Big Sky Connection



Eric Tegethoff


December 11, 2017

HELENA, Mont. - The number of people with Alzheimer's symptoms will more than double in the coming decades.


Is Montana ready for this dramatic increase?


According to a new study from UCLA, about 15 million Americans will have Alzheimer's dementia or cognitive impairment by 2060.


Today about 6 million Americans suffer from these symptoms.


Lynn Mullowney Cabrera, executive director of the Montana chapter of the Alzheimer's Association, says Montana's population is expected to age rapidly in the coming decades.


Unfortunately for those suffering symptoms of dementia, she says Big Sky Country is one of many states dubbed a "neurological desert."


"We have great expanses of state where we have insufficient numbers of geriatricians and other specialty providers, where we - like many other states - have primary care providers, just those folks that are on the front lines, that maybe don't have the latest in diagnostic criteria," she states.


According to the UCLA study, 47 million Americans already show evidence of susceptibility to Alzheimer's disease.


Cabrera says Montana is on the right track. In 2016, the Alzheimer's and Dementia State Plan was released. The plan is comprehensive and explores how the state can prepare itself.


Now, Cabrera says, the state will have to execute.


"As I've said in the past, there's no money, there's no teeth in it," she stresses. "But it gave us a road map."


In part, the plan looks at ways to make the state accessible for people with dementia.


Cabrera compares the effort to making cities accessible for people with disabilities over the past few decades.


Cabrera says family caregivers are the backbone of support, but that it's also important to find and retain nurses and nursing home workers to care for people.


"How do we enlist these individuals and entrust them and empower them to have positive experiences that then build on each other instead of negative experiences where they leave the field and we have far less than we need for capable providers?" she questions.


With this comes a hefty price tag. In 2017, caring for people with Alzheimer's cost nearly $260 billion, making it the most expensive disease in the country.


But Cabrera says the country can actually save money if it provides better community resources and prevents unnecessary hospitalizations.


An epidemic of unnecessary treatment is wasting billions of health care dollars a year. Patients and taxpayers are paying for it.

This story was co-published with NPR’s Shots blog.

Two years ago, Margaret O’Neill brought her 5-year-old daughter to Children’s Hospital Colorado because the band of tissue that connected her tongue to the floor of her mouth was too tight. The condition, literally called being “tongue-tied,” made it hard for the girl to make “th” sounds.

It’s a common problem with a simple fix: an outpatient procedure to snip the tissue.

During a pre-operative visit, the surgeon offered to throw in a surprising perk. Should we pierce her ears while she’s under?

O’Neill’s first thought was that her daughter seemed a bit young to have her ears pierced. Her second: Why was a surgeon offering to do this? Wasn’t that something done free at the mall with the purchase of a starter set of earrings? 

“That’s so funny,” O’Neill recalled saying. “I didn’t think you did ear piercings.”

The surgeon, Peggy Kelley, told her it could be a nice thing for a child, O’Neill said. All she had to do is bring earrings on the day of the operation. O’Neill agreed, assuming it would be free.

Her daughter emerged from surgery with her tongue newly freed and a pair of small gold stars in her ears.

Only months later did O’Neill discover her cost for this extracurricular work: $1,877.86 for “operating room services” related to the ear piercing — a fee her insurer was unwilling to pay.

At first, O’Neill assumed the bill was a mistake. Her daughter hadn’t needed her ears pierced, and O’Neill would never have agreed to it if she’d known the cost. She complained in phone calls and in writing.

The hospital wouldn’t budge. In fact, O’Neill said it dug in, telling her to pay up or it would send the bill to collections. The situation was “absurd,” she said.

“There are a lot of things we’d pay extra for a doctor to do,” she said. “This is not one of them.”

Kelley and the hospital declined to comment to ProPublica about the ear piercing.

Surgical ear piercings are rare, according to the Health Care Cost Institute, a nonprofit that maintains a database of commercial health insurance claims. The institute could only find a few dozen possible cases a year in its vast cache of billing data. But O’Neill’s case is a vivid example of health care waste known as overuse.

Into this category fall things like unnecessary tests, higher-than-needed levels of care or surgeries that have proven ineffective.

