In it they suggest that Valeant staff double under fake names as Philidor staff.
The use of alternative names by workers at Philidor is one of a number of new details emerging about the relationship between Valeant and the network of specialty pharmacies it uses to distribute drugs. The relationship is at the center of questions that investors have raised about the strength of the drug company’s operations and the disclosures of its business ties.Citron Research alleged that Philidor was used as a method of channel stuffing. However I think that it is more likely that it is used as a mechanism for customers to buy and insurance companies to pay for drugs that they would not have otherwise done so.
Two methods are - it seems - used to do this. One has been widely discussed - copay assistance.
The other is using name of a pharmacist that is seemingly unrelated (or at least where the relationship has not been disclosed) to "fill" the prescription. That pharmacist essentially donates or lends their NPI number. The captive pharmacies are variable interest entities because they are controlled but not owned. Valeant would in this case wish to hide their ownership.
There is a court case between Isolini (almost certainly an undisclosed Philidor and hence Valeant subsidiary) and R&O pharma (a pharmacy with a license in California). You can find the Isolini documents here (warning large folder).
The usual explanation for why Philidor wanted to use R&O pharma was that Philidor had been denied a license to operate in California and R&O had such a license.
We however have our doubts. One of the Isolini documents (provided by the Philidor/Valeant side of the transaction) had an invoice for all the product that had been shipped in R&Os name and for which R&O owed money.
That list contained identification numbers. We discovered that those numbers were in fact UPS shipping numbers and each of these deliveries is traceable. This (linked) document is a list of UPS tracking numbers.
And those deliveries went all over the United States. They went to California - sure - but they also went to other addresses.
Some went to States where Philidor was licensed but not R&O. Some went to States where R&O was licensed but not Philidor. Some went to States like Oregon where neither R&O nor Philidor was licensed.
So here is the pertinent question: why would Philidor (which is staffed by Valeant staffers using false names) use the name of a two-bit pharmacy to send prescriptions all over the United States including to States where the two-bit pharmacy was not licensed?
The only explanation I can come up with - and one that the company should address in the conference call - is that they did it because they were getting rejections or audits from insurance payers when using Philidor's name. Hence they used the NPI number of another pharmacy and the payers paid without audit.
I expect the company to provide an alternative explanation in the conference call because this looks like deception using a mail service to deprive property from a financial institution: classic mail fraud. And because it is against an insurance company (a finacial institution) the monetary penalty is up to $1 million per instance. And each instance is separate and fines are cumulative.
Don't even try to work out the fine.
PS. These conclusions are broadly similar to Roddy Boyd's most recent article (which is excellent).
For reference here are the first hundred or so of many UPS numbers - used the linked document to see them all.
I hope you and the others (SIRF, ProPublica, WSJ, ...) keep digging up new angles right up until the time of the conference call. There will be voices of fatigued people on that call.ReplyDelete
Keep up the good work.
This is fascinating. I have also written up a blog post: https://sonofsuit.wordpress.com/2015/10/26/redux-before-valeants-investor-call/ReplyDelete
These developments should make for a very interesting conference call.
how about diclosing the fact that you probably covered most of your position?ReplyDelete
Global Trader - sorry I have covered none of the position.ReplyDelete
So, these geniuses provided an incriminating disclosure in a lawsuit documents they willingly initiated and filed themselves?ReplyDelete
Either they are certain that Isolini-Philidor (ance hence Valiant) ties can not be proven, or... they are the classics, geniuses.
I also wonder, no real idea how laws work in this particular case, can insurance payers backwards-audit and claw-back? That could be the demise of this particular scheme even if the whole picture does not attract an official investigation.
Wow I want their lawyersReplyDelete
1) Try and firewall all dodgy behavior
2) Put $233 million through the equity line, instead of SG&A.
Any managed care provider who does not remove Philidor / related pharmacies from their lists are real suckers
A lot of hypotheticals and conjecture in the analysis. How did the company respond to your questions when you called them? Have you ever called the company directly and asked?ReplyDelete
"Citron Research alleged that Philidor was used as a method of channel stuffing". Isn't that your initial allegation? Isn't Citron just a mouthpiece for your research?ReplyDelete
John, You claim in this post that the UPS tracking numbers (and their associated delivery points) constitute proof that R&O is shipping to states in which it is not licensed to operate. Can you demonstrate that this is the case?ReplyDelete
I ask, because thus far appears that the deliveries in your list are only to states in which R&O was licensed to operate. Using the first tracking numbers you show, the first three states for deliveries are Illinois, Nevada and Washington. R&O is licensed in all three states.
