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PaperclipPerfector  20d ago (text post)   28818 thread views

Culture War Roundup for the week of December 16, 2024

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A Window Into How Health Insurance Companies Harm Consumers by Threatening to Deny Coverage

From the New York Times, we learn about how health insurance companies hire PBMs (Pharmacy Benefit Managers) to help them restrict access to doctor-prescribed drugs. For all the talk of insurance companies directly denying coverage, when it comes to pharmaceutical drugs, specifically, they're able to offload a significant amount of Delay, Deny, Defend onto third parties, in this case PBMs. By restricting coverage, insurance companies are able to reduce costs and increase profits. A bonus is that they don't even have to be The Bad Guy; they can pawn that off on a third party, who is ostensibly making the choices for them. They don't have to personally defend the decisions to deny; they can just obfuscate, wave in the direction of the third party, and let the complexity of The American Healthcare System stymie consumers.

The Times does a deep dive into a Good Guy Pharmaceutical Company and the lengths they have to go through to navigate this minefield to get their high-quality, purity-assured drugs into the hands of the market. Primarily, they've gotta give the PBMs a cut of the money, who in turn share it with the insurance companies and employers they represent. For a while, they were rebating 23% on average, allowing patients to access the drugs their doctors prescribed at prices that were reasonable to them, their employer, and their insurance company. One PBM reportedly wanted (and got) more - 60% rebate to keep prices low and avoid inflaming popular anger with denials. Of course, that still doesn't quite reach how good some Medicare plans were at 'negotiating'; they got about 70%!

The Good Guy Pharmaceutical Company knew how much people wanted its product; they knew that doctors were prescribing it; they knew how dangerous the alternatives could be for many in the market. They were offering a well-known, well-tested product, clean from any adulteration, and outrage would surely rule the populous if folks had to turn to alternative products or sketchier outlets, possibly with less-stringent quality control. So, they selflessly paid the toll to do the right thing, to get their product into the market, to save lives. NYT rightly applauds their admirable efforts to do what they could, at cost to their own bottom line, to protect consumers from the restrictive, denial-focused tactics of health insurance companies and their lackeys.

Oh wait. NVM. It's Purdue. It's Oxy. Flip everything 180 degrees. Apparently, nobody (other than Purdue and their supporters) thinks it's good to flood the market with high-quality, pharmaceutical grade opioids with well-known potency properties. They somehow don't think that this is preferable to folks getting funneled toward lower-quality, potentially dangerous alternatives. They're back to liking the gatekeeping of insurance companies and their lackeys, ya know, so long as they're doing so in keeping with their own political proclivities. Gatekeeping is Good and Right, so long as the folks who buy digital ink by the barrel can browbeat the gatekeepers into doing things the way they want it to be done. ...and they sure ain't even thinking about including libertarian politics on drugs in the list of their demands. Woke politics, tho? Sure, why not?

This seems like a misrepresentation or at least to have some logical leaps.

My objections:

  • It's perfectly fine to hold those beliefs and still want accountability for a drug company that does bad things. Someone's desired counterfactual isn't limited to a binary.
  • "I think these firms should do less to limit beneficial healthcare and do more to prevent harmful healthcare" isn't some gotcha where you should object "Well do you want more or fewer free markets"
  • The tradeoff between good-quality tested opioids and sketchy street drugs isn't real. I can't pull them up right now but throughought the 2010s the economist had like 4 studies cited that showed about 60% of people dependent on street drugs (from someone else's prescription to black tar heroin) started out on prescription pain killers like oxycontin.

I don't understand your first objection. There were a lot of "beliefs" hinted at in my post, not all of which I hold or think someone else holds.

Your second objection seems to entirely make my point. What counts as "beneficial" vs. "harmful" seems to significantly hinge on other politics. People select politics first, then determine "beneficial" or "harmful", and then decide whether something is 'corruption' or 'negotiation'... or whether it's 'righteous gatekeeping' or 'evil profit-seeking gatekeeping'. Your politics are baked in to your statements, which is why you think other politics can be just brushed aside and totally ignored. Moreover, because we've essentially nationalized policy (while retaining nominal private ownership), the entire arena is fundamentally a matter of confused national-scale politics, rather than distributed optimization to local and personal values.

Your third objection, and the responses it's already produced, absolutely seals my point. People are divided about the politics, which leads to all sorts of confusion in trying to 'design' a nationalized system with clear purpose and vision, instead leaving the matter ripe for all sorts of politicized framing effects.

I don't see the use in framing common disagreements between different groups as some sort of political contradiction. Wanting more government regulation of the border or guns, but also wanting fewer EPA requirements for food or DEI requirements isn't a contradiction or a gotcha, it's a valid expression of people's political desires. Similarly, wanting healthcare but not have addictive or unnecessary procedures or medicine pushed on you is totally acceptable. I reject the notion that it's just a matter of politics as a broad claim you've made. I concede there is a large amount of political finagling and ideology in many of these decisions (whether by doctors, congress, hospitals, the federal executive), but I also believe you could parse out 60-75% of policy as being harmful or helpful to individuals and have broad (over 75%) public agreement.

political contradiction ... contradiction or a gotcha ... valid expression of people's political desires

I have no idea what you're on about. I'm not claiming a contradiction or gotcha. I'm not claiming anything is invalid.

studies cited that showed about 60% of people dependent on street drugs (from someone else's prescription to black tar heroin) started out on prescription pain killers like oxycontin.

Note that this does not mean that they started with painkillers prescribed to them for legitimate pain issues. It's likely that many (most?) started with opioids that were stolen, diverted, or obtained for recreational purposes through doctor-shopping.

Yes, I flagged that in brackets.

The tradeoff between good-quality tested opioids and sketchy street drugs isn't real. I can't pull them up right now but throughought the 2010s the economist had like 4 studies cited that showed about 60% of people dependent on street drugs (from someone else's prescription to black tar heroin) started out on prescription pain killers like oxycontin.

Basically the drug warriors were pushing that line. But if you follow the references back, they end up at a study of street heroin users which determined that some large percentage started on prescription drugs.... but usually not their own.