Wasteful use of medical care has “become so normalized that I don’t think people in the system see it,” said Dr. Vikas Saini, president of The Lown Institute, a Boston think tank focused on making health care more effective, affordable and just. “We need more serious studies of what these practices are.”  

Experts estimate the U.S. health care system wastes $765 billion annually — about a quarter of all the money that’s spent. Of that, an estimated $210 billion goes to unnecessary or needlessly expensive care, according to a 2012 report by the National Academy of Medicine.

ProPublica has been documenting the ways waste is baked into the system. Hospitals throw away new supplies and nursing homes discard still-potent medication. Drugmakers combine cheap ingredients to create expensive specialty pills and arbitrary drug expiration dates force hospitals and pharmacies to toss valuable drugs.

We also reported how drug companies make oversize eyedrops and vials of cancer drugs, forcing patients to pay for medication they are unable to use. In response, a group of U.S. senators introduced a bill this month to reduce what they called  “colossal and completely preventable waste.”

But any discussion of waste needs to look how health care dollars are thrown away on procedures and care that patients don’t need — and how hard it is to stop it.

Just ask Christina Arenas.

Arenas, 34, has a history of noncancerous cysts in her breasts so last summer when her gynecologist found some lumps in her breast and sent her for an ultrasound to rule out cancer, she wasn’t worried. 

But on the day of scan, the sonographer started the ultrasound, then stopped to consult a radiologist. They told her she needed a mammogram before the ultrasound could be done.

Arenas, an attorney who is married to a doctor, told them she didn’t want a mammogram. She didn’t want to be exposed to the radiation, or pay for the procedure. But sitting on the table in a hospital gown, she didn’t have much leverage to negotiate.So, she agreed to a mammogram, followed by an ultrasound. The findings: no cancer. As Arenas suspected, she had cysts, fluid-filled sacs that are common in women her age.

The radiologist told her to come back in two weeks so they could drain the cysts with a needle, guided by yet another ultrasound. But when she returned she got two ultrasounds: one before the procedure and another as part of it.  

The radiologist then sent the fluid from the cysts to pathology to test it for cancer. That test confirmed — again — that there wasn’t any cancer. Her insurance whittled the bills down to $2,361, most of which she had to pay herself because of her insurance plan.

Arenas didn’t like paying for something she didn’t think she needed and resented the loss of control. “It was just kind of, ‘Take it or leave it.’ The whole thing. You had no choice as to your own care.”

Arenas, sure she’d been given care she didn’t need, discussed it with one of her husband’s friends who is a gynecologist. She learned the process could have been more simple and affordable.

Arenas complained to The George Washington Medical Faculty Associates, the large Washington, D.C., doctor group that provided her treatment. Her request to have the bill reduced was denied. Then bill collectors got involved, so she demanded a refund and threatened legal action.

She said she never got to speak to anyone. Her demand was routed to an attorney, who declined her request because there was “no inappropriate care.” She also complained to her insurance company and the Washington, D.C., attorney general’s office, but they declined to help reduce the bill.

Overtreatment related to mammograms is a common problem. The national cost of false-positive tests and overdiagnosed breast cancer is estimated at $4 billion a year, according to a 2015 study in Health Affairs. Some of this is fueled by anxious patients, some by doctors who know that missing a cancer diagnosis can be grounds for a medical malpractice lawsuit. But advocates, patients and even some doctors note the screenings can also be a cash cow for physicians and hospitals.

With Arenas’ permission, we shared her case with experts, including Dr. Barbara Levy, vice president of health policy for the American College of Obstetricians and Gynecologists and three radiologists. 

Levy said there’s a standard way to treat a suspected breast cyst that’s efficient and cost-effective. If the lump is large, as in Arenas’ case, a doctor should first use a needle to try and drain it. If the fluid is clear and the lump goes away there’s no cause for concern or extra testing. If the fluid is bloody or can’t be drained, or the mass is solid, then medical imaging tests can determine if it’s cancerous.

However, doctors often choose to order imaging tests rather than drain apparent cysts, Levy said. “We’re so afraid the next one might be cancer even though the last 10 weren’t,” she said. “So, we overtest.”

Levy and the radiologists agreed that at least some of Arenas’ care seemed excessive. But their opinions varied, which shows why it can be difficult to reduce unnecessary care. Standards are often open-ended, so they allow for a wide range of practices and doctors have autonomy to take the route they think is best for patients.