R&O's license numbers are as follows:
Illinois license number: 054018365
Nevada license number: PH03039
Washington license number: PHNR.FO.60406576
Each of those states has a public, searchable, web-based database for pharmacy licenses.
Furthermore, on slide 72 from today's presentation from Valeant, the company states: "R&O is a pharmacy in California with non-resident licenses in 34 other states"
Can you help reconcile your claims with these details? Thank you
Hi John. Anon back again.ReplyDelete
Slide 34 of today's VRX conf call.
Philidor holds non-resident licenses in 45 states, the District of Columbia and its resident license in Pennsylvania
•In the few states where it is not directly licensed, like California, Philidor does not dispense products to patients. Philidor has agreements with affiliated pharmacies that have California licenses, and those pharmacies have dispensed products to patients in California
OK, so if Philidor holds licenses in PA, why did it dispense product using R&O's license into PA (see the email in R&O docket subject: "IHS Audit")
What were the criteria for dispensing as Philidor vs dispensing as R&O? What was the intent?
You have the answer, I just like the question.
You did really good work here.
I assume VRX used option structure rather than purchase arrangement with earnout to: 1) 'fast forward' consolidation of cash earnings - wait for closing of purchase agreement; and 2) disclosure of purchases in FS footnotes investors. Why not positively impact organic growth and cash earnings ASAP?ReplyDelete
I also assume they economically paid for via option and earnout for 3rd party cash earnings since they control their pipeline of cash earnings?
Perhaps they simply sought to enjoy benefit of distribution channel profits that they directly impacted and that would benefit cash earnings?
I assume VRX/Philidor could not man R&O in same way as VRX did Philidor due to Calif licensing issue (and other issues?) and this lack of control over cash led to R&O going rougue on VRX. Did R&O expect VRX to not pursue $25 million in cash and drugs to avoid scrutiny? The pursuit of $25 million has contributed to loss of $25 B in market cap. Should they just walked away and used another guy to access jurisdications that Philidor did not have access too?
What other VIEs that are not disclosed does VRX have in place? If any, what is amount of cash earnings do they contribute? Why option structure instead of purchase agreements with or without earnouts?
Should we be deconsolidating VRX's debt and examining how cash flow flows to parent (or is blocked in various subsidiaries) and what cash flow needs are at parent? Should we be examining RCF, credit facility and debt maintenance covenants? They have $30B in debt.
We have all witnessed a serial rollups/consolidators who have recognized non cash revenue and capitalized cash operating expenses and that also experience cash flow restrictions to parent and ultimately financial distress and bankruptcy. Once they file, they restate financial statements and investors get a truer picture of what is happening economically. At times new claims develop due to bad behaviour (securities class actions, Justice Department claims, business restrictions due to bad behaviour). Growth plays shift to value plays and then shift to distressed plays.
Will 2 competing US Attorney efforts lead to 'full body scan' of VRX so that they will pull on threads and what develops over time? What new disclosures will turn up in future 10Qs and 10Ks due to US Attorney investigations? US and International Banks have faced a huge bill for settling bad past behaviour that have been uncovered by various authorities. Will US authorities be sympathetic towards Canadian company not paying tax in US yet dependent on the US consumer? Hmmm....
Flat VRX but watching...very good work John but perhaps a few too many suggested questions??
Correct me if I'm wrong but it seems that the VRX short case isReplyDelete
-VRX did something wrong through Phillidor or another speciality pharma
-Phillidor will be heavily fined
-This fine will flow through Phillidor and VRX will have to pay. Because they are levered 4-1 they are in huge trouble
Its a series of low probabilities events that all have to happen. First what Phillidor did has to be illegal (not just aggressive), who to trust, the army of lawyers VRX has or shorts with 0 legal training? Then it must lead to a big fine (I mean really big because its just a one time thing, one thing charges should not impact the valuation of a stock significantly unless they are huge and threaten liquidity/business model). Then the Phillidor structure will have to be deemed invalid so VRX becomes liable for the fine (which the army of lawyers at VRX says they do not think will happen)
All of this will have to happen, if any of them doesn't, then the stock is a buy. This thesis might have been good at $160 but at $110, frankly, I just think its ridiculous
Valeant claims that it has been indemnified by Philidor, and is not liable for Philidor's "misdeeds."
