination about what drugs are appropriate to give while they're in jail.

In Gregg County, a doctor does examine the inmates but is not allowed to go outside the list of approved medications. Sheriff Maxey Cerliano confirmed that list was drafted by a doctor, and not by the department itself.

Reporter Field  Sutton quoted an ER doc explaining that methadone "is typically prescribed for recovering drug users, such as heroin addicts. Sometimes it's also given to chronic pain patients." While withdrawal wouldn't normally lead to death, says the doctor, it can when it aggravates other health problems. Neighboring Harrison County (Marshall) also bans Methadone in the jail.

Sutton predicts the deaths may spur legislative action in 2013: "There's a growing movement to get state lawmakers to create a single policy for methadone inside jails and prisons. No bills have made it to the capitol addressing the issue, meaning it would have to be taken up in the next session."

MORE: See the original complaint of a lawsuit filed in federal district court by Amy Cowling's parents as a result of her death in the Gregg County Jail.

What strategies work to keep HIV+ ex-prisoners on their meds?

From the abstract to an article in the Journal of the American Medical Association, we get a bit more information about the shockingly high rates of HIV positive inmates who stop receiving anti-retroviral drugs when they leave prison. Researchers fear such inmates could become the source of drug-resistant HIV strains, which would be a grave outcome indeed.

Reuters reported that just 5.4% of former HIV+ inmates filled their prescriptions after ten days. Only 17.7% had done so within 30 days, and 30.0% after 60 days - still a strikingly low figure with 70% still off their antiretroviral medication two months after they leave prison.

There's a practical, public safety aspect to this that can't be ignored: The creation of drug-resistant HIV would be a very, very bad thing.

On the bright side, the study identified two variables that improve the chances HIV+ ex-prisoners get back on their meds after leaving confinement.

First, according to the abstract "Inmates released on parole were more likely to fill a prescription within 30 days ... and 60 days" by significant margins.

Even higher compliance rates, though, came because: "Inmates who received assistance completing a Texas AIDS Drug Assistance Program application were more likely to fill a prescription within 10 days," 30 days and 60 days. (See "Results" at the bottom of this page for the statistical details.)

In other words, HIV+ inmates on parole were slightly more likely to get their medication, presumably because they're under supervision, but they were much more likely to do so, especially in the short-term, if they're told where they can get help paying for the (quite expensive) drugs.

That makes a lot of sense, and it points to possible legislative solutions.

Perhaps there's some way to leverage stimulus funds designated for law enforcement or health services to go into the (already strapped) AIDS Drug Assistance Program, designating additional money to pay for indigent ex-prisoners to get that compliance rate somewhere closer to 100%? We're talking about a relatively small number of folks - an average of 700 or so people per year; that's a small price to pay for TDCJ to avoid becoming the source of some terrible, new medical scourge.

Once TDCJ has started an HIV+ prisoner on antiretroviral medications, making sure they're signed up to get their meds on the outside seems like as important a public safety function as locking prisoners up in the first place. The same could be said for mentally ill prisoners, for whom I'd like to see a similar study performed. More attention should be paid to that transition.

This is one of those moments when "an ounce of prevention is worth a pound of cure." I could make that argument for quite a few other reentry services, but in this instance it's particularly true.

Drug interruptions upon leaving prison could create drug-resistant HIV strains

HIV/AIDS is the number one killer of Texas prison inmates, and TDCJ spends about half its pharmacy budget on HIV medications, but many ex-prisoners don't keep taking the drugs once they get out, according to a new study from UTMB. Reported Reuters:

Results of a new study show that major interruptions in HIV drug treatment occur after release from prison.

Within 60 days of release from prison, just 30 percent of HIV-infected inmates in the Texas Department of Criminal Justice system filled a prescription for antiretroviral drug therapy, researchers report in Wednesday's issue of the Journal of the American Medical Association.

Moreover, 90 percent or more of inmates did not fill a prescription soon enough to avoid an interruption in their antiretroviral therapy, according to the report.

"These remarkably high rates of lengthy HIV treatment interruptions are troublesome from a public health perspective," study investigator Dr. Jacques Baillargeon, from the University of Texas Medical Branch, Galveston, noted in a written statement.

