Letter to the Editor


To the editor:

As the owner of Tanglewood Pharmacy, I’ve been serving the people of Stephenville for decades, and every time I fill a patient’s prescriptions, I see the harmful impact of DIR fees on our community and its citizens.

DC folks know DIR stands for direct and indirect remuneration. Around here, it just means money out of my pocket and higher costs for my patients.  DIR fees are the main reason many neighborhood pharmacies are forced to close their doors. Imposed on pharmacies, often retroactively, by large corporations known as Pharmacy Benefit Managers (PBMs), these fees keep me from predicting my future expenses – making it really tough to run a small business.

The only people benefitting from these fees are the PBMs. Out-of-pocket costs for prescription drugs continue to go up, and there is simply no transparency when it comes to the DIR clawbacks. The PBMs cannot and will not tell me how they arrive at their numbers, putting me, my patients, and our community in a bind – time after time.

What makes matters worse is there was a chance to fix this problem and the administration failed to act. Now, we need Congress needs to take action. I was hopeful when I saw the recent letter from the Senate Committee on Finance, where lawmakers urged the Department of Health and Human Services to reform DIR fees – almost all of the committee members signed it, but I was disappointed to see that Texas Senator John Cornyn’s signature was not one of them.

Healthcare is like anything else, you get what you pay for, and frankly, I can’t keep offering the services I do if I’m getting gouged by these DIR fees. Unless Senator Cornyn and the rest of the government wises up to the PBMs, local businesses and patients across Texas will continue to suffer.

Ed Horton
Owner, Tanglewood Pharmacy


  1. Mr. Horton I played right field for the Hico Civic Club’s Little League team in Iredell, Texas one summer night when I was 5 ears old and the coach’s name was Mr. Horton who his friends called Toe. That was over 6 decades ago. It wasn’t cheating for me to be playing Little League at 5 years old but more of a necessity so Hico could field 9 players to have a team. If I ever batted I just can’t recall.

    There is this guy named Mulvaney working as a do-it-all guy for Don Trump who is an old boy from Queens New York. So as I speak to your dilemmas and I answer what I read then it is Mr Mulvaney I refer to. They guy Trump (who cannot answer the matter when and where his name was ever legally prove that his last name Trump was legally changed it officially is Drumpf because he must answer to his grandfather’s legal signature) did take $600 billion from Medicare in 2017 I believe or was it 2018 so actually if that $600 billion falls in that problem you speak in your medical device business I have to know and see more detail but I can almost tell you John Cornyn will not be of any assistance to you. John Cornyn is not a good helper to those that needs medical assistance devices coming from the working class. He is a Republican that has operated of the lying branch of the Republican party. However I can tell you that the Mr Mulvaney guy has the assignment of removing $1 trillion from Medicaid and of course Senator John Cornyn will be along for that fun ride because the plan from this Presidential Administration is to send the Medicaid funding as Block Grants to the states. So perhaps I am adding to your business’ woes.

  2. Mr. Horton, that Mulvaney guy is pretty tied up and may have Trump try to make him a “scapegoat” for Trump committing A CRIME with your tax dollars. See Trump tried to bribe the new President of Ukraine. And Mr. Horton Trump is guilty room office but Republicans are cowards of his base. Stephenville is full of Republicans and think because of money they are smarter than everyone that has been abused and used by the capitalistic system.

    Mr. Horton in the military we have a saying “you go to drawing line then you can start wars”. Many of us know exactly what Putin and Trump are after and they say it will be perfected in 2024 but knowing veterans know its closer to 2021 or mid 2022. And it’s not good for any Republicans in this county and only a few in Texas. But your a man of medicine and here is you a “clue”, if Trump and Putin get Republicans in Erath County and those like them in counties across American then in a few years there won’t be any Autistic children and many other children we love today. Believe Me Soldier and you can include lots of your fellow Americans to not be around. They are on a Kissinger Mission. Henry Kissinger born not far from Adolf Hitler in Austria and served as a United States Secretary of State.

    The Trump administration is using Republicans and is hopeful he can get whites so mad at Mexicans, Arabs, Negro’s and non-whites that they will begin actually shooting other Americans so he can declare Martial law. Then its Katy-bar-the-door. Only thing come a few years later it’s be katy-bar-the-door for those brilliant that beamed his mission.

    We have stopped 6 nuclear plants in the Mid-East that came with the plans that were planned by Putin and Saudi Arabia beginning January 20, 2017. General Flynn was taped on that day as you saw his majesty take oath. Saudi Arabia has a nuclear reactor because they loaned $552,000,000 to Jared Kushner’s fathers company so it could survive.

    Lyndon Johnson certainly created a wealth builder with Medicare didn’t he. Lyndon was President and had his Vice-President and also as Vice-President he was President of the Senate Hubert Humphrey behind his desk one morning kicking him in the shin and said, “Now Hubert get down to that Gott-Dammed Senate and get me that Medicare I got to have it. Well Hubert got it.

    Republicans should know when the constant laser goes on flow and the laser gun comes to reality then the men that took arms against non-white today will get mowed down like losers as Trump calls people.

    1) https://listverse.com/2015/01/15/10-reprehensible-crimes-of-ronald-reagan/

    2) What we do to our fellow man… https://rooseveltinstitute.org/search/?s=+stock+buy+backs several pages and just skim the headlines…


  3. The D.C. folks is Donald J. Trump cause he has his alligators slinging HATE everywhere and Lyndon Baines Johnson, a Texan had Medicare passed for the people and that is why the United Medical Professions enjoy a much greater place as for as financial standings and millions more have received. finer healthcare. Also he passed the civil rights act passed and racist moved out of the Democrat Party to the Republican Party.


