This article is very much worth reading and I would recommend it to the reader that they follow the link and read this article which is extremely well written and full of very telling observations, and statistics. It details a compelling story and timeline that follows the challenges a caretaker faced in placing her partner – wife into a suitable facility that could handle medical, geriatric and dementia treatment needs. It is very humbling in reading this article to realize that the caretaker was a sophisticated supremely well-educated physician, and neurosurgeon, who ended up in the final analysis being defeated by the bureaucratic rabbit holes and dead ends in her supreme efforts to find adequate care for her partner.
Many state figures in advocacy organizations, Virginia governmental agencies, etc., were gracious enough to consent to be interviewed by the intrepid reporter for the Virginia Pilot newspaper. But I could not shake my impression that very few of them tried to exit their circumscribed bureaucratic governmental roles and go the extra mile in this situation. All of them offered credible systemic observations and reasons that did not help the Kafka-esque situation that the caretaker physician found herself in and ultimately defeated by.
On a closing note, I wish to apprise the reader that the state of Virginia actually has really only one designated geriatric psychiatric hospital in the state. This is the Piedmont Geriatric Hospital.
Piedmont Geriatric Hospital is a geriatric hospital located in Burkeville VA, south of Roanoke and Richmond. It has 123 beds and is located at the site of the previous Piedmont Sanatorium which actually was a TB sanatarium for African Americans. This facility was almost closed in 1999-2000 under then-Republican Governor George Allen (the former football coach), then again in 2002 under the administration of Governor Mark Warner but this was also averted, and then again in 2004 under a cost-cutting proposal of State Senator Frank Ruff which was also avoided. One can see that even this solitary resource for the geriatric state hospital patients of the entire state of Virginia almost was lost several times when cost-cutting in mental health was still being pursued as a rational move by Virginia before wise heads prevailed. If this facility had been closed, one can only imagine how dire the plights of the geropsychiatry patients in Virginia would now be.
Remember years ago when generic drugs had the promise of drastically lowering prices of the superstar medicines when the patents expired. Prozac was one of the first drugs that had that allure. And there is a story behind that.
When Prozac came out it was the first serotonin acting antidepressant. It had far fewer side effects. It did not constipate you, make you dry and drowsy and as my early deep South patients said, it didn’t take my Johnson away.” [But actually, it did that also in some fellows.]
And Prozac came out at the end of President Reagan’s administration when de-regulation had begun to hit its stride. In my highly speculative, inferential view of the drug industry back then, the companies looked around the national landscape and decided the regulation and informal strictures upon drug pricing were gone, that the Feds in the form of the Department of Justice AntiTrust law enforcement bodies would not be unleashed upon them. And so, the first drugs that started to come out in those days that truly represented NEW medicines in terms of their modes of actions and improved efficacies such as Prozac, were suddenly priced many times the usual and customary prices ranks of their ancestral brethren. Prozac and its following related serotonin blocking antidepressants that came out in the 1990s were priced MULTIPLE times higher than the preceding generations of tricyclic antidepressants.
This happened in other medication families, such as the anti-lipid (cholesterol, blood fats) medications, more potent antibiotics, the several new category anti-hypertension medications, but especially the new oncology cancer drugs. Those latter drugs still set records for their cost to this day. [I should know, I take two currently and owe my ongoing gift of longevity to them, but their cost still takes my breath away.]
Then, the patents of many of this ‘generation’ of medications that started to come out in the very late 1980s and through the 1990s, ran out and expired. And generic drug manufacturers raced onto the scene offering non-branded chemical twins of those previously outrageously expensive drugs and all of us millions of patient-consumers were happy at the cost relief we were afforded. The system of patent expiration and market lowering of prices through generic medications WORKED. Competition among the secondary off-patent drug companies lower prices the way they were supposed to. The American model of market competition reaffirmed our beliefs in this system and we worshipped at the altar of purses relieved by drug discounts.
Then something started to happen somewhere in the early 2000s. The generic manufacturers started to GET BIG. They bought each other, with the model of mutual cannibalization leading to huge (or “yuge”–I am not sure which adjective applies here LOL), generic drug companies. And for a while, their claims of bigger manufacturing efficiencies preserving cheaper prices lulled us into naive ignoring of what this trend really meant.