Health insurance companies have thin profit margins. If they want to get more money from them, they need to pay higher premiums. Why don't they? It seems like they're just buying cheap plans and complaining when they get cheap coverage.

This event has the potential of becoming a trigger of revolution and if this is the potential "tea party" this is the equivalent of going like "Well the profit margins on running the British Empire are low so we should be paying more taxes on that tea!". You can cue up all the technical differences with that situation is different from colonial taxation but the bigger picture is that both of these situation is extremely extractive institutions for the benefit of an elite, it never lasts forever and has potential to violently be ended by the subjugated.

How can it be extractive if they're profiting so little from it?

Insurance companies sell a service to individuals that the day that the individual needs healthcare they will pay the healthcare provider for that healthcare. So usually this is person is working and pays for that service of eventuality needing healthcare out of their salary, because in most cases if you need healthcare the person can't pay that premium(I hear that it is what is called). Now if that insurance company delays or even denies payment for that healthcare it means that the person can't get back to work to continue paying the premiums. It is more profitable for the insurance company to extract the money for a service and have people literally dying so they don't pay anymore for the service that possibly would have helped them survive.

They're obviously not doing this though because they don't profit very much and no one would buy their insurance if they did. I also don't see how it would hold up in court.

We are not in court. I'm just speculating that this would be a potential flashpoint for revolution with the reasoning that health insurance companies are extractive institutions and with historical example of the American Revolution that extractive institutions can be overthrown violently if they reach a breaking point of the "extracted". It is triggered by your "Let them eat cake!" moment! But for me the cost of being either right or wrong are extremely low, since I live in a country with a single payer health insurance.

you can go broke trying to pay down medical bills for health conditions you have no control over.

You can just not pay it. Medical bankruptcies are essentially voluntary.

People are furious because, among other things, you can go broke trying to pay down medical bills for health conditions you have no control over.

You may as well be shaking your fist at God

“Why do bad things happen to good people?” Why indeed

Yeah tricycle wasn't specific enough, it's not the bad things that upsets them, it's the follow up hit of 'you paid for protection against bad things but oops it didn't work, so sorry but also we're keeping that money you paid us for the service of giving you a false peace of mind before pulling the rug out from under you right when you need it most' that really infuriates people.

I agree with that in principle, but there's a risk of missing the big picture when crafting too technical of a response.

I think it's even worse than this. Setting aside violence and just focusing on anger, it is absolutely amazing to me that people think a technical response is actually a strong rebuttal. People are mad precisely because the whole thing is utterly byzantine, impossible for someone with a double-digit IQ to understand, and they're aware that the guys at the top of making tens of millions of dollars on products that confuse and frustrate their customers.

I'm sure many people would still be frustrated if they couldn't afford medical care, but I think they'd be less frustrated if there was just a big fat sticker on the medical care, an accurate price that the patient just couldn't afford. Instead, you have patients that were under the impression that they'd done the right thing, gotten insured, and would be taken care of when they needed care. When they are surprised by a denial, they are understandable frustrated. No one told them this would happen! Yeah, sure someone has to determine what qualifies and what doesn't, it's all very complicated, there are tons of experts and if you don't like the experts, you can get a lawyer to talk to their lawyers, and maybe you'll even still be alive when it's eventually resolved.

That's what people are reacting against - that some rich fuck gets to make tens of millions of dollars on a product that they feel deceived by and he feels completely invulnerable because he's got an army of experts and lawyers, and you don't have shit. Then, when someone expresses this, some blogboi shows up to explain that actually you're too stupid to understand why the experts and lawyers are correct and the rich fuck should be completely invulnerable.

No, I don't think that's likely to assuage people's anger. I'll note that I'm only partially sympathetic to the anger - I actually have just about as much ire for the patients in a lot of examples as the system. Nonetheless, I can barely imagine an approach less productive than lecturing people about how it's all actually very complicated and they don't really understand.

Maybe this is "overly technical", but tens of millions across the US doesnt mean shit. Thompsons salary couldnt buy all his customers a coffee. Theres just no way someone will ever not feel exploited without understanding this unless they live under a rock.

Yes, I am aware that every individual in the American medical system has the same standard line that they're actually totally fine and maybe even doing everyone a solid for working at such a charitable rate. After all, no individual (or even individual role) makes up a large amount of total expenditures, so every individual must actually be fine, good, and not extractive at all.

They really can't be extracting much since they are legally obligated to pay out 80% of premiums. They could pay out perhaps 15% more if the entire company did it for free.

It's complicated because of the perverse incentives created by bad regulations. The people running the insurance companies don't have a choice. This is proven by their low profit margins. They're not doing this to become unfairly profitable. They're doing that to survive.

It's complicated because of the perverse incentives created by bad regulations. The people running the insurance companies don't have a choice.

See, this works unless you think the people writing the bad-incentive regulation and the people running the megacorps as the same people.

Same as the subprime mortgage crisis. "The government made me do it 😩," howls the voice with more influence over government policy than your family tree could ever dream of.

They’re in a terrible position. We outsourced the rationing of health care to insurance companies because hospitals in the USA are not allowed to turn down patients. I’m sympathetic to the anger, but in my view it’s misdirected as the insurance companies aren’t the ones lying. The rest of the system is. The hospital isn’t going to refuse care, it makes them feel icky and uncomfortable. The government won’t explain to people that it’s simply impossible to give gold plated treatments to 300 million Americans many of whom have other conditions that might well take them out in a couple of years. All of the false promises of infinite care are fake and always have been. We just somehow accidentally ended up with a solution that allows hospitals and the government to heavily imply that there’s capacity in the system for everybody to get whatever they need, and very importantly to not be the people the public is mad at.

We just somehow accidentally ended up with a solution that allows hospitals and the government to heavily imply that there’s capacity in the system for everybody to get whatever they need, and very importantly to not be the people the public is mad at.

Well, we've ended up with a solution via the regulatory state and judicial activism for everyone in elected office except the President to not be the people the public is mad at, so this isn't out of character for Congress at all.