"Several studies suggest that many released inmates who discontinue antiretroviral therapy also resume high-risk behaviors such as injection drug use or unsafe sex," Baillargeon added, "and this combination may result not only in poor clinical outcomes for these individuals but also in the creation of drug-resistant HIV reservoirs in the general community."

The study involved 2115 HIV-infected inmates who were receiving antiretroviral therapy prior to their release from prison between January 2004 and December 2007.

Just 5.4 percent of inmates filled an antiretroviral prescription within 10 days of release, the researchers found.

HIV drugs are expensive so for prisoners with no access to health insurance it's not surprising if most stop taking them. But that also sets the stage for a significant public health crisis.

It's easy to say we shouldn't care about prisoners healthcare, but surely everybody should care about the possible "creation of drug-resistant HIV reservoirs in the general community."

I don't know if the solution is to provide meds to parolees with HIV or how this situation might be addressed, but it'd be a catastrophe of enormous proportions if Texas prisons became the breeding ground for some scary, new drug-resistant HIV strain.

TYC Sunset report coming soon, new notification rule on meds released

Some readers may be interested in the Texas Youth Commission's new rules regarding giving youth psychotropic medication, particularly the part of the directive that declares:

If a youth is prescribed psychotropic medication, the youth will be verbally notified and the parent/guardian will be notified via the Medication Notification Letter, Word Document HLS-190, of the diagnosis, name of the drug, purpose of the drug, potential side effects or complications of the drug, and safety precautions (if applicable).

If a prescribed psychotropic medication is discontinued, the youth will be verbally notified and the parent/guardian will be notified in writing on the HLS-190.

The policy goes on to spell out rules regarding hoarding and other types of noncompliance by youth.

In other TYC news, new Executive Commissioner said in an email to employees dated Oct. 28 that she'd be:

participating in the exit conference with Sunset Advisory Commission staff on behalf of TYC this week. This exit conference is the last step before the Sunset Advisory Commission staff will write their final report and make recommendations to the Commission. The final report on TYC is expected to be released November 12th and will be considered by the Sunset Advisory Commission in December.

So we can expect the Sunset report on TYC to come out perhaps as early as next week.

Prescription drugs kill more people than illegal ones; new harm reduction strategies needed

Lately on this blog, discussions of "harm reduction" have centered around the Attorney General's nonsensical legal opinion and Bexar District Attorney Susan Reed's efforts to bully out of existence a legislatively approved needle exchange program in San Antonio. But to judge by newly available data, drugs targeted via needle exchange programs cause less "harm" to the general public than the ones distributed by pharmacists.

The biggest public safety threats related to illegal drugs in the United States arise from drug enforcement strategies that force the product to be delivered through a black market, resulting in violent conflicts among distributors, dangerously impure products, coercion and bribery of police, and a variety of other anti-social outcomes. Purely from a safety perspective, however, new data reveals that prescription drugs cause more deaths related to the drugs' actual effects, reports the New York Times ("Legal drugs kill far more than illegal, Florida says" June 15):

An analysis of autopsies in 2007 released this week by the Florida Medical Examiners Commission found that the rate of deaths caused by prescription drugs was three times the rate of deaths caused by all illicit drugs combined.

Law enforcement officials said that the shift toward prescription-drug abuse, which began here about eight years ago, showed no sign of letting up and that the state must do more to control it.

“You have health care providers involved, you have doctor shoppers, and then there are crimes like robbing drug shipments,” said Jeff Beasley, a drug intelligence inspector for the Florida Department of Law Enforcement, which co-sponsored the study. “There is a multitude of ways to get these drugs, and that’s what makes things complicated.”

The report’s findings track with similar studies by the federal Drug Enforcement Administration, which has found that roughly seven million Americans are abusing prescription drugs. If accurate, that would be an increase of 80 percent in six years and more than the total abusing cocaine, heroin, hallucinogens, Ecstasy and inhalants.

The Florida report analyzed 168,900 deaths statewide. Cocaine, heroin and all methamphetamines caused 989 deaths, it found, while legal opioids — strong painkillers in brand-name drugs like Vicodin and OxyContin — caused 2,328.

Drugs with benzodiazepine, mainly depressants like Valium and Xanax, led to 743 deaths. Alcohol was the most commonly occurring drug, appearing in the bodies of 4,179 of the dead and judged the cause of death of 466 — fewer than cocaine (843) but more than methamphetamine (25) and marijuana (0).