By 2014, a new trend had emerged in price gouging. But first, to entities that did not hit the consumer individually so directly, but rather to the national drug middle man, the national drug store chains, the pharmacy entities selling to the national managed care companies. Those entities initially bore a fair amount of the early years of price increases, trying to retain subscribers, large health plans and to stay competitive. And we consumers let them fight the battles, absorb the sting of increasing costs and happily assumed the behemoths in the healthcare ‘industry’ that we no longer comprehended would duke it out and protect us.
I cited the year 2014 above as a sentinel boundary because in that year the first big anti-price fixing lawsuit came to be brought against the real culprits, our former friends, and beneficiaries, the generic drug manufacturers and marketers.
It turned out that those companies had morphed into the typical monopolistically large company. It seems that often when companies reach a certain enormous critical mass in their particular marketplace, they start to take advantage of their size and try, and often succeed, in controlling their marketplace. They eat up more of their competition and eliminate their rivals, removing that usual checks and balances set of economic controls attendant to free-market competition. And they can do so, since if they in the class of company Death Stars, they usually possess enormous cash reserves and can dominate the forces in their marketplace, such as advertising, opening large numbers of stores, etc.
And, then they start to look for other means of expanding their economic dominance outside the application of ordinary marketing and production. They start to work with the few remaining equally dominant rivals in their industry by working to set the prices of their goods MUTUALLY. In other words, price-fixing. And this started to happen in the generic drug industry. And by 2014 the lawsuits by states and the Federal government’s corrective enforcement bodies started.
And the depth of price-fixing was bold, audacious and as bad as the scandals around the price of Epi-Pens and other medications that lit up the ire of the public in the past several years. Expect that it involved hundreds of generic medications and dozens of generic manufacturers. The cost to the public began to be conservatively calculated as running into the many, many billions of dollars.
An explanatory article from a litigation firm offers just about as good an explanation as I have found regarding this whole mess. It also defines for readers not familiar with the generic drug world, the in’s and out’s of the terms and the relationship of brand name drugs, their patent lives, and the generic drugs. Generic Drug Price-Fixing Lawsuit, from the firm NastLaw.
A listing of many of the firms involved in the price-fixing include several well-known names that are indeed giants in generic medicine pharmaceutical constellation:
- Mylan Pharmaceuticals
- Teva Pharmaceuticals
- Heritage Pharmaceuticals
- Impax Laboratories
- West-Ward Pharmaceuticals
- Par Pharmaceuticals
- Aurobindo Pharma
- Mayne Pharma
- Sun Pharma
- Upsher Smith Laboratories
- Mutual Pharmaceuticals
- Fougera Pharmaceuticals
- Taro Pharmaceuticals
- Dr. Reddy’s Laboratories
- Zydus Pharmaceuticals
As usual, I like to offer the reader-selected news pieces that report on the trends and phenomenon that I ardently discuss. One recent article, Price of an OCD drug jumped 1,200%. State attorneys general blame price-fixing focuses on an old psychiatric drug, clomipramine. When it came out it was moderately costly but then it went generic relatively early in its life as it had been an old drug on the research shelf of forgotten drugs [a fascinating story by the way]. Then it was caught up in this national price-fixing orgy by the generics. This report cited above, very aptly illustrates what happened in many instances of recent generic price-fixing.
A notable issue is that this drug was not tossed on the heap of many other old generics and lost in a puddle of several look-alike drugs. Clomprpamin had special, money magnetizing features. It was one of only a few drugs that worked on its condition, OCD, or obsessive-compulsive disorder. It had a large target patient cohort, millions. It had proven itself and a huge number of patient-consumers were already happily taking this prescribed drug that was a miracle in their lives, freeing them from the truly ghastly confines and disabling, total life-disrupting clutches of OCD. And their psychiatrists utilized this drug in confidence and medical subscription of it was not universal but very very high, as good old Prozac also helped a minority percentage of OCD patients.
Currently, the investigations [such as: EXCESSIVE PRICING OF OFF-PATENT PHARMACEUTICALS: HATCH IT OR RATCHET? by JENNIFER L. GRABER, New York University Law Review, Volume 92, Number 4, October 2019; and In the United States District Court for the District of … – Maine.gov] attendant to these various gargantuan anti-trust, price-fixing lawsuits are completed and their fascinating reports are easily available online for any curious reader. The suits are starting to draw to their conclusions. Some of the investigations were aided by some high-level drug company executives involved in these massive fraudulent conspiracies, have turned “state’s evidence,” and cooperated with the plaintiffs.
