While banning of ‘downer’ cattle from the food chain (see Agencies, below) is a good first step on the road back to sound protection of the food supply and hence blood supply from mad cow, additional measures are needed. Replacing the inadequate survey plans used to date by USDA for mad cow surveillance with a rational, complete methodology, and development of compensation policies for farmers who come forward to report problem animals.  At present, the farmer must pay to transport the animal and for the government’s tests; if the test is positive and the animal destroyed the compensation given falls far short of fair market value.  Further, if one cow tests positive, the farmer’s entire herd may be destroyed, wiping out his and his family’s income with little or no compensation whatever.  Currently, knowing these costs and risks, many farmers quietly dispose of such animals, increasing risks of transmission.

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> STATE-LEVEL ISSUES

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California – Soon after 5:00 am on February 19^th, the California state legislature ended over 45 hours of being in session, locked in the Capitol Building until a final 2008-2010 budget was passed, more than three months after the Governor convened a special session to address a $40 billion state deficit.  In the final bill, spending cuts amount to $15 billion; temporary taxes $13 billion, and new borrowing $11 billion. The spending cuts come from health care, education and entitlement programs; specifics are pending. The federal stimulus bill is expected to reduce the amount of new borrowing required by over $5 billion.   
Meantime, lacking a budget, state agencies have already begun requiring mandatory unpaid furloughs two days per month of their employees (for example closing all Dept. of Motor Vehicles offices in the state every other Friday), and preparing layoff notices for some 20,000 state employees.  Other cost-savings measures: No Californian awaiting a tax refund from 2008 will be getting it any time soon; local governments are not receiving various expected payments from the state, and over 100 construction projects have been stalled, with several hundred more facing cancellation (jeopardizing almost 100,000 jobs).  The cutbacks mirror what is going on nationwide in the commercial world, and constitute a dangerous premonition of what government as well as industry may soon be going through in many states.  In April of 2008, just fewer than one-half of the states reported having budget shortfalls; in January of 2009, 47 are in this predicament.
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On March 13^th , however, the state’s Legislative Analyst announced that, due to the economic downturn, expected revenues were not realized, and the state once again faces a deficit, now at a level of $8 billion.
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> CONGRESS
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The Economic Stimulus bill passed both chambers of Congress on February 13^th and was signed into law by President Obama at a solar-panel manufacturing plant (to symbolize future growth opportunities) three days later.  Work on the legislation essentially began shortly after the large financial bailout bill was passed in September: One-third of a year of sinking employment, production and stock prices passed (as well as the discovery that the first bailout had been far less effective than expected) before this new, assistance, targeted toward other sectors of the economy, could be made available. Local press in the days since contained detailed accounts of the plans by local governments and others for use of the many pots of money in the bill. (The money, of course, is not available yet; Washington takes months to convert a Presidential signature into checks in the mail.) The final bill ended weeks of wrangling over how much should be tax reduction and how much direct spending.  Briefly, in health care, $90 billion was allocated for shoring up the state-administered Medicaid program for low-income persons;  $20 billion was included for helping those losing jobs to take advantage of COBRA (a federal provision that requires insurers to offer much-higher-cost individual insurance policies to those laid off) by providing a 65% subsidy of those costs;  $2 billion will go to Community Health Centers, ¾ for renovations and technology and $500 million for direct care. $1.1 billion is also included for comparative effectiveness research, discussed in the last Update, and $1 billion for immunization and other prevention programs.
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> WHITE HOUSE / ADMINISTRATION / AGENCIES
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It has been widely recognized that the withdrawal of former Sen. Tom Daschle from the nomination for Secretary of the Department of Health and Human Services (DHHS) placed a serious slowdown on the new Administration’s efforts to enact health care reform.  The lengthy period without nomination of a suitable replacement nominee took a real toll on the Department.  For example, when the Economic Stimulus bill was being debated, the Senate bill would have provided $5 billion for prevention programs – STB, asthma, substance abuse, HIV-HCV-TB. Without DHHS advocacy, the final amount fell not just to the House figure of $3.8 billion, but to only $1.0 billion – a loss of at least one-third.