Sometimes the resource allocation decision maker is definitely hospitals or the medical system, like triage and organ donation lists. But the medical system only likes to make decisions like that when it's about scarce medical resources, like livers, lungs, or beds. It hates the idea of making decisions based on scarce monetary resources -- that's not their side of the counter.

I recall during the Obamacare debates, much hay was made over "government death panels," the scary spooky term for making decisions about limited resources using government authority in some cases. My personal view on this has always been that someone has to make these difficult decisions. The medical system doesn't want, and probably shouldn't want, to make monetary decisions for patients. So someone has to do it, and either it's got to be the patient/patient's family (who is rarely a rational economic actor because the most expensive decisions involve literal life or death), or it's got to be the government, or it's got to be some non-governmental organization with fat pockets, usually a corporation.

There's a throughline in American politics where either you end up believing corporations are worse than government, or you believe government is worse than corporations. Everyone instantly knows which political party is associated with which. And for what it's worth, the US's third parties are essentially just more intense versions of the corresponding mainstream party on this measure! (With the Trumpian realignment, we may be creeping towards a point where the parties swap places here.)

I guess if you decide both are bad you end up an anarchist. But I have no idea what you become if you decide both government and corporations aren't that bad. Is this neoliberalism?

Fraud in general is a method of resource allocation; giving you a half pound of flour when you paid for a pound allocates more resources to the seller. If the seller is financially in trouble, the fraud may actually be keeping his business profitable. Yet this doesn't make fraud fine.

Deliberately or recklessly denying valid claims allocates resources, but is still a form of fraud.

I mean this is how power works. When you hear “should group X be making the decisions” what it tends to mean is “group X shouldn’t be held accountable to the public for making those decisions.” That’s why “shouldn’t be political” is a red flag in my mind. It’s a decision to be made by someone, and that decision will be made. But “not politics” generally should be translated “by people with the power to make the decision, but who face no consequences or responsibility for it.” And generally, if you want terrible outcomes, that’s the best way to get them. When the government is not making the decisions about healthcare, it’s generally someone else who is, and as our system actually works, it’s a bunch of actuaries hidden in the bowls of a giant bureaucracy in a big insurance company who decided how to calculate a formula in excel. Does he face any consequences for the results? Not really, as long as the company makes money and doesn’t get sued.

Government should be involved in those kinds of decisions simply because the government is at least in theory accountable to the public interest. If people’s health care access gets bad enough, eventually the pitchforks come out.

It used to be that people would curse God when they were struck down by fate, now they curse insurance companies.

So, corruption?

If I had a point, which I'm not sure I did, it would be that how you view it turns on other politics. How many people who are screaming about how they want the gov't (Medicare) to "negotiate drug prices", presumably making them cheaper and pulling profits out of drug companies, are going to call these rebates "corruption"? ...can they do so with a straight face, when Medicare plans were getting the biggest rebates of them all? How many people viewed all doctor prescriptions (and their charges for their own services) as sacrosanct, with any gatekeeping by insurance companies being evil, and will now be dissembling that these doctor prescriptions totally need gatekeeping, because doctors are apparently dumb and bad? How many people who would be crying, "Legalize all drugs!" with arguments about how important it is to have quality-controlled pharmaceuticals available are going to say that Purdue actually was "Good Guy Pharmaceutical Company", just fighting for the cause of reducing fentanyl deaths by taking the hit in profits to get their product in the market?

The whole industry is an awful mess, with kludge upon kludge, and many folks can't even figure out what they want from a system. They're easily swayed by framing, and so "negotiation" becomes "corruption" if it's framed that way; doctors are sacred and we need to stop insurance from getting in their way or they're dumb and need gatekeeping depending on how it's framed, etc. The lack of a clear vision and susceptibility to framing makes the whole thing prime for more kludges promising to be fixes, more unintended consequences from a lack of clear purpose in the heaping of regulation upon regulation. (I didn't even mention the confounding factor of people wanting to use it to transfer incomes or the sheer constitutional (little c) inability of folks to allow people to make choices with prices.) It lets anyone be the temporary Bad Guy in the fervor for the latest Current Thing. We broke it, now we've clearly bought it, with no bloody clue what to do with it. So the best thing people can do is try to part it out in favor of their political goal of the minute.

It’s worse. They know what they want, it’s just impossible to provide. They want walk-in world class healthcare for cheap. They want it for cheap if not free. They want to walk into a doctor’s office, get seen quickly, then go to a specialist, pay twenty dollars each for the office visit including any tests, get a prescription for pills that they then pick up at Walgreens for less than $50 for a bottle of name brand life-saving drugs.

I don’t care how you re-engineer our health care system, the system cannot provide what the public wants. No system can. If it’s fast and doesn’t ration care to patients, it cannot be cheap. If it’s cheap, it’s because you either wait or you push the very sick out of the system (likely both). People want fast, world-class, cheap healthcare. At best, we can provide ONE of those things. If you want cheap healthcare, it’s going to be long waits and heavily rationed. Most orthopedic care is going to be reserved for tge very rich. You can expect to wait months for an office visit. And if you need something more than the primary care physician can do, that’s another couple of months to see whoever can fix the problem, and another couple of months to actually get anything done about it. If you want fast medicine, you have to pay for it. Likewise if you want to give everyone world class care without heavy rationing.

It’s a hard sell because people want all three and are assuming corruption or profit is the reason they can’t have cheap healthcare on demand. And politicians can’t or won’t tell people that they are asking something impossible, so the insurance companies get the rap fo4 doctors not being willing to work for the pay of store clerks and drug development costs being high.

Fast and cheap is at least theoretically possible. A big chunk of healthcare is walk-in in China, where the life expectancy already exceeds that of the United States. Appointments with specialists are easy to get, with most wait times measured in days to weeks rather than months.

There may be some state subsidization going on, but the direct cost to the consumer, along with overall cost of care is much lower than in the west. Overall I admit not knowing how their system actually works.

There is something resembling health benefits by employers, but as far as I can tell it's literally just a health savings account that the employer contributes some money in every year rather than insurance.