What's your view on this?
There's no accounting fraud There may be disclosure issues but that's minor.ReplyDelete
However, there is a bigger problem.
The slideshow s.34 says the R&O Pharmacies were used to ship product to states Philidor not licensed to.
But Philidor is licensed in PA.
I think what you're looking at, from a technology perspective, is an adaptive network.
Orders were centrally routed into the call center in PA.
After taking the order, Philidor would assign for fulfillment (either manually or algorithmically, most likely the latter) to the pharmacy which the algorithm predicted had the highest expected value of reimbursement, given the available sets of (payer, pharmacy, medication) the order could be mapped to.
The expected value would change over time, sometimes overnight, so the algorithm would need a lot of small pharmacies like R&O to work.
Peter Parker = Spiderman = spinner of webs. A web is a flexible network.
Couldn't get any crazier.ReplyDelete
This is Phillidor's Director of Pharmacy operations, and head of West Wilshire Pharmacy.
She used to run the pharmacy at a Super Fresh in Morrisville, PA.
John, do you have an OCRed CSV of the 430 pages of invoices from the Eric Rice court doc? If so, could you share on Google Drive please? Would like to calculate the total order volume - # of scripts and $ value. ThanksReplyDelete
Also, can you please say which state they shipped orders to where neither Philidor or R&O were licensed? So far, I've found them to be licensed in all the states I've checked: CO, IL, WA, MN, NV, CA.ReplyDelete
Valeant claims that it has been indemnified by Philidor, and is not liable for Philidor's "misdeeds."
What's your view on this?"
John has no US legal expertise to even be able to evaluate this. He might claim otherwise but its the truth. If VRX well paid lawyers said the structure will stand in court, thats the most likely scenario. If it doesn't, well, the shorts got lucky because they got no way to know that beforehand
Philidors indemnification is worth nothing. No financial klout there.ReplyDelete
"Philidors indemnification is worth nothing. No financial klout there."ReplyDelete
Really, you got court cases and legal experience in this matter? or are you only guessing based on your extremely limited research on this topic?
Pershing Square will now hold its own VRX conference call on 30 Oct at 09:00. It seems that Mr. William Ackman was not pleased with JMP's performance yesterday. PSH is now VRX's investor relations department! Any wagers on a 100+ page slide deck?ReplyDelete
Hope you are not short AlibababaaaaaReplyDelete
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You might not understand how they do it, but you must know that they will do the right ethical things that will make the world a better place. so just invest in them and let them guide you.
The difficulty becomes, how to find these people... Start by reading...
Valeant 5YR CDS is just ticking through last week's highs @ 6.43%
WIth the amount of debt they have out there, this is teetering on implosion.
The market clearly thinks you're wrong and John's right.
GlobalTrader trying to salvage his long...ReplyDelete
GlobalTrader, John is saying that an indemnification from a limited liability entity with no financial resources isn't worth the paper it's printed on. That is not a legal argument, it's a financial one. There is a legal argument to be made, which has to do with whether Valeant will be responsible for Philidor's liability. This would likely hinge on whether Valeant effectively controlled Philidor as the WSJ seems to be reporting. In any case if you're going to try to attack John, you should try to do it with reasonable arguments. If you're just trading the dip as your moniker would imply, then best of luck to you...ReplyDelete
An indemnification is worth something only if the indemnifier has financial assets to pay the huge amounts. This is not a legal issue. It is just simple math.ReplyDelete
If the allegations are true and Philidor is a sham front for Valeant, then the the indemnification is worthless because Philidor is worthless. If the allegations are false and Philidor is a legitimate business, that for some bizarre reason engages in inexplicable behavior, then you don't need the indemnification to begin with because no one has done anything wrong. Thus, John is absolutely correct. The indemnification is worth nothing, either way.
By the way, if it is also true that Valeant has the option to buy Philidor for 0, then Valeant is just indemnifying itself. Again, just simple math showing the idiocy of the indemnity.
My two cents.
BTW, there is never only just one cockroach. If you see one, assume there are many more.