The American College of Radiology recommends an ultrasound for a 32-year-old — Arenas’ age at the time of the procedure — with an unidentified breast mass. Mammograms are also an option, but “most benign lesions in young women are not visualized by mammography,” the guidelines state.

Dr. Phillip Shaffer, a radiologist who’s practiced for decades in Columbus, Ohio, said he didn’t think Arenas needed the mammogram. “I wouldn’t do it,” he said. “If I did an ultrasound and saw cysts, I’d say you have cysts. In 32-year-olds the mammogram does almost nothing.”

Dr. Jay Baker, chair of the American College of Radiology breast imaging communications committee, agreed that the ultrasound alone would have “almost certainly” identified the cyst. But, he said, maybe something about the lumps concerned Arenas’ radiologist, so a mammogram was ordered.

None of the radiologists consulted by ProPublica could explain why two ultrasounds on the return visit would be necessary. According to Arenas’ medical records, the practice told one reviewer that two were done to make sure the cysts hadn’t changed.

Shaffer didn’t buy it. “They just billed her twice for one thing,” he said.

Levy, the gynecologist, said it’s “excessive” to do two ultrasounds. And, she said, there was no need to send clear fluid to pathology.

Arenas offered to waive her privacy rights so the practice that provided her treatment could speak to ProPublica. Officials from the practice declined to comment. Her medical records show that in response to reviews by her insurance company and the attorney general’s office, her doctors said the care was appropriate. 

Since then she has her cysts drained without images in her gynecologist’s office for about $350. But Arenas said on two occasions she’s used a needle at home to do it herself. (Doctors do not recommend this approach.) She admits it was an extreme choice, but at the time she worried she would be subjected to more unnecessary tests.

“I was taken advantage of because I was a captive audience,” she said.

In a brick-and-glass office park just outside Roanoke, Virginia, Missy Conley and Jeanne Woodward have battled on behalf of hundreds of patients who believe they’ve been overtreated or overcharged. The two work for Medliminal, a company that challenges erroneous and inflated medical bills on behalf of consumers in exchange for a share of the savings.

The two women excitedly one-up each other with their favorite outrages. How about the two cases involving unnecessary pregnancy tests? One of the patients was 82 —decades past her childbearing years. The other involved a younger woman who no longer had a uterus.

Another case involved an uninsured man who fell off his mountain bike and hurt his shoulder. The first responders pressured him to take an air ambulance to a hospital when it would have been faster for his friends to drive him. He got charged $44,000 for the whirlybird. Such unexpectedly pricey flights — and the aggressive billing that comes with them — have been featured in stories by NPRThe New York Times and The Atlantic.

Medliminal gets dozens of calls a week from consumers who are fed up with the medical system.

Woodward, a nurse and certified medical auditor, regularly sees patients billed for unnecessary lab tests. A man with diabetes may only need his glucose measured, but the doctor may order a bundle of 14 unnecessary tests, she said. The extra tests inflate the tab.

If there’s a billing dispute it can take months of phone calls and emails to get a case resolved, said Conley, who gained an insider’s knowledge during years working for insurance companies.

Patients fighting bills on their own often give up and pay the bill or let it go to collections, she said. “The whole system is broken,” Conley said.

Saini, president of The Lown Institute, said profit is a major driver of overuse.

“Providers are getting constant messages from superiors or partners to maximize revenue,” Saini said. “In this system we have, that’s not a crime. That’s business as usual.”

Patients aren’t true health care consumers because they typically can’t shop by price and they often don’t have control over the care they receive, Saini said. The medical evidence may support multiple paths for providing care, but patients are unable to tell what is or is not discretionary, he said. Time pressure adds urgency, which makes it difficult to discuss or research various options.

“It’s sort of this perfect storm where no one is really evil but the net effect is predatory,” Saini said.

Once the service or treatment is provided, the bill is on its way, with little forgiveness.

In 2015, Dr. Dong Chang, the director of the medical intensive care unit at Harbor-UCLA Medical Center, a public hospital in Los Angeles, decided to see whether the care being delivered in his ICU was appropriate.