If you adjusted for the life expectancy hit of air pollution, they'd be comparable to SK and Japan in longevity, so their public health actually seems to be effective. Big gains in the past decade as well.

There may be some state subsidization going on, but the direct cost to the consumer, along with overall cost of care is much lower than in the west. Overall I admit not knowing how their system actually works.

Reasonable government health care is a part of the East Asian package.

It's an emergent trait of demographics, and not really something that is replicable in a Western context.

For similar reasons, there is essentially no violent crime in any East Asian country. It's not government policy, it's a fundamentally different society.

It's an emergent trait of demographics, and not really something that is replicable in a Western context.

Actually Australia manages to do it as well. It is entirely replicable in a Western context, though maybe not in the USA as it is currently constituted.

There's a way to do it, it's the sausage principle - don't look how the sausage is made. You redefine "cheap" as "no payment at the point of consumption" (or a nominal payment) and you hide the real costs. The best way to do it is through taxation since nobody reads the budgets and nobody is able to figure out how much exactly money is spent on what, and even if somebody does that, it's no longer your money, it's some abstract tax money and you can always demand that the billionaires pay more - it has nothing to do with you. If for some reason the obvious way is not available, you can at least separate payment and consumption by calling a pre-paid subscription scheme "insurance" and by deducting the payments in a way that you never get to touch the money before payment (e.g. payroll deductions) so you don't feel it's your money - it's just your employer provides you the service for free, how generous of them.

You can redefine "fast" as "you can talk very fast to somebody who is in no position to help you". Many healthcare organizations do that - e.g. to get an appointment to a specialist, you need a "referral" from your primary care doctor, and maybe the primary doctor will see you next week, and then the appointment to the real specialist will be in another couple of weeks, and so you waited almost a month or so without even noticing it. And there's no guarantee that specialist can do anything for you either - maybe they will refer you to some tests, then to another one and so on - and you can spend many months in this without even getting as much as initial diagnosis. Of course, added value of this is each interaction must be paid for (sometimes several times over - you can't just put lab technician pay, lab materials pay and visit pay on the same bill, we're not some kind of savages!) but "insurance" covers it so you never actually know how much does it cost, not that it'd help you since you can't elect to use another lab technician anyway if you thought this one charges too much, and in fact nobody is going to tell you how much it costs anyway - because that's exactly what was asked for from the start.

And there's no "rationing" - it's just the doctors are very busy. And for some reason there's never enough of them. As for the quality, if you have to wait several months to see a specialist, and there's no other one in 500-mile radius of you, how much are you in the mood to refuse to visit one because you think they're not world-class enough? How do you even know what's world-class - how many ENT specialists or podiatrists have you seen in other countries to be able to know the difference? It certainly costs a lot, and it seems to be a lot of demand, so it must be very good, right?

So the system is actually going out of it's way to provide exactly what is being asked for. It's just since, as you noted, it's not possible to actually provide it, it works very hard at making it appear as if it's doing it. Because that's exactly what we're pushing it to do. And it is delivering that to us as much as it can. People think it's a hostile system - but very often it's not, it's just reacts to our demands of it within the limitations placed on t and tries to deliver what it can.

Honestly, all I want is the same level of care and availability that I can get from a veterinarian, plus the ability to pay for market-rate insurance to cover against genuine catastrophe. I know this isn't what most people want, but it really is all I want out of the system. I have just about arrived at the point where I think people in aggregate would be better off if there was almost no medical regulation and the government paid for nothing other than a few emergency services.

My dog has seizures. When we discovered this, we were able to get her into a vet and get blood work done and meds prescribed at reasonable prices. Now she doesn't have seizures. Nothing about this was massively complicated, no MRIs were done, no insurance was involved, we just put her on barbiturates and now she doesn't have seizures. The number of human medical problems that seem to have roughly comparable complexity and that run about bajillion dollar in bills instead of being handled quickly and easily is mindblowing.

I mean, the question is ‘what’s the relevant difference and is it possible to have it apply to humans’. I’m guessing there’s at least parts of veterinary practices that cannot- if lower liability because they’re just dogs is really a significant part of the puzzle, then we can’t really reduce human medical bills that way.

I'm well aware that it's not actually possible for the American medical system to become an actual market where normal market pricing applies. Liability is a great example of why, along with regulatory burden, licensing requirements, and so on. But still, it's pretty annoying to consider edge cases.

For example, Apple produces the AirpodsPro 2. These are cool and fairly common product, many people own them simply because they're good for normal earbud purposes. Apple, being full of ingenuity, now has a hearing test and hearing aid functionalities on them. Awesome! Unfortunately, those functionalities aren't available yet because implementing that software update transforms them into a medical device that requires FDA approval. So, we have people that own an object that could test their hearing and implement hearing improvements for them. It's all ready to go! But the FDA says you may not use that functionality until they say you can.

I don't know just how many things there are like that, but it's a great example of how ponderous and captured this whole apparatus is.

I agree that this is true, but it doesn’t mean the public discontent with the current situation is entirely wrong. For example, the ideal balance may be further in the cheaper/slower/worse direction than the current US system.

You can expect to wait months for an office visit. And if you need something more than the primary care physician can do, that’s another couple of months to see whoever can fix the problem, and another couple of months to actually get anything done about it.

Is this supposed to be a description of the worst case under a theoretical cheap system? Because this describes a process faster than what I went through this year in the US with top-tier employer health coverage in a major city. While at the same time I regularly see stories online from people in Europe paying for health care through their taxes being astonished about the concept of waiting for a specialist. Are they lying? Is the care they are getting really that much worse? Surely any place other than the US has health care that counts as "cheap" compared to the US?

people in Europe paying for health care through their taxes being astonished about the concept of waiting for a specialist. Are they lying?