So now, several dozen generic drug companies, stand apparently close to receiving severe penalties. Judges sound ready to affix verdicts that in anyone’s view, have to emerge as GUILTY as hell in my view. Fines should be in the hundreds of millions, if not billions of dollars for the biggest. Executives should be fined right down to their golden umbrellas stands and go the jail for years. In my view, their sentences should last through their remaining ‘prime’ years of earning power as business moguls and they should be barred from every business and manufacturing-related type of employment except fast food grill production or manning/personing the picker line of recycling computer components for precious metals [to lend their ‘positions of penalty’ some glamour].
So, stick around your favorite business news sources. In the not too distant months to come, we shall likely hear the verdicts that I hope will inject marketplace competitive corrections into the not so level playing field of generic medication pricing for the last 15 years or so of price-fixing tricksterism.
Another correction that needs to be reinserted into our national marketplace of commerce, must/should be the resurrection of anti-trust and anti=price fixing regulatory and law enforcement bodies. We have worshipped at the false idol of total de-regulation for nearly 40 years and it has cost us dearly.
It is no news at all to anyone reading this or anything else at all in the media for the last couple of decades that in the United States, we have the costliest health care services in the world and that we do not get our full “bang for our [many] bucks” in the cost equation. Yet as far ago as the 1970’s the world’s wealthiest groups in the world came to our hospitals and big name healthcare clinics for the “top healthcare.” I recall then when certain families of a certain “royal” family born of petroleum revenues and riches came to my training, teaching and later, practice affiliated hospital for all sorts of medical and very secret psychiatric care. Those folks always created a great stir in the entire hospital system. They usually took over at least an entire wing of a floor of the hospital and had instituted all their dietary restrictions, religious requirements, and at times brought some of their own staff; contrary to the usual undertone of some prejudice, their trappings and accouterment of their societal practices actually made things easier. But the greatest stir was always when they left the hospital to return home at the end of the treatment stay for whoever the patient(s) was or were. These folks would bestow expensive “trinkets” upon the hospital staff they had liked and favored. The gifts were in the league of Rolex watches and whatever was in vogue at the time but included eye-popping jewelry, expensive Italian shotguns and on and on. Cost of the medical care was of course no impediment for these folks and their new contemporaries in the decades since, in the rapid incubating industries of high fashion, investment, mergers and acquisitions, international banking (and who knows, maybe even money laundering), drug lords under assumed identities (usually in highly securable and ‘safe’ free standing clinics instead of rambling hospitals with as many security holes in them as one one of my old sweaters. This phenomenon of perhaps ostentatious consumerism of costly healthcare is one of the weird epiphenomena of our healthcare ‘industry’ that illustrates its almost bizarre contradictions. And it occurs in all the big name medical institutions in the countries in the northeast, south, midwest, far southwest, upper far west; you name a region with big world beating specialty medical care in one or more disease and you will find from time to time, the world’s supremely wealthy beating a path to their door.
Some countries have taken difference copycat or “opposite-cat” approaches to this medical social snobbism of extreme consumerism. India and Thailand have in the last few years gotten into or started the cheaper markets for elective surgeries especially for fractions of the costs of standard American healthcare institutions. There does not seem to be too much wrenching of scrub scrubs suits, self-flagellation with IV lines by surgeons decrying this development but it is going to be interesting if this development starts to significantly cut into the receivables of lots of hospitals.”Oh, I had my gall bladder done in the Punjab, I had a great time, and save $9,000 too!” Which is to say we still do not have true competition in this country. Any of you free marketeers listening out there? All we have is siloed, protected from almost any similar medical business, sectors, having no overarching economic influences that touch more than one sector and therefore the Great God of Free Market Competition that has for 30 years been supposed to have controlled prices. What we have are ‘cooperative co-monopolies.’
Let us review for a few lines what we have tried.
A recent and typical article in the South Dakota newspaper, the Argus Leader, “Psychiatrist shortage worsens court bottleneck,,” sadly but truthfully illustrates one of the worst reasons for one sector or causative reason for one aspect of the mental health crisis of delivery of services in this country in all sectors, public and private, inpatient and outpatient whether clinic or private office based. There is a tremendous shortage of shortage of psychiatrists in this country. This issue has been building for over 30 years!