Resources were scarce in his ICU, and he suspected it might be possible to manage them better. So, he and his colleagues reviewed the records of all the patients in the unit over the course of a year to see whether the patients might have been either too sick, or too healthy, to benefit from intensive care.

The results shocked them. They determined the care may not have been beneficial to more than half of the patients. “ICU care is inefficient, devoting substantial resources to patients less likely to benefit,” their study, published in the February edition of JAMA Internal Medicine, concluded.

Chang and his team also reviewed the use of intensive care at 94 hospitals in two states, Maryland and Washington, focusing on four common conditions that can lead to treatment in an intensive care unit.

They found wide variation in the types of patients hospitals determined needed intensive care.  One hospital put 16 percent of patients with diabetic ketoacidosis, a serious condition that can result in a coma, in intensive care, while another hospital did so with 81 percent of such patients. The range for patients with pulmonary embolisms was from 5 percent to 44 percent and for those with congestive heart failure, it was 4 percent to 49 percent.  

Chang attributes the difference to doctors using intensive care based on their habits, hunches or training. Profit, he said, may also be a motive, but it didn’t appear to be a driving force.

“We really don’t have good standards and a good discussion going on about who should receive ICU care,” Chang said.

The unnecessary intensive care can also be harmful. The study found intensive care patients underwent more invasive procedures, like the insertion of catheters, including central lines, which carry the risk of infection. Overuse of the ICU is bad for patients who don’t need it, Chang said. Survival rates were also no better at the hospitals that used intensive care the most.

Reducing unneeded intensive care stays would save big money. Intensive care costs about $10,000 for a typical stay and accounts for 4 percent of national health care expenditures, according to research cited by Chang’s team.

If the hospitals in Maryland and Washington with the highest rates of intensive care use had behaved more like those with lower use, it would save around $137 million, the study estimated. That’s the savings for fewer than 100 hospitals in two states. There are about 4,000 hospitals nationwide, suggesting that reducing unnecessary intensive care use could save billions of dollars a year. 

Chang hesitated to call the overuse of intensive care “wasted” health care spending. He said the medical literature calls it “non-beneficial” care, which is maybe a nicer way of saying the same thing.

For O’Neill, her dispute of the fee for her daughter’s ear piercing was a trip into the hell of medical billing.

O’Neill is an attorney, so she knows how to weed through fine print. But it took her untold hours and phone calls to the hospital and her insurance company to root out the issue. The hospital had initially billed her insurer for the $1,877.86 for “operating room services” related to the ear piercing. The company rightly rejected payment for the cosmetic procedure. So, the hospital billed the family, according to her medical and billing records and correspondence.

The surgeon billed the family an additional $110, which O’Neill paid.

The operative report describes the piercing in obscure technical terms: “The bilateral lobules were prepped with betadine and a 18 gauge was used to pierce the left lobule in the planned position …”

O’Neill said she got nowhere in several conversations with the manager of the hospital’s team that deals with payments directly from consumers. Then in mid-July, O’Neill wrote a letter to the manager explaining that they were at an impasse and urged the hospital to cancel the bill.

In early August, ProPublica contacted the hospital and surgeon to inquire about the ear piercing. The hospital spokeswoman replied in an email that, generally speaking, ear piercings during surgery are rare and only done at the request of a family. (The medical records say O’Neill requested the ear piercing.) It would not result in a separate operating room charge, she wrote.

The spokeswoman’s explanation didn’t jibe with the hospital’s bill, which even listed the billing code for ear piercing. She declined to discuss O’Neill’s case or explain the discrepancy.

In mid-August, the self-pay manager sent O’Neill a letter saying, “the remaining balance of $1,877.86” would be removed “as a one-time courtesy adjustment.”

The manager added that the hospital hadn’t done anything wrong. The account was “correctly documented, coded, charged and billed according to industry standards,” she wrote.

And that’s just the problem. The hospital’s $1,877 bill for the ear piercing waswithin industry standards.

As for O’Neill, she and her daughter had to endure one additional insult. The surgeon’s piercing of one ear was off-kilter so it had to be redone. This time O’Neill had it done at the mall, for about 30 bucks.

Have you seen examples of wasted health care spending? Share them with Marshall.