Maybe. Different countries in Europe have 'solved' this differently. The NHS in England has a website that lists average waiting times for specialist care.

https://www.myplannedcare.nhs.uk/

18 weeks for Orthopedics in East Sussex https://www.myplannedcare.nhs.uk/seast/east-sussex/specialty/?sname=Orthopaedics

Ireland has a website that shows how long patients have been waiting.

https://www2.hse.ie/services/activity-performance-data/waiting-for-care/waiting-lists/

I think this is getting at what I mentioned as "the confounding factor of people wanting to use it to transfer incomes or the sheer constitutional (little c) inability of folks to allow people to make choices with prices". I have two thoughts.

First, I'm not sure that fixing that would fix the other irrationalities I mentioned. Regardless of how you pay for it, questions like whether doctors' prescriptions are sacrosanct or whether they're actually dumb and bad will persist, for example. In the comment I linked to, the question of whether doctors should play a gatekeeping role is one that we've sort of stumbled into, via unintended consequences, rather than being a rational, clear, and vision/purpose-driven choice.

Second, I would say that people "want" this for literally everything. Of course people want world-class, free/cheap food provided to them, paid for by someone else. Of course people want world-class, free/cheap housing provided to them, paid for by someone else. Etc. Once you go down the rabbit hole of thinking that you can make some argument to justify forcibly spending other people's money on your consumption (be it because you think there is some 'positive right' involved or have some ideological preference to transfer incomes or whatever), the question reduces quickly to just one of how much you can force them to pay, how much income you can transfer, and how much consumption that will get you before the well dries up or political constraints take hold.

In many of those other arenas, we actually can/do "design" systems that work to give people what they actually personally value (via revealed preferences) - a price system. This usually has to give up on the idea that they're going to strong arm others into paying for it, but it allows consumers to locate themselves on their own pareto frontier, rather than imagining that they can just take more from the imaginary well of other people's pocketbooks and magically push the world to a state far to the top right of the pareto frontier. They can choose for themselves how much they value speed or quality or money. It's when they think that they get to choose between speed, quality, and other people's money that we run into problems; of course they're going to sacrifice other people's money. Guaranteed they'd sacrifice other people's money if they could get away with it to give themselves endless steak rather than spaghetti. No, this problem is not unique to healthcare; it's just one of the domains where we perpetually fail to acknowledge what we've truly figured out about the world and somehow keep being confused about why doing this obviously perverse thing keeps producing the same well-known failures.

Corruption isn’t always and everywhere a bad thing. Sometimes bribery is just straight an improvement on the official process of bureaucracy is bad enough.

If the bureaucracy is so bad that bribery is preferable, that doesn't make corruption not bad. In that case, both the official process and the corruption are bad.

Eg, the US healthcare system.

I think the bottom line, is this is just what a low trust society looks like. Everyone smashes the defect button as often and as quickly as possible, in every situation. There is literally no solving this problem, only clearing the way for a different species of defector who will ruin things, do material damage, and end lives with their greedy, corruption and indifference.

I was sitting in the car one day, pondering how low trust our society has become. I was at a gas station while my wife was using the bathroom. And I couldn't help but notice that the emergency gas shutoff switch is just out there, in the open, totally exposed. It got me thinking about the damage that will be caused when our low trust society devours that. I mean, it's there, unguarded, for a reason. Gasoline is dangerous, you can't just have it spilling all over the place. In case of emergency, you might not have time to grab the manager, have them get their keys, etc, etc. So it's just out there, for anybody to hit, whether there is an emergency or not. Which makes me wonder how long until some asshole tiktok prank becomes smashing that button as many times a day as possible until gas stations across the country have to start locking them up. Which then leads to more avoidable accidents at gas stations.

It's just going to be this way with everything. Nothing is going to be too trivial, or too important for some asshole to pillage, either metaphorically or literally.

What it looks like to me is that it's far from "everyone" that smashes the defect button - more like 10% of dysfunctional criminals and elite sociopaths. The rest try to cooperate, it's just that your tribe's definition of "cooperate" is not the other tribe's.

I often feel like people get the system they deserve. That the system is a product of the people, and trying to change a system’s rules on its own can only have marginal effect. We have a low trust, somewhat dysfunctional society and so any form of healthcare is going to be similarly dysfunctional.

Nerdy discussions of voting systems like ranked choice vs FPTP always trigger this feeling in me, like the voting system doesn’t matter at all. Maine implemented ranked choice and it’s not really going to improve Maine, Maine was only able to do it because it’s the whitest state in the country and as a result extremely non-polarized.

I got thinking about this when Richard Hanania pointed out that the political systems practised by Vietnam, Japan, Korea and China could hardly be more different from each other: China is nominally-communist-but-really-state-capitalist-and-authoritarian, Vietnam is actual no bullshit communist, Japan and Korea are modern capitalist societies. And yet, the day-to-day experiences of living in any of those countries are remarkably similar: low crime, low rates of children born out of wedlock (coupled with low fertility in general), high rates of educational attainment, high life expectancy. It suggests that, to the extent that your country following a particular political system makes a difference to the lived experience of its citizens at all, the difference is mainly felt on the margin. A particular political system can help to safeguard and maintain stability and economic productivity in a country, but you'll never establish a stable, functional and economically productive country without a critical mass of human capital, regardless of which political system it nominally follows. A corollary of this is that debating what political system your country should follow when it doesn't have the prerequisite human capital is like debating what colour to paint your car when it doesn't have an engine.

I agree you need human capital. But compare say Hong Kong with Beijing over the last hundred years.

Or compare the Ming Treasure Voyages cancellation with the European Age of Exploration. China was on top of the world, but their institutional infighting manifested as stasis while Europe's often-more-literal infighting manifested as a mad scramble for power, and the difference in incentives set China back centuries.

Compare East Germany with West Germany, or South Korea with North Korea. The economic effects of better vs worse governance on nearly-the-same-genes can literally be big enough to see from space.