    The Poverty States — the red states — hate him for that. And led by what George Washington warned us of: The hate went red.

    From George Washington’s FAREWELL ADDRESS | SATURDAY, SEPTEMBER 17, 1796

    “However [political parties] may now and then answer popular ends, they are likely in the course of time and things, to become potent engines, by which cunning, ambitious, and unprincipled men will be enabled to subvert the power of the people and to usurp for themselves the reins of government, destroying afterwards the very engines which have lifted them to unjust dominion.”


    Something to think about Mr. Horton about which specific D.C. folks have caused the woes.

    I’m a Grandson of Ella Bullard

  4. From Ralph Nader in my email tonight was this letter on UnitedHealthcare actions:

    Beware of the Medicare Disadvantage Corporate Trap – Wake Up AARP
    While the Democratic presidential candidates are debating full Medicare for All, giant insurance companies like UnitedHealthcare are advertising to the elderly in an attempt to lure them from Traditional Medicare (TM) to the so-called Medicare Advantage (MA) – a corporate plan that UnitedHealthcare promotes to turn a profit at the expense of enrollees.

    Almost one third of all elderly over 65 are enrolled in these numerous, complex MA policies the government pays so much for monthly. The health insurance industry wants more enrollees as they continue to press Congress for more advantages.

    Medical Disadvantage would be a more accurate name for the programs, as insurance companies push to corporatize all of Medicare, yet keep the name for the purposes of marketing, deception, and confusion.

    Elderly people enrolled in MA will experience its often merciless denials when they get sick. As hospital expert – attorney, physician, Dr. Fred Hyde put it: “It’s not just what you pay, it’s what you get.”

    Start with the cross-subsidy of MA from TM. In 2009, the Congressional Budget Office estimated these overpayments would cost the federal government $157 billion over the coming decade. Obama’s Affordable Care Act started to reduce these subsidies to the giant insurers, but they still amount to many billions of dollars per year.

    Add that with Medicare Disadvantage you are restricted to networks of vendors. That restricts your choice for competence and skills, and sometimes, requires you to travel longer distances for treatment. This could mean fewer enrollees will utilize their healthcare and more profits for the insurance companies.

    Under Medicare Disadvantage you are subject to all kinds of differing plans, maddening trapdoor fine print, and unclear meaning to the insurers arguing no “medical necessity” when you’re denied care.

    The advertisements for Medicare Disadvantage stress that you can sometimes get perks – gym memberships, hearing aids, and eyeglasses, as enticements, but they avoid telling you they are not so ready to cover serious needs like skilled nursing care for critically ill patients.

    Under Medicare Disadvantage, there is no Medigap coverage as there is for TM. Co-pays and deductibles can be large. Under a recent Humana Medicare Advantage Plan in Florida, your co-pay for an ambulance is up to $300, up to $100 co-pay for lab services, and another $100 for outpatient x-rays.

    A few years ago, UnitedHealthcare corporations dismissed thousands of physicians from their MA networks, sometimes immediately, sometimes telling their patients before telling their physicians.

    Dr. Arthur Vogelman, a gastroenterologist, said he received a termination letter in 2013 from UnitedHealthcare. He appealed, documenting his successful treatment of many patients. The company denied his appeal, with no reason, as it had for thousands of network physicians.

    Dr. Vogelman called it “an outrage. I have patients in their 80s and 90s who have been with me 20 years, and I’m having to tell them that their insurer won’t pay for them to see me anymore. The worst thing is I can’t even tell them why.” Except that the company wanted more profits.

    After a lengthy protest by national and state medical societies in 2013, UnitedHealthcare began to be less aggressively dismissive.

    Studies show the main reason MA enrollees return to TM is how badly the corporate insurers treated them when they became sick.

    Medicare itself is getting overly complex. But nothing like the ever changing corporate rules, offerings, and restrictions of Medicare Disadvantage. How strange it is that AARP, with its Medigap insurance business run by UnitedHealthcare, doesn’t advise its members to go with the obviously superior Traditional Medicare. AARP reportedly receives a commission of 4.95% for new enrollees on top of the premiums the elderly pay for the Medigap policy from United Healthcare. This money – about seven hundred million dollars a year – a significant portion of AARP’s overall budget.

    AARP responded to my inquiries into their Medicare Advantage policy saying that it does not recommend one plan over another, leaving it to the less informed consumer. That’s one of AARP’s biggest cop-outs— they know the difference.

    There is no space here to cover all the bewildering ins and outs of what corporations have done to so-called managed Medicare and managed Medicaid. That task is for full-time reporters. The government does estimate a staggering $60 billion in billing fraud annually just on Medicare – manipulating codes, phantom billing, etc. You need the equivalent of a college-level course just to start figuring out all the supposed offerings and gaps.

    Suffice it to say that, in the words of Eleanor Laise, senior editor of Kiplinger’s Retirement Report, “the evidence on health care access and quality decidedly favors original Medicare over Medicare Advantage, according to a Kaiser Family Foundation review of 40 studies published between 2000 and 2014.”

    All this anxiety, dread, and fear, all these arbitrary denials of care – prompted by a pay-or-die commercial profit motive – all these restrictions of what doctors or hospitals you can go to, do not exist in Canada. All Canadians have a Medicare card from birth; they have free choice of health care vendors. There are few American-style horror stories there; patients have better outcomes, and almost never even see a bill. The whole universal system costs half per capita of that in the U.S., where over 80 million people are uninsured or underinsured – still! (See singlepayeraction.org, for civic action to rid Americans of this perverse chaos).

    Ralph Nader
    Ralph Nader
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