Marshall Allen

Marshall Allen is a reporter at ProPublica investigating the cost and quality of our health care.

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Above: The first  full-scale test fire of SPG's Mars Ascent Vehicle rocket motor. Right: Dr. Brian Evans (Images Courtesy of the Space Propulsion Group)

by Jim Larsonbrianj
Butte has long known how to bring rocks from the earth; now Butte joins the effort to take them from the sky.
A local aerospace firm is on track to design and build the propulsion component of a space vehicle that will land on Mars and then take off again, and when the rocket rises into the thin Martian atmosphere, it will carry a payload of samples gathered from the red planet’s crust.
“It’s something that is a complete Butte product that could be sitting on the surface of Mars in a few years,” Dr. Brian Evans said. 
NASA calls the rocket the Mars Ascent Vehicle or MAV, and it is a key part of NASA’s Mars Sample Return mission.
Evans is the Chief Engineer for the company, the Space Propulsion Group, and under his guidance, SPG has developed a hybrid rocket fuel that may be critical to the success of the mission.
The MAV will bring rocks from Mars to a “mother ship” waiting in orbit around the red planet. Those samples will be brought back to earth for study, Evans said.
The rovers that currently study the Martian surface analyze rocks, but they can’t perform the extensive tests that can be done on earth, Evans said.
Waiting for the samples to be gathered will require that the MAV be on the planet’s surface for up to two years, Evans said, and that is where the fuel’s role becomes crucial.
Neither liquid nor solid rocket fuel can withstand the extreme temperatures experienced on the surface of Mars, but SPG has developed a fuel that can, and they have demonstrated that to NASA. It is paraffin based fuel that uses mixed oxides of nitrogen as an oxidizer, Dr. Evans said. He noted that for combustion to occur, heat, fuel and an oxidizer are needed.  (Oxygen is the oxidizer involved in most fires on the earth.)
SPG came out of Stanford University in 1999 and was previously based in Silicon Valley, Dr. Evans said. The company began testing in Butte-Silver Bow in 2009 to take advantage of lower costs and an accommodating business and political climate. Dr. Evans joined the company in 2010, “right out of school,” he noted.
In 2012 SPG finished up an Air Force contract, and with little else on the horizon, the ten-person company dropped to three employees. Shortly after that, two of them left, leaving just Evans.
During that time Evans worked on the creation of a new PhD Program for Stanford, and it was in a lab there that a call came from NASA, he recalled.
A phone rang in the back of the lab, Evans said, a phone that he had never heard ring before and that he never heard ring after. On the line was a former student and friend and NASA Jet Propulsion Laboratory project manager. She knew about Evan’s work with paraffin-based fuels and had done related work when acquiring her own PhD, Evans remembered.
“So they had this situation,” Evans said. NASA wanted to bring rocks back for study, but the fuels available to them couldn’t withstand a prolonged stay on Mars. “Their problem was that their current propulsion systems, solid rockets and liquid rockets, wouldn’t work for their planned mission. They’ve been trying to do this for 25 years, but the propellants have never worked,” Evans said.
Enter SPG. Evans noted that the group’s style of hybrid rockets, “don’t suffer that issue. They can survive in that environment.”
During testing, Dr. Evans and his team demonstrated to NASA that SPG’s version of paraffin rocket fuel could withstand the temperatures that would be faced on the Martian surface, and the company currently is working to show that their fuel and vehicle can sustain a burn long enough to meet the Mars mission requirements, and those tests are on track to be successful, Evans noted.
Current testing is scheduled to conclude at the end of December, according to David Micheletti, SPG’s Vice President of Business Development and Program Management. 
“The next phase, according to what we’re being told, would to be to build a vehicle, an actual launch vehicle, that would utilize this ten-inch motor that we’re currently testing, and we got some feedback recently that NASA’s seriously considering having us do that next year,” Micheletti said.
The company conducts tests at the Butte AeroTec Facility, a testing area commissioned by the Montana Aerospace Development Association (MADA), Micheletti said.
The facility is public-private partnership, notes Micheletti. 
(Story continued below)

An artist's conception of the Mars Sample Return Mission (Image courtesy of NASA)