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COTT is pleased with the nomination March 3^rd of Ms. Kathleen Sebelius, Governor of Kansas, to the position.  One of the acknowledged accomplishments in her career was, in her previous position as state Insurance Commissioner, that she denied the request from Wellpoint, the insurance giant, to convert Kansas Blue Cross from a non-profit to a for-profit subsidiary corporation. This stance was the only reversal in Wellpoint’s 14-state buy-up of Blue Cross plans. As non-profits, these plans had been for the most part good community citizens, using state funds and their own revenues to help meet the crippling need for health care for the uninsured.  No longer.
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On March 13^th, President Obama announced a new Working Group on Food Safety, comprised primarily of USDA and FDA representatives.  He also indicated that USDA will no longer permit the inclusion of ‘downer’ cattle (ones that cannot walk on their own, perhaps due to Mad Cow disease) in the food chain. He also announced the appointment of Dr. Margaret Hamburg, former Health Commissioner of New York City, as FDA Commissioner. 
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See the next section for news of an additional development at Wellpoint.  On the Blood Safety front, excerpts from recent FDA Enforcement Reports can be found at the end of this Update as Attachment #4.
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> INDUSTRY
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According to the Financial Times of March 5^th, Wellpoint is attempting to sell its specialty pharmacy, NextRx, a mail-order pharmacy warehouse operation in Indiana, which Wellpoint forced all Blue Cross members who were persons with hemophilia to use. (NextRx serves many other Wellpoint customers as well.) Wellpoint customers have not had choice in provision of factor: they have not had the ability to go elsewhere if they find arrangements with one of the providers inadequate.  No buyer has been announced, and so the fate of these customers is unknown. Wellpoint may convey its customer list (and their insurance contracts) to the buyer, or agree to continue service for some period, for example.  The Times indicated that such sales might be seen from other insurers with their own pharmacies as well, as the US financial situation becomes increasingly challenging.  It also noted that the possible advent of a great increase in the number of insured, resulting from the new Administration’s efforts toward health care reform, and recent announcement of reductions in Medicare payment rates, were likely factors contributing to the decision to sell.
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In early March COTT learned of an HTC presenting patients with a liability waiver, which if signed, holds harmless that particular HTC from a legal responsibility for an injury associated with the treatment of hemophilia.  This could be triggered by the UK finding of vCJD in a person with hemophilia. It is deeply troubling when the institution an individual or family depends on for their hemophilia care is asking or demanding to be legally protected from known or unknown risks associated withy the treatment of hemophilia. For a community still recovering from the twin epidemics of HIV/AIDS and HCV it is tantamount to adding insult to injury. If our products are as safe as we believe, then why is it necessary to indemnify a given hemophilia treatment provider against legal liability?
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> COTT Operations
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The Washington DC 20^th COTT Anniversary celebration event has been shifted from July to October of this year. In addition, a joint session with the Hemophilia Federation of America (HFA) has been added, for reunion and mobilization centered around those in the community who have survived the HIV and hepatitis C infections that befell us so viciously, triggering the creation of COTT, and who have worked to create an organization that is vigilant concerning the threats to the safety of the blood supply from all quarters.   The Celebration event to follow the above session, will be the centerpiece of the occasion.  It will include reviews of our history, recollections from key players in that history, and remarks from policymakers who stood by us throughout and look to us to help in the important work ahead of us.  In addition, there will be a film festival the night before, a showing of a variety of hemophilia-related films which serve to make the history come alive.
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COTT joined with HFA in presenting a legislative training for the Maryland association on March 2^nd , including review of state websites on the flow of Economic Stimulus funds, role-playing and emphasis on describing the situation of the hemophilia community as one with a high-cost, chronic condition.
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COTT participated in HFA’s first symposium, March 12-14 2009 in Indianapolis, under its new Executive Director, Kimberly Haugstad. We appreciate their support for COTT’s Town Meeting, and for a well produced and moving Memorial Service. We are looking forward to a new era of cooperative work between the Hemophilia Federation and the Committee of Ten Thousand.
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COTT acknowledges the assistance of Hemophilia Health Services and Factor Support Network in publication of this issue of the COTT Washington Update.