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Notes -
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?
I've seen a lot of strong factual repudiations of how misguided Mangione was because he didn't seem to understand how insurance works. I agree with that in principle, but there's a risk of missing the big picture when crafting too technical of a response. 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. It makes people feel powerless and angry and confused about why a better system cannot exist.
It used to be that people would curse God when they were struck down by fate, now they curse insurance companies.
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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.
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.
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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.
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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.
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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 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.
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.
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?
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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.
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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.
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.
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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.
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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.
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.
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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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