Global Trader, your ignorance of the way top-notch investigative short-sellers work is astonishing. Let's start with Enron. No one understood exactly how the fraud worked until the end, when the puts in the off-balance sheet entities were revealed. No one understood exactly how the fraud worked at Worldcom until the end, when it became clear that expenses were being capitalized. To move closer to home, no one knew exactly how the fraud at Longtop worked until the end, when the auditors finally got around to visiting the lenders. In each case all the investigative short-sellers knew was that things did not smell right, that two and two did not add up to four, and that there were at least huge omissions in disclosure. The investigative short-sellers were more insightful than the Big Four auditors, and they were better versed in what was going to be illegal than the company's lawyers. Just ask Jeff Skilling and Bernie Ebbers; I am sure that they will confirm this, if you can get their prison guards to let them speak to you.ReplyDelete
Top-notch investigative short sellers like John dig up things then take a huge risk, shorting something which everyone else is telling them is hunky-dory. If they were to wait until everything is explained, the stock would already be at 0.
In the case of Valeant, John and Rodney Boyd have done a terrific job, bringing up troubling questions. I am sure that they have made some mistakes because they don't have subpoena power. But at the moment things look real bad for Valeant. What the hell were they trying to accomplish with Philidor and all its machinations? They have not answered that question. The best that shareholders can hope for is that the answer is something unsavory, rather than something illegal. Valeant stock still has a P/E of 40. That doesn't remotely discount the emerging reality, especially with its debt burden.
Global Trader, John may not be a lawyer, but I am.ReplyDelete
So let me put this in simple terms for you.
An indemnity is a contractual promise, no more or less, to indemnify and save harmless the indemnified party against certain losses. And like all contractual promises, it's worth is determined by the means of the party giving it.
It is of course important to know the precise terms of the indemnity to identify its scope and any exclusions or limits. For example, it is reported that the Philidor indemnity is capped at the upfront plus milestone payments ($133M).
However, even if losses suffered by Valeant arising from the Philidor option/acquisition fall within the scope of the indemnity given to Valeant, and Philidor is liable at law to indemnify, that is of no worth to Valeant if Philidor does not have the means to make good the indemnity. Valeant can sue on the indemnity and obtain judgement against Philidor, but if the latter is not worth powder and shot then the indemnity is worthless.
It's a bit a bit like buying a contract of insurance from the homeless person living under the bridge. You can technically say that you have insurance, but for practical purposes it is meaningless.
The question then is ultimately not a legal one (if we assume, in Valeant's favor, that the indemnity is otherwise responsive) but a financial assessment of Philidors capacity to honor any indemnity it has given.
And on that note, there's nothing in Valeant's presentation that I have seen, nor anything otherwise in the public domain, that suggests that Philidor has $133M, or anything like that sum, to make good any indemnity which it has given.
I don't see any tracking numbers being delivered to Oregon. I ran a script on your whole UPS text file.ReplyDelete
One other thing, and I may have missed it but I don't think so, is that it's ludicrous that the nominal owners of Philidor have never been revealed. Are we to believe that Valeant has no idea who they bought their "option" from? It's a nine figure transaction... I'd like to believe DD was conducted in some way.ReplyDelete
Now the REALLY fun thing would be if this was to kill two birds with one stone, i.e. setting up a specialty pharmacy while ALSO shoveling tens of millions of dollars to related parties. We'll see, I suppose, but so much about this doesn't make sense. I don't have a position, but maybe if the IV comes down I'll pick up some puts.
If you look at the economics of the whole thing, the structure is kind of ingenious. Valeant simply ships more when it needs to. It can effectively keep its own inventory in the Philidor/affiliates network.ReplyDelete
Philidor has effectively just set up a call center. It gets X dollars per scrip processed, which means it wants to maximize auto-refills (it doesn't have to pay call center workers to do that). Philidor is therefore incentivized to get as many repeatable refills on insurable product as it can. Because Valeant gets more product shipped, and because Philidor is not going to go out of its way to ship generics, Valeant can afford to sponsor/waive the co-pay. Philidor does not have to actually front that much money.
So basically, Valeant has paid $133 million with payments on another $100mm of KPIs to buy a company whose only real asset is a string of permits and 1000 low-paid people sitting in cubicles in north Philly and Scottsdale, answering phones.
Which means the two main issues are:
1) has Philidor done anything illegal and if so did Valeant know about it when it did?
2) Is the arbitraging of the co-pay waiver (giving doctors zero-co-pay coupons for example) a kosher way to build your business?
I'd argue on the second one that it is not, but this is a much larger bezzle than just Philidor and Valeant.
