OS ANGELES — There’s nobody the drug companies are spending more to fight than Michael Weinstein.
And Weinstein takes pride in their hostility. “That’s a badge of honor,” he said. A longtime HIV/AIDS activist, Weinstein is the driving force behind a drug price control initiative in California that could set a national precedent.
It’s just the latest in a long string of legal and political fights he’s picked.
Over the years, his nonprofit AIDS Healthcare Foundation, which runs clinics around the world, has sued GlaxoSmithKline over its prices, Pfizer over its marketing and Gilead Sciences over its patents. Weinstein has taken on the porn industry and Los Angeles developers.
He’s won, and lost, and drawn plenty of criticism along the way, perhaps most when he enraged fellow public health advocates by breaking with the medical consensus to question the wisdom of urging some gay men and others at high risk of HIV to take the PrEP drug regimen to try to prevent infection.
Critics have called him a “thug” and a bully. Fellow activists accuse Weinstein and his organization of ignoring others’ views and failing to build consensus.
The Florida HIV/AIDS activist Michael Emanuel Rajner told STAT that the only time he ever met Weinstein, “I felt as if I were standing next to Satan.”
Pharma builds up a war chest
Though he’s promoted a slew of causes over the years, Weinstein said he sees drug pricing as “one of the great issues of our time,” because the high cost of medication causes suffering.
Campaigning kicks off in earnest this week over his attempt at a solution. The November ballot measure would cap how much some state health plans pay for drugs by limiting them to the heavily-discounted price negotiated by the federal Department of Veterans Affairs.
Whether this would actually save significant money for the state or for patients is hotly debated. The state health plans cover as many as 1 in 6 Californians, by some estimates, but the measure wouldn’t affect other insurance plans — except, perhaps, by setting a precedent. That’s why the stakes are so high: If it passes, the approach could ripple across the country, costing the industry billions.
The “Yes” campaign has endorsements from Vermont Senator Bernie Sanders and Rev. Al Sharpton, and it’s raised $9.5 million, almost entirely from Weinstein’s AHF. (The nonprofit generates most of its revenue from running pharmacies, and spends some of that on advocacy.)
The drug industry, led by Merck and Pfizer, has poured $87 million into the “No” campaign, which also has on its side the California Medical Association and a surprising number of patient groups, including some that have taken money from pharmaceutical companies.
The huge influx of funds from pharma is likely to make Proposition 61 the most expensive fight over a single initiative in California in at least 15 years. It’s the most pharma has put up to sway voters since the industry spent $135 million on dueling ballot questions in 2005, to avoid having to discount drug prices for the poor.
Normally, that kind of well-financed opposition would leave such a ballot initiative dead in the water. But this isn’t a normal year.
Campaigning in the era of EpiPen outrage
When Weinstein and his team first started planning nearly two years ago to put drug pricing before California voters, practically no one knew who Martin Shkreli was, or how much EpiPens cost. Back then, Weinstein said he “couldn’t have predicted and wouldn’t have predicted” today’s upswell of concern about high drug prices — or the seething public anger at the drug industry.
But it sure has been good for his cause.
With their parade of drug price hikes this past year, “the pharmaceutical companies have been the gift that keeps on giving when you’re running a campaign like this,” said Garry South, the lead strategist for the “Yes” campaign. Indeed, two recent focus groups found that the single most powerful way to persuade Los Angeles voters to support the ballot measure was to tell them that companies like Merck and Pfizer opposed it, Weinstein said.
Dr. Adams Dudley, director of the Center for Healthcare Value at the University of California, San Francisco, put it in starker terms: “There is no way Prop 61 passes without Martin Shkreli and EpiPen.”
Drug companies are aware of the anger and trying to use it to their advantage, by telling voters the ballot measure won’t really help most residents.
“The measure is a problem masquerading as a solution,” says one “No” campaign video highlighting the large majority of Californians — including the privately insured, teachers, and local government employees — whose prescription drugs would not be covered under the initiative.
The drug industry takes aim
Tom Norton, a pharma industry consultant who worked for Pfizer in the 2000s, has written that that the measure’s passage “would be a pricing disaster for the entire US drug industry.”
Norton told STAT the drug industry is alarmed both by the potential precedent and by the sophistication of the price control effort. Weinstein’s team “is nothing to take lightly,” Norton said.
So the drug industry has made attacking Weinstein a central feature of their campaign.
The “No” campaign has devoted the entire second paragraph of their official argument to voters to casting doubt on Weinstein and his organization with words like “controversial” and “suspiciously.” It sends out a regular stream of press releases headlined “The Truth About Michael Weinstein and AHF.” And it suggests that he’s trying to personally profit from the initiative.
“It’s absolutely relevant who this group is, who its leader is — we think the organization is worth taking a look at,” said Kathy Fairbanks, the spokeswoman for the “No” campaign.
Asked why the campaign rarely misses an opportunity to call Weinstein “controversial,” Fairbanks said, “I think that’s understating things.”
The opposition has made hay out of the fact that Weinstein wrote the initiative so it doesn’t cover any of the managed care programs which are funded by Medicaid but operated privately — including the one AHF runs. (Weinstein said that’s because the state doesn’t have jurisdiction over privately managed plans, which already negotiate with drug companies.)