I think a more interesting wrench in the gears is the question of better vs worse culture, though. South Korea has a lot more lights than North Korea in all the satellite photos, but at 0.72 and still falling TFR they might as well start turning lights off now before the last person "leaves". Their genes haven't significantly changed, and their government changes over the past 60 years (since the TFR started falling from 6) seem unrelated, but the cultural changes have been massive and baffling. Nerds started getting a mathematical handle on voting system foibles and game theory back around the time of Condorcet (though we've now got much better alternatives to FPTP than IRV-misnamed-as-Ranked-Voting, so the lesser-nerds' focus on the latter at this point in history is weird...), and likewise for economics and at least the most obvious Communism-level economic mistakes. But does anybody have any sort of mathematical analysis of WTF happened in South Korean culture, to cause the gender war to get so bad and the fertility rate to plummet eight-fold in 2 or 3 generations? It's like the stereotype of the pushed-into-overachievement kid burning out and becoming suicidal, but on a 50-million-person scale!

Two crazy statistics to think about:

  1. 51% of Koreans born in 1985 (39 year olds) have never been married.
  2. 3% of South Koreans are born out of wedlock.

So there is social pressure to not have kids out of wedlock, and more than half the population is deferring marriage until after the fertility cliff. I blame the marriage deficit on high financial expectations on young couples and a culture which teaches that marriage at 35 or later is okay. The birthrate crisis is downstream of the marriage crisis.

South Korea made childhood hellacious so nobody wants to subject people to it. It’s not a mystery.

That pushes the mystery back one step, anyway. Why did they do that, and other countries didn't?

Other countries have totally done that, South Korea just went unusually far.

It’s not because of the gender war, it’s because they have a broken culture that is ultra-hyper-competitive for no good reason and encourages all parents to pour all their resources into a single child who lives a miserable life in the hope of being 98th percentile in a hundred exams in a row and getting a job at Samsung (that pays as well as an average white collar job in the US). Many people increasingly check out of that system.

getting a job at Samsung (that pays as well as an average white collar job in the US)

Less, I expect. I knew programmers at Samsung in Korea back when programming was an ordinary white-collar job, and they made a lot less than American programmers did.

Korean pay scales reward seniority, not technical skills. All engineer starting pay is 1/3 to 1/5 the equivalent US starting salary, except Samsung which is 1/2.

But the US is an outlier in programmer salaries and in minimum cost of living. So someone can live comfortably on 40k USD in Seoul. Compare the US where cheap 100 to 200 sqft rentals don't exist anywhere.

Someday I need to post my student budget. I was able to save up 10k USD over three years while making less than 10k USD annually, paying tuition and living in central Seoul.

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I often feel like people get the system they deserve. That the system is a product of the people, and trying to change a system’s rules on its own can only have marginal effect. We have a low trust, somewhat dysfunctional society.

The interesting question is: how do you change the people, or at least stop them from changing for the worse?

I spend a lot of time in Switzerland, and on paper it should be pretty similar to many US states. Population size and density, GDP per capita, Gini index, cost of living, ect. are all pretty comparable to one of the "nice" US states. Even healthcare is kind of similar (certainly closer to the US than to the EU). Also, they have insane immigration, and have had for decades: 40% of permanent residents over 15 have an immigration background, 35% don't hold citizenship. Walk through a major city, and you'll hear a dozen different languages spoken within minutes. Walk onto a construction site, and none of them will be one of the national languages (OK, you'll probably hear Italian).

And yet, Swiss society is insanely high trust. Bikes unlocked, phones left on empty cafe tables, unaccompanied children move all over town on bikes or public transit. Farm stands have cash sitting in an open box, stores don't have locks on any product, self checkout is 100% unsupervised (and isn't using a digital scale to check what you bought).

The question is: why? How do they run a 1%-2% immigration rate, and instill the honor principle/high trust into everybody that arrives? How do they keep their citizens from defecting, practically ever? Of course, rate of incarceration is extremely low, too.

Or maybe we have to turn the question around: why are Americans choosing to defect so frequently now? Is the gini index not covering real differences in inequality?

You don't change the people. Switzerland has very few immigrants from Africa or the Middle East so they don't have too many problems yet.

https://en.wikipedia.org/wiki/Demographics_of_Switzerland

Of course, immigrants from those countries commit crimes at a rate of several times the native population.

Switzerland isn't doing anything "right" except for restricting immigration from unsavory countries. Neverthless, numbers are increasing, so unless they start deporting people soon, they can say goodbye to that high trust society within a few decades. None of this should be surprising to anyone.

How do they run a 1%-2% immigration rate

Where are the immigrants from? A Bavarian/Piedmontese family moving to Switzerland counts as an immigration background but is not likely to lower trust significantly (they're crossing a border but originate in a different part of the same mountain range) while a family coming from another continent that speaks a different language is going to be far more challenging to assimilate quickly.

Where are the immigrants from?

That's relatively diverse, at least from language, income and a "native trust level" perspective. The largest groups are, in descending order: Italy, Germany, Portugal, France, former Yugoslavia, Albania and Turkey. None of those groups is more than 10%, an together they're below 60% of immigration origin.

Maybe that diversity helps with not forming ghettos. Maybe all these origin countries have higher-trust societies than the most common countries the US gets immigrants from. But my intuition says this isn't the case.

The largest groups are, in descending order: Italy, Germany, Portugal, France, former Yugoslavia, Albania and Turkey.

Maybe all these origin countries have higher-trust societies than the most common countries the US gets immigrants from. But my intuition says this isn't the case.

Number one origin for immigrants in the US by far is Mexico, number two is India, followed by the Dominican Republic, Vietnam, Philippines, El Salvador, Brazil, Cuba, and South Korea.

I believe your intuition is bad. Mexico, India, the DR, El Salvador, and Brazil are notoriously low trust.

At least on this metric, all of the countries listed are rather lower trust than Switzerland itself, which has been gaining in trust over the past 30 years despite immigration from lower trust societies.

Italy, France, and the DR are similar trust societies. Same for Portugal and India, and El Salvador and Turkey. Albania is lower trust than any other country mentioned.

Italy and Germany (#1 and #2 for Switzerland) are significantly higher than Mexico and India (#1 and #2 for the US) by that metric. Though that metric may be suspect; it has China higher than Switzerland, and there's at least plenty of anecdote pointing towards China being low-trust. Perhaps they don't trust the surveyors.