It started when the ability of hospitals and training centers for many kinds of residencies in subspecialties in all aspects of training of “residents,” who are doctors in training in specialties such as family medicine, pediatrics, OB=Gyn, general surgery, psychiatry, internal medicine, and even the subspecialties such as all kinds of cardiology (interventional, electrophysiologic), pediatric surgeries (orthopedic, neurosurgical) dermatology, endocrinology, all the subspecialties in radiology etc. This obviously stupid development came about when during the Reagan administration, Congress in its misplaced attempt to do something about Medicare and Medicaid fraud, thought that training centers should be allowed to transfer (divert was pejorative condemning word that was back then to convey some kind of behind the the scenes skullduggery in money manipulation) those revenues to help fund training programs.
Now it must be understood that ALL training programs in medical residencies are expensive. Residents have to have salaries to live on, though they have always been just enough to make ends meet especially if you have a family…and residents are NOT paid wild, glorious fantastic salaries and live the good life, driving Benz’s, Beemers and Lexus’es. They drive used cars (I sure did for years, but the truth being I do anyway as my motto became with bunches of daughters in 2 different cohorts and one later adopted son, “Never Buy Retail.” Buyin Easter shoes for all the girls annually was something we saved for after the Christmas-Hanukkah holidays and even then we shopped at place called “Discount Shoes,” which was almost a 200 drive away from our home in Durham so we could afford the Easter “pony shoes,” as I jokingly called them for the feminine horde.
Residents in training also generate very little revenue from their clinical work. In the old days (imagine old man reminiscing vocal sounds and harrumphs in the background), residents at least in surgery could be billed to insurers including Medicare and Medicaid as “assistant surgeons,” and generate some lower fees which helped. This disappeared under the new punitive regulations until residents in the surgeries and other specialties that had procedures they could charge full rates for. That circumstance would typically come legally at the end of their training when they were “chief residents,” could function autonomously and ran the lower level residents and interns’ services, scheduling, teaching, assigning patients, reviewing work-ups, approving studies, in other word, the junior attendings. In this way the essential supervision of all residents lower than the chief, was handled and parcelled out at different levels and handled as appropriate to the training of the resident, by the resident one year ahead of the next resident. It worked for deacdes since the aftermath of the “Flexner” report which occurred in 1910 or so. It catalogued the incredibly sad state of medical training then in the USA and proposed virtually the entire modern training system we have today. It was a masterful work of presience with Dr. Flexner foreseeing what would be needed to train doctors to high standards, generally how to involve modern developments not even dremaed of then and legislate firm, universal standards of training at all training centerss. For instance courses were standardized and required, and another telling example is that surgery residents started to have to keep verified surgical diaries listing all the procedures they had performed, assissted in, and observed throughout their residencies. Even now these have to be reviewed and presented at the time being considered for board certification.
In psychiatry things were different as they always were. With the exception of psychological testing, psychiatry had no expensive, bodily invasive medical or surgical procedures that could be charged for with nice high fees. Psychiatry residents in training even in wealthy settings such as Cambridge, San Francisco, Westword in LA, the tony areas of New York City bordering Central Park, Ann Arbor, Chicago, Georgetown in DC, mostly had patients who were poor, had little or no insurance, even Medicaid especially in the early days of Medicaid. And when insurers began to pay for psychiatric services, they were paid for at the discriminatory rate of half, 50%, of medical/surgical rates. And so the residents in psychiatry did not generate enough monies to pay their own expenses to their training programs, office, staff, salaries and especially the time of their superising psychiatrists. Although youger pscyhiatrists in training always had psych resident mentors above that offered peripheral supervision, formal superision was conducted by one’s supervising faculty psychiatrist. It was very expensive, given the nature of what the psych trainee did, which was an interview. The supervision onsisted of the faculty psychiatrist who followed the case as long as the trainee treated the adult, teen or child, heard all the “material,” and then taught, offering advice how to interpret, how to supportively interview, how to form all alliance, how to foster self insight, how to help the person effect and move to real points of change in their lives, how to see them through crises in their lives. And of course, all the ancillary social issues were handled and learned as well, what to do with substance abuse, dysfuntional families and marriages, deaths and losses and on and on.