The “No” campaign also hasn’t hesitated to point out that Los Angeles County is suing AHF to recoup $5 million that the group allegedly pocketed from overcharging for medical services. Asked about that, Weinstein put STAT on the phone with the county’s director of health services, who said the issue boiled down to a technical billing dispute — and said he expected AHF to largely come out on top.
The county official, Dr. Mitchell Katz, also said that while he doesn’t always agree with Weinstein, “he has been an extremely successful advocate, and I think that he’s made a difference.”
‘A really awkward history’
Weinstein, 63, cuts a trim figure, with angular features and an air of conviction. His corner office on the 21st floor of a downtown Los Angeles high-rise has a panoramic view, sweeping from streets lined with palm trees to the Hollywood sign, and it’s overflowing with photos and tokens from the many battles he’s waged.
Mounted on one wall is a memento from his first big fight: A framed poster publicizing a community march against a 1986 state initiative that would have led to the quarantining of California residents with HIV/AIDS. Weinstein helped defeat it.
Just below it, Weinstein keeps a decorative ceramic slab that his mother made for LA’s first AIDS hospice, opened by his group in 1988. He also keeps a plaque on his desk that reads “Aut viam inveniam aut faciam” — in Latin, “I shall either find a way or make one.”
Weinstein, a gay man who’s married to his partner of two decades, has made plenty of enemies over the years, including within the gay community.
Rajner, the Florida activist who called Weinstein “Satan,” said he believes AHF pushes its own agenda at the expense of other interests. (Ged Kenslea, the AHF communications director, said that being a direct provider of medical care gives AHF different priorities than the social service groups with which it’s often at odds.)
AHF has also run provocative ads that aim to promote safe sex by raising fear of AIDS or frowning on promiscuity. To some people, it can feel like Weinstein — who made his name fighting stigma — is stigmatizing the community.
“Michael has this really awkward history of … coming from a paternalistic, ‘I know better than you,’ point of view… He continues to drive a line of shame and fear in his advocacy,” said Eric Paul Leue, an HIV/AIDS activist.
Leue, once a collaborator, also runs a porn industry trade group that opposes yet another ballot measure Weinstein is promoting this year; it would require porn actors to use condoms on set. But even before this campaign, Leue had a bitter falling out with Weinstein and the AHF over PrEP, which has been shown to prevent infection with HIV.
Weinstein has called it “a party drug” that encourages unsafe sex and has argued that the pill should not be prescribed as a public health strategy. That view runs counter to the bulk of public research — and has enraged many activists.
Weinstein told STAT he thinks his position on PrEP has been caricatured; he said he has no problem with its use on an individual basis. AHF doctors sometimes prescribe it to patients. He also said he’d support a long-acting injectable version of PrEP but believes that in pill form, patients are taking it too inconsistently for it to be a viable public health tool.
Asked about the the charges of paternalism, Weinstein responded with an anecdote: He recalls someone at a panel complaining to him,“‘You’re like our mother telling us to wear our galoshes.’ I said, ‘Well, somebody has to.’”
Will it work? ‘Neither side really knows’
If Weinstein’s fight against high drug prices sounds like that of the righteous underdog, well, that’s exactly what he wants you to think. “I think we’ve been very successful in portraying this as, and getting the press to see it as, a ‘David and Goliath’ battle,” he said.
In reality, though, it’s messier than that. Several dozen groups representing patients and veterans, like the Latino Diabetes Association and the western chapter of the Paralyzed Veterans of America, are on the side of the pharma industry. They’re raising serious questions about fallout from the measure: Might drug companies stop giving discounts to veterans? Cut back on research and development? Hike costs for privately insured consumers to make up for losses in the public market?
(Weinstein said such dire scenarios will only come to pass if pharma chooses to hurt the public rather than accepting lower profit margins for drugs on some insurance plans.)
There are also questions about how and whether the measure would actually achieve its most basic goal of cutting prescription drug costs for the state.
The “Yes” campaign says the measure would save the state $1 billion a year and reduce copays for Californians taking the covered drugs. The “No” campaign says it would drive up costs by tens of millions annually because it would invalidate discounts the state has negotiated with drug companies.
“Neither side really knows whether or not it’s going to work,” Dudley said.
An independent analysis from the state Legislative Analyst’s Office concluded that “the amount of any savings is highly uncertain.”
A billboard blitz
Both the “Yes” and “No” campaigns are expected to significantly increase their activity and spending this month, after a relatively quiet summer.
The “No” campaign wouldn’t disclose details of its advertising plans, though observers said they expect a blitz.
But the “Yes” campaign was eager to talk: They just launched a TV ad in the military hub of San Diego featuring veterans condemning the drug industry for threatening to cut VA discounts if the measure passes. Next week, they’re going up with 360 billboards across the state featuring endorsements from Sanders, groups for retirees and nurses, and others. They’re planning a bus tour, too.
Other states are watching closely: The AHF is pushing to get a similar measure on the ballot in Ohio in 2017. South said he’s already received phone calls from people in Massachusetts, Colorado, and Washington interested in learning about the “Yes” campaign and its strategy.
Weinstein said the campaign has “already accomplished half of what we wanted, which is there’s going be a very impassioned debate about drug pricing.”
And if he loses? “It won’t be the end,” he said.