They're mostly Germans and Italians with some Iberians thrown in.

I think honestly this isn’t a system we created and thus don’t “deserve”. The thing is that we’ve been taught to be cynical hyper-individualistic, hedonistic, lazy jerks. It comes from everywhere. You’ve been taught that your traditions are old and stodgy and nobody cares about them anymore. You’ve been taught that your ancestors were rotten, terrible people who genocide their way around the globe. You’ve been taught that striving is pointless and that the rich will keep you down. You’ve been taught to deconstruct everything, but never to construct.

There are lots of reasons for it. Some are hyper-consumption: if you lose access to a community in which someone can solve your problem for free, then you have to buy that service somewhere. You don’t know someone who can cook and you don’t know how to? Door Dash. Daycares are essentially replacements for extended family. It used to be that if both parents needed to work, grandparents were close by and retired and the kid could stay in a place where he’d be safe and with a loved one. Now you hire a company who pays strangers less than $20 an hour to do the same. Go down the list of home repairs, car repairs, lawn maintenance, and a lot of services replace community.

The other part is that traditional systems are terrible for governments who want to control their populations. A strong community doesn’t need or want much government interference. The Amish have their communities in pretty good order without too much need for the state to come in and control them. They don’t need welfare because they have their church to help those in need.

The final thing is the issue of legitimacy. Legitimacy comes from the people. But in order to get people to vote for whatever it is that you want, job one is to convince them to want it, or convince them that they’ve always wanted it, or that “good people” are like this. So people vote as they’ve been taught to do. You have to be taught to believe in an atomized society with no deep connections so that you’re more willing to accept the breakdowns, less willing to trust community.

Thank you. I... Guess I should say something else but actually I'm just thanking you because you voiced one of my frustrations eloquently. People making worse versions of things because the good version is patented, people creating deadweight loss to get rid of to reap the benefits... or inducing unnecessary paradigm shifts so that they can be at the top of the transition team...

I guess I really do believe that theres no actual way to create more value for people. The modern amish have everything they need really. What was the point of all this junk we made? The medicine is nice yes. The food. The energy. I don't mind the AIs, though people trying to sell them to us is just another example. Take away friends, replace with 20$/month subscription. The cars... seemed nice but slowly grow to disgust me as I see how the travel distances expand to match their speed, keeping me only farther from other people. The trinkets and stopwatches and beer umbrellas add spice... but it turns to ash in my mouth without someone to share them with.

I don’t think it’s the technology. It’s the mindset that comes through the media that’s teaching everyone to defect, that everything is rotten, and that you should focus on yourself and getting yours. And when 300 million of us get that from the firehouse of media, we act on it. And the results are pretty clear. When no one is trustworthy, and nothing is worth protecting, you get defections.

I think you’re assuming the conclusion. The economic forces which make babysitters and dishwashers ubiquitous wouldn’t disappear if we’d never started critiquing imperialism.

I also think your view of the past is rose-tinted as hell. 1700s America wasn’t an endless quilt of Amish communities, waiting to be tempted out of Eden. It was a hungry, dirty, disease-ridden frontier just starting to climb the curve of industrialization. Communities weren’t solving each others’ problems “for free.” They were paying their dues on their own social contract.

I’m not necessarily suggesting the Amish are perfect. I’m suggesting that we’ve kinda thrown out the baby with the bath water when we went full bore on the car and convenience society. And when we decided to destroy the myths of America and at least nominal Christianity as the default belief system. When tradition and community are uprooted in favor of door-dashing, you lose the personal connection to other people around you. When your neighbor fixes your car you end up bonding over it. You know him better, and it can lead to connections that don’t happen in transactional relationships. When you attend the local church with all of your neighbors and friends, you form connections and bonds and the kids play together and so on. When everyone around you believes in the same sort of things and wants to preserve the community, then you have more trust, especially if everyone knows each other and has a relationship that’s more than passing in the streets in individual cars on the way from one building to another. Walk down the streets of your own neighborhood, odds are that you couldn’t give the names of more than 10 people in your own neighborhood, and it’s highly likely that outside of that neighborhood, you see them often.

I think the social contract is exactly the problem. It’s the reason that high trust is actually possible, because people believe in that contract, try to live up to it, and know each other well enough to broadly enforce it. That’s how most high trust societies work. Asia, in general has Confucius and the ideals of social contract and familial relationships and reciprocal relationships as the core of their beliefs. Read the stuff. Confucius was all about the social contract, how you should relate to other people, how you obey your elders and serve your various roles in society. I’m convinced that while most other systems weren’t that explicit, they all had those kinds of ideas — you are not merely some atomized individual seeking autonomy and the best life and hedonistic pleasures. You are part of a community greater than yourself and have some duties to people and the broader institutions around you.

As I said above I don’t think any of this is down to technology. Asia has a lot of this and has more high tech than we do. Orthodox Jews form these kinds of high trust enclaves in New York City. It’s simply making the decision to follow traditional practices and to build community with people around you and sharing things and skills with those around you. To some extent, I think it might be helpful to get out of the mass and social media spheres or at least limit the kinds of media and social media you allow into a community like that. It’s not Amish, just being intentional about what is and isn’t allowed to be seen in your own home.

1700’s America was the wealthiest society on earth at the time; death by starvation was more or less unknown and nutrition standards were high by the standards of the day.

The colonies had a way higher standard of living than the old country.

Maddison gives US gdp/cap in 1700 as below world average (which seems a little low, I admit), only catching up to the UK around 200 years later. French peasants, who according to those numbers were richer than americans, were always one bad harvest away from starving during the 18th century.

This is yet another condemnation of GDP as a metric for prosperity, then. Whatever the numbers say, starvation was dramatically less common in the New World colonies than the old world. If an economist wants to quote numbers to me, that tells you what an economist is worth.