The point is that training of psychiatry and psychological Ph.D. level mental health clinicians was and still is tremendouls costly. Some experts estimate that until recently with the coming monies from the former Congressman Patrick Kennedy’s and other’s reparative training fund bills for the mental health professions, that some 80% of training funds nationally disappeared.
So what happened; by the end of the 1980’s training programs closed, not many but a fair number. Most reduced staffs and residents, especially the latter by half or more. My own program reduced the number of residents by 2/3.
All the big cheese observers of the “psychiatry scene,” especially but also all the other mental health discipline began to complain, then warn, then project the coming crisis of shortage of mental health provider crisis with astounding statistics and then starting to scream from the national battlements (a la the battlements of the French Bastille in my fertile imagination). We were not replacing the measley 6,500 or so child psychiatrists we used to have TOTAL in this country by the 2000’s. Those that died or retired were lost to service and most of the time communities did not have replacements.
My own experience with this was telling. In 2006 i lost my psyhiatry partner to a terminal diagnosis of cancer in a close member of his family. He was in his mid 70’s and decided to retire, moved with his wife to be near their family. This was an unexpected and rapid necessary exit from our practice but it left me in the veritable “lurch.” Our practice was an almost half child oriented practice. At the time mental health reform in NC was a true disaster mostly because it was in the middle of its development, little was finished or formed or ready in the new outpatient service delivery structures across the state. Long term employee professional of the local county or combined several county mental health centers were told they had to re0\-apply for their positions, including the Ph.D.’s and MD’s. So what happened in our town was typical; all three lady child psychiatrists left within two months and there were no practitioners other than me for the entire country. I worked for two years trying to recruit another child psychiatrist to come to my practice. I thought the prospect of the magnitude of the immediate need would surely attract someone. I recall telling several visiting candidates, ‘Don’t worry, you’ll be full in one or two weeks. guaranteed.” They all had better offers elsewhere in the medical centers or big cities. I worked two years on Saturdays and Sundays seeing and caring for the public mental health center county kids, and finally truly “burned out,” something I thought would never, ever happen to me! I finally had to face reality and closed my practice of many years and took a salaried job, but a wonderful one working as the first psychiatrist on the Cherokee Qualla Boundary Indian Reservation, my wife’s ancestral home. It was wonderful for both of us and my wife was able to return to her childhood home and be with all her relatives especially her elders. I worked my contract and helped to find a Native American replacement psychiatrist finishing psychiatric training (there was only one in the entire country) and persuaded him to come and after nearly five years’ development work there, my work was done and I then faced my now olde rage ‘category-status’ and decided to return to my original first rotation at my training residency and become a state hospital psychiatrist and “give something back.” However, slightly selfishly this state hospital offered a full range of psychiatric residency teaching opportunities that made me “teaching self” water with great anticipation since it took residents in psych rotations from several medical schools. But it so doing I in effect contributed to the growing shortage myself of psychiatrists in the country.
So what does all this have to do with South Dakota? South Dakota has a smaller population and only one state hospital. It has had even FAR worse problems staffing their one hospital with psychiatrists and has had to close beds the last one or two years because of lack of coverage or clinicians to treat them.
But as in the rest of the country the huge new influx of “legal patients,” has swamped the hospital, doing as this near tsunami of “incompetent to proceed” to trial patients has done is almost ALL the other state hospital hospitals [including my own], taken beds always for ordinary psychiatric patients in crisis.
The result as this article typically reports patients have been stranded for days to weeks in ill equipped small community hospital ERs, waiting for an acute admission bed to ‘open up.’ This practice is so widespread in the country that it has acquired a convenient name, “psychiatric boarding,” or just plain “boarding.” In some states, advocacy organizations have sued states and their hospitals for such practices. It is a widespread problem with presently no real solutions. Most state legislatures are not willing to fund and construct the many dozens or hundreds of beds that would accommodate these legal patients so they are treated and accepted first by the admissions units of the state psychiatric hospitals who have NO choice but to do so because these patients are court ordered.
I will take the liberty and quote three paragraphs from the above referenced article to illustrate the problem as it currently bottlenecks both the inpatient psychiatric hospital’s mission and obligation to treat its patients and the legal system that must observe and uphold the constitutional right for a defendant to be able to understand and participate in a capable manner in their court proceedings and to fully cooperate with their counsel.
From the Argus Leader, “A shortage of psychiatrists in South Dakota is hampering efforts to address a bottleneck for court-ordered mental health evaluations in the state.
