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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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