Because I'm a retarded autist with only one special interest I have to weigh in with relevant evidence. When daguerrreotypes became popular in the 1840s they were vastly more accessible in the USA than in any other country on Earth including their home of France. In the USA you routinely see occupational portraits of people of every social class and profession, carpenters, lamplighters, sailors, farriers, mill-girls, coopers, teamsters etc. In France and the UK (with every other country being negligible) you only see the upper classes, military officers and the like, you never see occupationals of random working class people. It is clear to me that already by 1840 the USA was VASTLY wealthier than every other country on Earth, at least when it came to the wealth of average people and even the lowest like night watchmen or lamplighters in the USA had more real purchasing power than most lawyers or doctors in France or Germany. Note, this only applies to the North in the USA, the South basically had daguerreotype production patterns that were closer to Continental Europe.

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What are you basing this on?

We've seen a remarkable, unprecedented increase in GDP per capita in the last 200 years. However, the GDP gains may overstate the actual gain in wealth. In 1800, someone would take part in fulfilling but unpaid labor such as child rearing or food preparation. This is not measured in GDP because no goods or services were exchanged. Nowadays, the equivalent person might use daycare and Door Dash while they pursue their higher paying job as a laptop worker for a big nonprofit. More GDP is being created by the commoditization of previously unpaid work even if no more value to society is being created.

So maybe GDP per capita has increased 5,000% but real wealth has only increased like 2,000% or something. We're vastly better off now than before, but imagine how much better things could be with stronger communities.

It's not about GDP. Individuals don't choose their career to please the Federal Reserve. So why are women--because men, naturally, aren't expected to do anything so fulfilling--choosing instead to sell their labor on the market?

As far as revealed preferences go, this one isn't particularly shocking. Since the dawn of civilization, the rich and powerful have been paying other people to deal with their kids. Technology has made that dubious ambition much more attainable.

So why are women [choosing to sell their labor on the market instead of child-rearing].

Bad equilibrium.

A lot of labor is people competing for zero sum positional goods. There are 10 houses with a view of the lake. If I have one, you CAN'T have one. So I work extra hours to get ahead in the rat race. So do you. We're all running as fast as we can to stay in the same place.

The career woman personally benefits from her big non-profit job, gaining high prestige and access to positional goods such as housing. But this is all zero sum.

Look to East Asia to see how negative this can be when taken to an extreme.

I think this is a large part of it. Scott even has an essay on this topic where he discusses reasons the Amish pay between a fifth and a tenth of what the rest of us pay for healthcare. A few of those reasons (the second, fourth, sixth and arguably the seventh too) basically come down to the Amish being honest and everyone else knowing they're honest.

Which makes me wonder how long until some asshole tiktok prank becomes smashing that button as many times a day as possible until gas stations across the country have to start locking them up. Which then leads to more avoidable accidents at gas stations.

By law, they can't lock them up. In a blue state we'll just get op-eds and politicos opining about how this is why we need to ban gasoline cars and go to all electric. There IS a solution to this particular class of problems, but it's banned. Basically the "railroad bull" solution -- swift and painful punishment for the assholes that do it.

I have lately wondered if what we're missing is a bunch of, I suppose, nuns with rulers or the equivalent to punish modest anti-social behavior (defecting, in this conversation) promptly with a transient painful stimulus that neither leaves lasting marks nor a permanent legal record.

But I don't think it would work in all cases, or maybe even at all. And it's almost certainly disallowed by the Constitution. And suffers from a lot of ambiguity as to where to draw the lines.

Yeah, the problem is "promptly". Nothing about the justice system is prompt, nor really can be; it can be faster, but not prompt enough for simple conditioning like I'm suggesting. That is, some fools start doing obviously stupid shit. Some of them are caught immediately by guards, who give them a thorough beating and are not punished. Word gets around. Trying to do this in a world where the guards can't be trusted either obviously has problems, and formalizing ways of verifying the guard's behavior will tend to make the system too slow.

A good chunk of our current society has made every effort to metaphorically disarm and discourage the previous set of 'nuns with rulers'. I don't see how trying to artificially implement them from the top down is going to do anything but make things worse.

Put bluntly, if you want a high-trust society, get more Daniel Perry's and stop punishing them when they actually step up and do things.

I have heard tourists (here n Japan) remark on how surprised they are that the iPhones in the shops are just sitting there for you to look at and aren't locked up. The reason is that if you steal one you'll be summarily caught and sent to jail. This seems like a blindingly obvious policy.

Having written that I admit sometimes the catching takes time. Last Saturday in Kyushu some asshole stabbed two teenagers in a McDonald's, killing the girl, and is still at large.

While there may be rule of law here, when it does go south there are very few Daniel Pennys.

Edit: Found him

Comparing two different nations with very different setups, society, and ethnic spread is always a bad comparison.

What works for one doesn't always work for another. I envy Japan on a level you cannot imagine for their train network, that doesn't mean I expect the same to be implemented in the US.

More Daniel Pennys or Kyle Rittenhouses can't magic up a high trust society. They're mainly useful in showing the insane behavior of agovernment that abdicated responsibility and then punished anyone that refused to be preyed on.

The government just has to do its job and enforce order. But apparently that's too much to ask for a variety of reasons.

More Daniel Pennys or Kyle Rittenhouses can't magic up a high trust society.

I disagree, the thing that makes a society "high trust" is the understanding that bad actors will not be tolerated.

The people of New York City have collectively chosen to tolerate bad actors and punish those who do not tolerate them. Thus the people of New York City have chosen to be a low trust society and the only way that will ever change is for people to choose differently.

And it's almost certainly disallowed by the Constitution.

There's nothing in the Constitution that bars corporal punishment. There's a prohibition on "cruel and unusual" punishment, but we know this doesn't mean all corporal punishment, because it was widely practiced at the time and not ended until long after the ratification of the Bill of Rights.

Certainly it's plausible that a Supreme Court containing at least five left-leaning Justices who take a somewhat cavalier attitude towards their oath to uphold the Constitution might rule that the Eighth Amendment bans corporal punishment, but that would be them, not the Constitution.

Here's a two minute video explaining PBMs in a humorous fashion by a Doctor/Comedian influencer.

https://youtube.com/watch?v=_khH6pZnHCM

TLDW: United IS its own PBM.

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