The study also found that while the number of people who died with heroin in their bodies increased 14 percent in 2007, to 110, deaths related to the opioid oxycodone increased 36 percent, to 1,253.

Florida scrutinizes drug-related deaths more closely than do other states, and so there is little basis for comparison with them.

The implications of this shift are enormous: More than one in five people in Texas prisons are there for crimes related to illegal drug sales or possession, but those strategies don't affect the drugs killing the most people. The same tactics could never be applied en masse to prescription drug abuse - the economies of scale would quickly overwhelm police and prisons. It would also tick off powerful political constituencies like doctors and drug companies who hire armies of lobbyists to promote their interests, as opposed to their Mexican drug cartel counterparts who just hire armies.

The substitution effect here is palpable: People abuse prescription drugs largely because of the stigma and legal difficulties arising from gaining access to illegal ones, even though they're not as safe. So to that extent, the shift toward prescription drug abuse counts as a drug war "success," but only if you redefine the term "success" to mean causing more deaths instead of preventing them. (The Economist recently declared it a success to shift people from using meth to cocaine, but the Florida study says coke is much more dangerous to users than crank; by that logic, to judge by these data, it'd be a public safety success to get people to shift from Vicodin or Xanax to marijuana, which didn't kill any Floridians last year.)

"Harm reduction" historically focused on illegal drugs, but what if that's not main source of drug-related harm? What's needed now, apparently, are more addiction treatment resources and harm reduction strategies aimed at legal prescription drugs.

Binge drinking among Texans far outpaces illicit drug use

This chart surprised me in a recent federal survey showing that the prevalence of illicit drug use in Texas is lower among all age categories than most other states. I was also surprised by the wide variation among states regarding illicit drug use. Vermont had the highest rate of past month illicit drug use among young adults aged 18 to 25 (31.0 percent), and Utah had the lowest rate in that age group (12.93 percent)." In Texas, the "last month" usage rate for that age group was 16.77 percent, very much on the low end of the scale.

Interestingly, Texas had about the same last-month use rate for non-medical use of pain relievers as for marinuana - 11.94% among those age 18-25 had taken pain pills for non-medical reasons, compared to 12.09% among that age group who'd smoked pot..

Given how many people we send away for drugs, and for how long, not to mention our proximity to the border, I guess I'd wrongly assumed Texas faced more serious drug abuse problems than other states. According to these data, alcohol still outpaces illegal drugs as Texans' intoxicant of choice by a country mile - 40.99% of Texans age 18-25 engaged in binge drinking in the past month, according to the survey.

The full report is available on the Web here, via Medical News Today.

Arrests for pain, anxiety drugs worrisome for legitimate patients

I get a little edgy when police start making arrests for a legal pharmaceutical that I've been prescribed recently by my personal physician: It makes me wonder under what circumstances I could become a target?

Over the last year or so I've struggled with some health problems that caused my doctor to prescribe one of the medicines now named by drug enforcers as a primary target, according to the Houston Chronicle ("Southeast Texas called 'mecca' for pill pushers," Oct. 22). So if I'm driving or out in the world and have my medication with me (as I've been advised to), if a cop sees me with it will I be arrested?

I wonder: How much documentation must I carry with me to imbibe prescribed medication? Under what circumstances would possession be illegal and when would it be okay?

I was also disturbed to learn about a bill signed by Governor Perry that I'd missed during the 80th Legislature, expanding DPS regulatory authority to include most medicines. That's just wrong: I want doctors regulating my prescriptions, not cops! Reported the Chronicle:

The DEA classifies drugs in "schedules" or levels, based on the risk of abuse. Drugs such as lysergic acid diethylamide (LSD) and heroin are considered level 1 and have no accepted medical use in treatment in the U.S.

The level 2 drugs, such as the painkiller OxyContin, are available by prescription but are regulated at the federal level by the DEA and at the state level. Pharmacies electronically transmit prescription information to the Department of Public Safety, which works with licensing boards to identify doctors and pharmacists who may be inappropriately prescribing or dispensing drugs.

This summer, Gov. Rick Perry signed a bill that would expand monitoring by DPS to include level 3 through level 5 drugs, which would include Xanax and drugs combined with hydrocodone, which are levels 4 and 3, respectively.