An Argus Leader Media investigation found mentally ill defendants were jailed for half a year or more as they waited for exams to determine whether they are competent to stand trial.
The state’s mental health hospital says it is not responsible and does not have the resources to conduct all of the exams, and that’s forced counties to seek out private psychiatrists to help manage a surge in criminal cases involving defendants with mental illnesses.
The problem is that few private practitioners in the state are qualified…”
Finally, to close out this long winded treatise on the shortage of psychiatrists, I will further take the liberty to quote the Argus Leader’s data in this article which gives startlingly information on how understaffed the entire state is with (or if you prefer from a pessimistic standpoint) without psychiatrists, the following passages will delineate the dimensions of the shortage that exists NOW:
“A Kaiser Family Foundation analysis this year found South Dakota has enough mental health professionals to meet only about 15 percent of the need for services in the state. There were an estimated 30 psychiatrists statewide in 2014, according to the U.S. Bureau of Labor Statistics.
The South Dakota Department of Labor and Regulations puts its estimate at just 20 psychiatrists statewide.
Based on BLS and Census data, South Dakota has fewer than one psychiatrist for every 30,000 people, one of the lowest ratios in the region.”
At the end of the article, the author listed the relative ratio’s of psychiatrists per 100,000 persons in 2014 that last year for which such data was fully available. These statistics are woeful as one accepted statistic commonly accepted for urban areas is ONE psychiatrist per only 3,000 people to 30,000 persons at most. The Midwest illustrates its serious shortage more than almost any area of the country. But all areas have them, except by and large cities in which there are one of more medical schools and concentrations and availability of specialty training programs.
Psychiatrists per 100,000 people, 2014
South Dakota 3.5
North Dakota Data not available
Sources: Bureau of Labor Statistics, U.S. Census Bureau
Western State Hospital in Lakeland WA is undergoing troubles again. In an article published on the local tv news outlet KOMO-tv, entitled, “Western State Hospital warned again about the loss of federal funding,” by Keith Eldrige on Friday, July 7th, 2017 the details and some of the history leading up to this sad state of affairs is enumerated in straight forward and informative fashion.
A little background is in order to be fair and honest to the reader as taking thins out of context can almost always lead to a quick and wrong impression. As state hospital go, Western was doing fairly well under very trying circumstances that have been in NO way unique to it alone. It has been besieged in recent years like all state hospitals by the new wave of “ITP” or incompetent to proceed patients that have emerged in nothing short of droves of thousands across the country. These patients are one of the most obvious results of the “trans institutionalization” of patients from the ‘under-bedded’ state and local public psychiatric hospital systems nationwide through the misguided efforts to cut inpatient psychiatric beds drastically to save monies in state budgets, in turn, themselves slammed around economically by the huge impact of the Great Housing Bubble burst [read runaway Wall Street greedy foolhardy faulty and dishonest mortgage packaging of the 2000’s]. States had to cut budgets drastically and almost universally their mental health segments had to be cut and beds cut and the hospital closed out of hand in many states. So we had the well-known issue of the chronically mentally ill appearing out in the public without almost any housing and inadequate outpatient services in almost every state. And to survive they did things that put them in jail in droves. It was perhaps a little ironic or surprising that one very conservative [I do not mean that politically at all] group nationally, the associations of country sheriffs and other such law enforcement policy groups became some of the EARLIEST non-clinical groups yelling to the rooftops along with mental health advocacy groups such as NAMI, the Judge Bazelon Center, and Dr. E. Fuller Torrey’s national advocacy group, The Treatment Advocacy Center.
But this article illustrates the Herculean tasks that states face in transitioning themselves from the traditional custodial role utilizing large massive hospitals and viewing treatment as often lifelong or at least so long that it may as well be lifelong, to a system aiming at re-integrating the chronically mentally ill safe enough to be returned to the communities and constructing complete new and entirely different systems of housing and care for literally thousands of persons within spans of a relatively few years. There are no simple answers in any quarter and the task which may have been viewed as achievable within approximate task-timer periods clearly is proving to be greater, harder, more coslty and complicated than likely almost anyone could have imagined.At the least, enforcement by the “feds,” may have to consist of extending time periods of effort to the states and partnerships that help with costs and perhaps even approaches not yet widely appreciated by any of us.