The question I have on co-pays is whether legally, waiving a $20 co-pay on an 80/20 insurance plan and then billing the insurer $80 is fraud. One could argue that under the plan the insurer signed with the insured, the insurer is only liable for 80% of the cost. So if the pharmaceutical company is sponsoring the co-pay, that means the net cost to a third party is only 80 so the insurer should pay 64. but then someone has to be found to pay the 16, or else it all iterates down to zero. This is obviously why the copay charities exist, but abuse of that is easy. What is the flow to make this "work"?
And Medicare/Medicaid's specific prohibition on waiving co-pays, defining the lack of collection as systemic abuse, is an obvious reason why they won't deal with M/M patients. But doesn't that mean the private insurers should take a page from Medicare/Medicaid? Or are they simply too conflicted - like brokers they take a spread on the whole turnover so they actually prefer turnover be higher year after year?
"An indemnification is worth something only if the indemnifier has financial assets to pay the huge amounts. This is not a legal issue. It is just simple math. "ReplyDelete
The legal issue is how does Phillidor liabilities (which at this point only exist in John's mind) somehow will flow through VRX even though VRX lawyers structured the entity in a way that would shield them away from any liability (slide 23 "we do not believe we have any liability to phillidor").
This is a situation which requires knowledge of law for someone to be able to assess that the structure would fail in court. The shorts don't have that. As I said the short case seems weak at best
first phillidor has to have done something wrong even though they got lawyers and outside law firms being used to avoid those issues
secondly, they need to receive a HUGE fine (because its a one time expense). The only way VRX stock drop can be justified by recent events is if there is a HUGE fine involved
and thirdly, the structure that they built and limited liability (a key component of US law) will fail them and the structure will not hold up in court.
If you assign a 50% chance of each of those events (which looks very generous given that they consulted with laywers all the way through) the final chance of VRX going bust would come out at 12.5%
and as far as the whole 'maybe this is enron and there are more shoes to drop'. well so far the whole enron accusations has been very exagerated. The citron report, of course, was a joke. sure, other shorts raised questions. but thats all that they are, questions. when a stock drops huge and momentum builts to the downside, frequently, people will behave emotionally instead of rationally (but they will cling on to 'reasons' for their bias). this will lead them to overestimate the bear case. and hence, the probability of the enron scenario.ReplyDelete
I have been shorting for a long time and I know this because I have been in the other side and got my face squeezed. The short case here looks quite weak
Fortunately you don't even need fraud for this bear case.ReplyDelete
"My favourite part of this story is that Bill Ackman, one of my least favourite hedge fund managers, has around a third of his fund invested in this monster."ReplyDelete
lol, you think being in the other side of an investor with a 80%+ success rate in his stock picks is a good thing?
John, you claim that they illegally shipped to Oregon yet there is no proof of that.ReplyDelete
You said you used the linked document with all the UPS numbers (22,053 in total). I took that document and wrote a macro to pull the delivery address for each entry. Oregon never once showed up as a state for a delivery from R&O.
Note, no records appeared for 2,108 UPS IDs listed in the attached document. My guess is that there were some errors in the text recognition from the scanned pdf of the court filings. I have not endeavored to manually correct these entries but this should not matter as you claim to have used this exact list as the basis for your claim that R&O fraudulently shipped to Oregon where they have no license.
Given this data does not substantiate you claim that they fraudulently shipped to Oregon, Could you please clarify the basis for your claim or correct it to reflect that they have not engaged in fraudulent shipments to that state?
John - i hope this thesis of yours works out as well as the FairFax one LOLReplyDelete
you got burned badly on that one, I know. Can't believe you were so wrong and are so wrong again.
Surely the answer to that question is "yes". If a fund manager has an 80% hit rate but doesn't own the whole world, then you know that when he loses, he loses big. That's obviously true of Ackman - he has a lot of big wins, a smaller number of big losses, and a proven habit of not cutting losses early enough. That's why his fund is called "Pershing Square", not "Gotham Partners". If you're on the other side of Ackman and you have good risk management you have a totally different risk/return profile.ReplyDelete
Is it possible that other pharmaceutical clients advised by McKinsey are doing the exact same thing?ReplyDelete
VRX Were reviewing information, including rejection in CA, Cindy Hamilton chief compliance Oklahoma State Board of PharmacyReplyDelete
2 Sequoia directors resign re: the fund's largest ( 30% ) holding.ReplyDelete
The next leg down is commencing. Caremark and Express Scripts have kicked ethically challenged Philidor out of their reimbursement eligible pharmacy networks. That's a good start. Philidor will be worthless soon which means Valeant will have to write off the $133MM of SG&A paid to Philidor and capitalized on the Valeant balance sheet. It may be the wrong period, but at least it finally will hit the P&L (although in the wrong category).ReplyDelete
I wonder how many more Philidors Valeant controls? Pharmacy benefit managers may have to play whack a mole for a while.