State Sen. Tommy Williams, R-The Woodlands, said he sponsored the bill to give Texas law enforcement agencies the tools to investigate drugs that are classified as less prone to abuse by requiring all prescriptions for controlled substances to be sent electronically to DPS. The official enforcement date for the law is September 2008.

Still, some law enforcement officials in Texas argue that hydrocodone and Xanax should be grouped with more addictive drugs and targeted separately — not with other schedule 3, 4 and 5 drugs. They are pushing for the Legislature to reclassify hydrocodone and Xanax as level 2 drugs, which would make them subject to far greater scrutiny, similar to OxyContin, officials said.

"We have to change the overall approach that the state has in regards to regulation, " said Houston Police Lt. Gray Smith, with the narcotics division.

Honestly, I don't want my prescription information transferred to DPS, and I don't think most Texans know that that happens. Did you? I'm fairly shocked by it. I wonder what they do with all that data?

What do you think? Why should state troopers have access to Texans' prescription information? And should criminal law enforcement focus its limited resources on tracking what drugs your doctor gave you or how often you renew your prescription? Does that make you feel safer, or less safe?

ADDENDUM: This story from KHOU gives a fuller picture of the real problem: If the real source of crime is stolen or black market drugs, how does it help to gather information on legal prescription holders?

My baby rocks, y'all

Okay, folks, my sweetie's hit the big time. I've written before about Kathy's cool web organizing project mixing animation, podcasting and e-activism to promote prescription drug reform for Consumers Union. Here's a fun frame:

Titled, The Drugs I Need, the project features terrific Austin artists: the Austin Lounge Lizards and the Animation Farm. On Friday morning the Today Show ran the entire song and animation. On Sunday, the New York Times ran their second story in a week about the project. Then on Monday she moderated a panel at SXSW on e-activism with a bunch of national hotshots. Now this comes from the 3-15 London Financial Times (via email, no link) with a great update on the campaign, and an analysis that it may have catapulted prescription-drug-reform politics into a whole new level. I especially like the story's lead:

In any fall from grace in American life, the descent towards ignominy is marked first by criticism, then ridicule, writes Christopher Bowe. Just ask Bill Clinton. Or the French.

Now the pharmaceuticals industry appears to have entered that ring of hell. An internet cartoon called The Drugs I Need, which mocks the companies' feel-good television advertising and blasts their high prices, has caught the public imagination. Produced for Consumers Union, a watchdog, the campaign has triggered 60,000 letters to Congress in little over a week. In the process, It has been picked up by internet political cartoonists Jibjab.com, where it is the first external animation to appear on its site.

The advert features a paisley-pattern pill character strutting through a sunflower-filled landscape, singing: "They've spent billions to convince me, so now I realise Progenitorivox beats diet and exercise... But I want Progenitorivox, because I saw it on TV. Those families look so functional,
that paisley pill's for me."

That's pretty good for a bunch of Texas yokels, huh?

Austin political song and animation taking off

I mentioned not long ago how proud I am of Kathy for a new song and animation she ramrodded for Consumers Union to promote prescription drug reform in Congress. It's a truly cutting edge project combining podcasting, flash animation, and Consumers Unions e-action system to promote a reform message with an outrageously funny twist. (The above shot depicts "male lactation" as a possible side effect.) Called "The Drugs I Need," the song was written and performed by the Austin Lounge Lizards, with the video done by Austin's Animation Farm. It blasts big drug companies for pawning off products with deleterious side effects without making all their test results public.

Well, yesterday the New York Times covered it in their Science section, and they quoted Kathy! I'm glad she's getting some credit, because she deserves it. She tells me it's been plugged on over 50 blogs now, and is being promoted by Jib Jab.

Check out the song and animation (both are downloadable) at www.prescriptionforchange.org.

"The Drugs I Need"

Consumers Union, which publishes Consumer Reports magazine, has produced a hilarious spoof song and animation entitled, "The Drugs I Need." The song makes fun of prescription drug advertising (you know, the drugs we didn't declare war on), asking consumers to take action on upcoming legislation in Congress. You can view and download the animation and/or an MP3 of the song at www.prescriptionforchange.org. It's really funny.