 “We met with the folks from SPG in about 2009,” Micheletti said. (At that time Micheletti had not yet joined SPG. He was the Vice President of Aerospace Programs at MSE in Butte, and he was the President of MADA, a volunteer organization. He joined SPG in 2017, and he is currently Chairman of the Board of MADA.)
“From the very beginning this has been a four-way partnership that includes my organization, which is the Montana Aerospace Development Association or MADA, SPG of course, the City of Butte-Silver Bow and Solvay Corporation. Those were the founding partners of the facility out there, and those four entities continue to be the primary partners," Micheletti said.
When testing began in Butte-Silver Bow in March of 2009, SPG did all of its fabrication and engineering in Silicon Valley, Micheletti noted.
In 2016, when a new test cell was built at Butte AeroTec, and a new round of tests began on a three-inch test motor, “Brian moved from down in the bay area up here. When Brian moved here, that meant essentially that the company moved up here, because he was the company,” Micheletti observed.
But Evans couldn’t run the tests alone, Micheletti said, and so three more employees were added.
Then, on the first of September, SPG received a new contract from the Air Force, a continuation of the work that ended in 2012. More staff was added, and the company is “currently at nine employees,” Micheletti said. Those workers include engineers, technicians and an administrative employee, he said.
If SPG does indeed get the go ahead to build the MAV, and that seems likely, the number of employees will probably double, Micheletti observed.
“We’re optimistic that that level of activity and growth of the company will continue, and Jim Kambich is hoping that we’ll occupy even more of these offices,” Micheltti said.
Kambich is the Chief Executive Officer of MERDI  , the non-profit that owns the Thornton Enterprise and Technology Center at the corner of Wyoming and Broadway in Butte. SPG  occupies the west wing of the third floor in the Thornton.
Kambich accompanied Micheletti in 2004 to the Mojave Desert to look at testing equipment owned by DARPA. 
There, near the town of Mojave, lies what is now called the Mojave Air and Space Port. It is the home of a number of aerospace companies. From there, four years later, with funding procured from the US Dept. of Commerce, ten semi-loads of equipment were brought to Butte-Silver Bow’s TIFID. The equipment was assembled and the Butte AeroTec test facility was born, Kambich said.
SPG brought their own equipment to the Butte site as well, and they ran their first test in February 2009, Kambich said. “It’s become a lower cost test facility than you would have in California,” he noted.
Testing at the Butte facility has not only brought SPG to the brink of participating in a Mars mission, but it has also given the group something that many R & D companies don’t have, and that is a viable product that can be sold, Dr. Evans noted during an interview in Butte’s Science Mine education center.
And in addition to their work for NASA, SPG has recently been awarded another Air Force contract, a continuation of the work they were doing previously for America’s air arm. With both the civilian and military work, it is possible that the company that had been reduced to a lone PhD, will have 20 employees in the near future.


The influential OMB director’s door is open to corporate and conservative interests, according to logs that the White House fought to keep secret.

The calendars for Mick Mulvaney, the former South Carolina congressman who now runs the White House Office of Management and Budget, offer a glimpse of who has access to the highest levels of the Trump administration.

Among those visiting Mulvaney: Trump friend and casino magnate Steve Wynn; a flurry of officials from the conservative Heritage Foundation; a string of health care and Wall Street CEOs; lobbyists for Koch Industries; a cryptocurrency evangelist; and a prominent member of the Catholic group Opus Dei.

The Trump administration fought in court to block public records requests by Property of the People, a Washington-based nonprofit transparency group, to release the calendars as well as visitor logs from several other White House offices. Lawyers for the group ultimately prevailed and provided the documents to ProPublica, which we are posting in a searchable format.

As OMB director, Mulvaney is the driving force behind the president’s budget and influences regulations and government procurement. It’s been widely reported that he will become the acting head of the Consumer Financial Protection Bureau. He also has the ear of the president, who is reportedly a fan of Mulvaney’s performances on the Sunday political shows. The calendars, which cover February to September, typically don’t include details on what was discussed at the meetings. In some cases, the timing of contact with Mulvaney line up with OMB business.

“The OMB director is a member of the cabinet and also a senior adviser to the president — because of that, the director often spends a ton of time in the West Wing,” said Kenneth Baer, who was senior adviser and associate director at the agency for several years of the Obama administration.