The leg after this is when the pharmacy benefit managers update their formularies to prune Valeant drugs due to abusive Valeant price gouging behavior.
It was nice to see some positive ethics around Valeant for a change. Warren Buffet's bridge partner was one of the 2 Sequoia fund directors who resigned over the continued Valeant position.
This came across twitter a couple of days ago...ReplyDelete
" This tells you Valeant IS gouging those who can pay."ReplyDelete
I suppose a soviet style system where prices are set by a member of government is what you would like to see
Not sure a "soviet style system" is necessary. Perhaps Mr GlobalTrader thinks that Medicaid and Medicare are soviet style systems. Perhaps that's why Valeant tries to avoid them - because they are Soviet style systems and Valeant has a philosophical disagreement with such systems. Perhaps it tries to avoid them because they are stricter on pricing and are not compatible with growing scrip count.ReplyDelete
The American right seems to have no problem with making the armed forces a public good, and social security a public good, and water (a health matter), sewage carriage/treatment (which is quite arguable a health matter), police (public safety (in the end tied to health) and highways a public good, while making other health care a private good, regardless of 'need.' Someone who is 64 who gets a life-threatening cancer might die because they and their relatives could not afford treatment, or would exhaust their savings doing so before declaring bankruptcy. Someone who is 65 would get Medicare coverage. Is that 'soviet style'?
Personally, I don't think Canadians, most Europeans, Hong Kong, Japanese, Australians, etc have a serious problem with their healthcare systems. I'd love to see a list of Valeant drugs and their prices in major countries in 2010 to 2015. My bet is that Valeant still makes a fair bit of money off drugs sold in other countries (or it wouldn't bother trying to sell them there). My gut is they make more in the US.
Look at http://www.compareyourcountry.org/health?page=2&cr=usa&cr1=oecd&lg=en
Look at health expenditures as a % of GDP. Look at US public healthcare as percent of GDP vs total (which tells you that private vs GDP making up the entire difference between public and overall between US and the rest of the world). Note that data only goes to 2013. Other estimates put US healthcare expenditure at 18+% of GDP (vs Japan and most of industrialized Europe with longer lifespans and better quality of life (despite higher alcohol consumption) in late life at 10-12%).
The most recent report from the Internal Federation of Healthcare Plans (also 2013 data) shows more comparative info
which does not make the US look like a particularly "reasonable" place to get health care.
I found the WSJ article regarding Valeant/Philidor tactics/strategy to be interesting.ReplyDelete
Healthcare as a concept is a really difficult one. Rabid American owners of American healthcare stocks tend to think of everything as winner-takes-all system - a kind of economic liberalism Ayn Rand-style. Valeant's history is almost a perfect example of the tenet of 'ethical egoism' of Ayn Rand's philosophy. Ayn Rand came at her views because she grew up with intellectual liberals (not the GOP's meaning of "liberal") in St Petersburg around the October Revolution and the subsequent difficulties borne by that community, then moved to the US to NYC, Chicago, then Hollywood in short succession in the second half of the 1920s - it must have been like a repressed teenager getting her first view of a party.ReplyDelete
Her eventual philosophical view was that altruism was to be rejected, because it was an insult to the capabilities of the recipient. This is the problem of health care. Those who need healthcare need it. Those who can't pay for it when they need it still need it. Under the tenets of economic liberalism, too bad for them. The cost of needed healthcare then becomes a tax on life. Ayn Rand was against tax by the state, but the ever-rising cost of healthcare is actually a tax by those who 'control' healthcare, which are mostly publicly traded entities. The 'problem' for most people is mostly a really arcane set of state and federal rules about who can provide what care and use what drugs. If American litigiousness were more restricted, and healthcare rules/laws were substantially loosened, I expect the cost to American healthcare would go waaaaaay down. Economic growth would rise dramatically because companies would have far more money to pay people and invest and would spend less money on private healthcare (i.e. health insurance for their employees).