My wife, Kathy Mitchell, runs Consumers Union's national e-action system, and this is her latest pet project. I'm really proud of her, and the song and animation are first class. I thought Grits readers would love it, and hope you'll help spread it around. Consumers Union commissioned the Austin Lounge Lizards to write and perform the song (they're perhaps Texas' top satire band), and the terrific animation was done by Austin's Animation Farm.

After viewing, it takes viewers to an action alert where they can tell Congress -- big hearings are scheduled for Tuesday and Thursday -- to make drug companies release all the results of their testing (they don't have to now) and improve oversight of drugs already on the market.

Check out the song, and thanks, folks, for any help you can give spreading word about this fun project.

UPDATE: This thing has gotten wide play already. BoingBoing picked it up today! (3-1) They called it "awesome" and "raunchy." Fun!

Strayhorn Medicaid Fraud Probe Misplaced

She may be "One Tough Grandma," but that doesn't mean Grandma always knows best. Texas Comptroller and former Austin Mayor Carol Strayhorn recently announced a new anti-Medicaid fraud initiative aimed at taking prescription drugs away from foster kids.

Strayhorn's press release claimed to uncover "Medicaid prescription drug fraud and abuse that just in the state’s foster care system alone is costing taxpayers – conservatively – an estimated $4 million a year."

That estimate's completely phony, though. Here's where the $4 million figure comes from:

“More than 272,331 state and federal dollars were spent on anti-psychotics for foster children in one month and more than $74,000 on anti-depressants. That would make the estimated annual cost of anti-depressants and anti-psychotic drugs for children in the foster system conservatively $4 million,” she said. “Mind you that figure is a very conservative estimate for these drug expenses in just the foster care system alone.”

In other words, $4 million is the total cost of these doctor-prescribed drugs to foster children. There's only $4 million worth of "fraud and abuse" if every single prescription is unwarranted. The idea that some children who've lost their parents might be prescribed anti-depressants doesn't strike me as scandalous, but she's spun it that way.

Now, I don't support overmedication of children, and I want the foster care system to be monitoring that subject more carefully. What I object to is labeling Medicaid transactions fulfilling doctors' prescriptions to Medicaid-covered patients as "fraud." It's dishonest demagoguery, a smear on foster families and on an underfunded, overstressed system, to claim all these prescriptions are fraudulent -- thematically akin to right wing stereotypes of "welfare queens." Frankly the Comptroller knows better. (Hopefully the quotes don't reflect her true attitude, but that of whatever overzealous staffer wrote the press release.)

I worked for a couple of years at the Texas State Medicaid Office back when it was run by Dr. Mike McKinney. In my experience you may find some fraud among Medicaid recipients, but the vast majority of waste, 98+%, will be found investigating more traditional healthcare providers. After all, they receive the $15+ billion annually in payments from Medicaid -- all the recipients get are services.

The few bits of fraud found among prescriptions for foster kids will generate a good newspaper story, but will mean nothing in terms of the massive Texas Medicaid budget. She should be auditing Medicaid billing by the big hospitals like Seton and Columbia HCA, as well as nursing homes, medical transportation services and other types of Medicaid providers, for the really big bucks.

So from a budget perspective, Strayhorn's proposal is all sizzle and no steak. By contrast, here's where Attorney General Greg Abbott thinks we should focus on Medicaid fraud:

"Medicaid Fraud comes in many forms. In some cases, a doctor files claims for reimbursement for tests he or she did not perform (billing for services not rendered). Other cases may involve a hospital submitting a claim to Medicaid for a complicated, more serious illness than the patient actually had (upcoding). Or perhaps a physical therapist submits claims to Medicaid for services which were not medically necessary or which were not validly prescribed. It could also be a company billing for an expensive motorized wheelchair but delivering only a scooter to someone who qualifies for neither one."

Here's the key point when thinking about Medicaid fraud: The most a patient can get from Medicaid is free healthcare, which they'd often otherwise get in the emergency room at four times the cost. That's not hurting the state as much as docs and hospitals pocketing cash they don't deserve, and it isn't nearly as widespread.

Targeting foster parents might play well in a Republican primary, where you get to say you got tough on those beggarly welfare frauds, but if you want to maximize state savings from anti-fraud efforts it makes little sense. It's odd and troublesome for the state to go after poor people first, while white collar fraud in the system is rampant, and almost assumed by those involved.