The quickest way to get access to Mulvaney appears to be to hire his former congressional chief of staff, Al Simpson, who joined the lobbying firm Mercury in February.

Simpson had seven meetings and a phone call with Mulvaney in a four-month period, between April and August. He appears on Mulvaney’s calendars more frequently than anyone who is not a current government official. Often, Simpson brought lobbying clients with him, including representatives from building materials giant Cemex; pharma firm AmerisourceBergen; and BlueCross BlueShield of South Carolina. Those three firms paid Mercury $360,000 in the first nine months of the year, disclosure filings show.

A Mercury spokesman said: “The firm fully complies with all registration and disclosure requirements when representing clients.” The OMB press office did not respond to requests for comment.

In July, Simpson and Koch Industries lobbyists Brian Henneberry and Raymond Paul met with Mulvaney.

In other cases, billionaires themselves came in to meet with Mulvaney. They include Charles Schwab, medical entrepreneur Patrick Soon-Shiong and Wynn, the casino magnate whose relationship with Trump goes back decades. Wynn met with Mulvaney in April. Wynn’s firm has lobbied on tax issues on Capitol Hill. Wynn himself, who has large holdings in Macau, has reportedlybeen involved in pressing the Trump administration on China issues. Wynn was also named finance chairman of the Republican National Committee in January. Wynn’s spokesman declined to comment.

In late February, Mulvaney had a call with Eugene Scalia, the son of the late Supreme Court justice and a prominent lawyer at Gibson Dunn. At the time, Scalia was representing business groups that wanted OMB to delay the implementation of a regulation known as the fiduciary rule. Scalia didn’t respond to a request for comment. Many of his meetings with health care executives came as Republicans in Congress tried to repeal Obamacare.

Mulvaney met with few, if any, consumer groups. That’s in contrast to President Barack Obama’s first OMB director, Peter Orszag, whose visitor logs show meetings with both a long string of corporate executives as well as philanthropic and consumer representatives.

Among the more surprising visitors to Mulvaney was Jeff Bell, a former Reagan aide who is marked on the calendar as being with the Catholic group Opus Dei. Bell told ProPublica that his March meeting with Mulvaney, a Catholic, covered “religious and political matters” but declined to comment further.

Another was Valery Vavilov, CEO of Bitfury, a tech company focused on cryptocurrencies like Bitcoin. When Mulvaney was still in Congress last year, he co-founded a “blockchain caucus” to promote the technology behind Bitcoin

At the May meeting, “Mulvaney expressed his desire to encourage government use of blockchain and he asked our group for suggestions of simple use cases that could be a first step for government adoption,” a Bitfury spokesman told ProPublica.

Do you have information about Mick Mulvaney or the Office of Management and Budget? Contact Justin at This email address is being protected from spambots. You need JavaScript enabled to view it. or via Signal at 774-826-6240.

Big Sky Connection


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November 10, 2017

Eric Tegethoff

BILLINGS, Mont. - How does the country move toward renewable energy in a way that benefits working families? That's one issue being addressed at the 46th annual Northern Plains Resource Council meeting on Saturday. 

Keynote speaker Tyson Slocum is the energy program director for Public Citizen, a consumer advocacy group. He says Public Citizen is interested in promoting energy resources that are affordable, reliable, and sustainable - and that renewable energy is now meeting that criteria.

"We want to make sure that we are encouraging low-cost renewable energy deployment," he says. "And because of technological innovations, that's what's happening right now, in energy markets across the United States."

In Montana, he says prospects look especially good for wind energy. While wind power in the state now provides enough energy for about 200,000 homes, the Department of Energy predicts it could produce enough for 6.4 million homes by 2030.

Slocum says jobs in coal are decreasing because of market forces - in large part, due to the growing renewable-energy sector. But he says there are ways to ensure that coal communities aren't left behind.

"We owe an obligation to those communities that are heavily reliant on extractive industries, to try and focus new investments in those communities for manufacturing of renewable energy resources," he stresses. "That said, there are an awful lot of jobs in the renewable-energy sector."

The Northern Plains meeting is a two-day event starting Friday, held in downtown Billings. Other meeting topics include climate change, accessibility to clean energy and "jobs versus the environment: a false choice." 

Find more on how to attend at