"Big Pharma" in the eyes of the public is two related but separate issues; 1) the weird employment-insurance-hospital loop that has developed in the US, and the terrible second-order-consequences of all the open-high/settle-low insurer<->carer system it led to, and 2) the medicine advertisements, and all the terrible consequences thereof.
The second one seems like a much easier thing to get rid of using hard government power, and should be the low-hanging fruit.
The first will require a decade of masterful leadership, co-operation from competing interests, and delicate undoing over time that I don't think any country in the west has right now.
I think it's fair to characerize this as a symptom of the emplyment/insurance/hospital loop outlined in issue #1 of the original comment.
That relationship between those three parties is the root cause of the messed up incentive model responsible for the ridiculously high costs of all products/services in US healthcare; pharma included.
The true root cause of high pharmaceutical costs in the United States is our competition crushing patent system. If we eliminate patents, we open up the market completely to competition. More competition will bring extremely low prices. Innovation will not be harmed as most innovation is done in universities and is government funded, in the private innovation will happen anyways as the first mover advantage in these markets is huge.
it’s been a long while but i remember it takes ~15 years and 500 million to push a major drug through fda testing. The argument was who would do that if a competitor could just copy it at the end? has that situation changed? What other changes would need to be included with removing patents to alleviate that issue. genuine question, even 10 or more years since i read up on this.
Do we really need the FDA? What if we created a agency that simply does independent testing but leaves it up to the consumer to make their own choices?
This one is particularly prickly because the high cost paid in the US funds medical R&D and extremely expensive clinical trials which other countries are free riding on by imposing price controls. We still need to fund the R&D and clinical trials (unless they could be made less expensive somehow), so the most obvious solution would be to have other countries pay their fair share so the US could stop subsidizing everybody else. But that's hard to get.
Europe does drug R&D and still manages to sell their drugs at a reasonable price to sick people (generally because their governments utilize their buying power for the good of their citizens).
It seems to me that US people have been sold FUD by there own pharma companies, if I’m honest.
> Europe does drug R&D and still manages to sell their drugs at a reasonable price to sick people
Most novel R&D, in America and Europe, happens in biotech. (“Big” pharma does trials, manufacturing scaling and distribution.) The investment thesis for most of this research does not work without the American market.
This doesn’t mean high drug prices are a necessity. Just that the funding needs to be replaced if we want to preserve innovation.
But to be fair, the US pharma sector spends roughly as much on marketing as it does on R&D. And a huge chunk of that R&D budget goes into analogue drugs to either sidestep patents from rivals or maintain profit margins when their own patents expire (they can then use that huge marketing budget to get the newly patented drug to take over for the old one with the nearly-expired patent, despite small or non-existent benefits from a medical perspective). So long story short, there's a pretty good case to be made that public research with somewhere between 1/10th and 1/5th the budget of big pharma is all it takes to match or overtake them in innovation, as measured by actual benefit to the patients.
> But to be fair, the US pharma sector spends roughly as much on marketing as it does on R&D.
Spending money on marketing lowers prices by increasing volumes.
If you spend a billion dollars on R&D and then spend nothing on marketing and sell to 200,000 customers, they would each have to pay $5000 to fund the R&D. If you spend a billion dollars on R&D and two billion dollars on marketing and sell to a million customers, they would each have to pay $3000 to fund both the R&D and the marketing.
And it also does something useful, assuming the new drug is actually beneficial, by making people aware of the existence of something that would make their lives better. It helps no one to invent a great new thing that then nobody uses because nobody knows it exists.
> And a huge chunk of that R&D budget goes into analogue drugs to either sidestep patents from rivals or maintain profit margins when their own patents expire (they can then use that huge marketing budget to get the newly patented drug to take over for the old one with the nearly-expired patent, despite small or non-existent benefits from a medical perspective).
It doesn't actually cost that much to do that because you already know what you're looking for in that case. It's the real R&D that costs money.
> So long story short, there's a pretty good case to be made that public research with somewhere between 1/10th and 1/5th the budget of big pharma is all it takes to match or overtake them in innovation, as measured by actual benefit to the patients.
The biggest problem with public research funding is how to allocate it.
With a profit motive and market competition, the people who allocate research funding inefficiently go out of business and the people who allocate it well make a lot of money, and then have more money to fund more research.
Without that, research funding turns into defense contracting and then we waste trillions of dollars and have nothing to show for it. Or worse, politicians say we'll only need 1/10th of the budget even though the incentives aren't actually there to improve efficiency, and then we get 1/10th of the research.
> Spending money on marketing lowers prices by increasing volumes.
That explains why they do it, but not why it's useful to the public. Marketing isn't necessarily a zero sum game, but it in the case of direct-to-consumer drug advertisments, it's pretty close.
> Spending money on marketing lowers prices by increasing volumes.
Do you have any proof of this - had you said it increases profits - I'd have readily agreed with you.
> If you spend a billion dollars on R&D and then spend nothing on marketing and sell to 200,000 customers, they would each have to pay $5000 to fund the R&D. If you spend a billion dollars on R&D and two billion dollars on marketing and sell to a million customers, they would each have to pay $3000 to fund both the R&D and the marketing.
Or, in line with their "fiduciary duty to shareholders", the company still sells at $5000 to a million customers: see Martin Shkreli, Epipens, or dozens of other real-life examples that prove your lower-price hypothesis wrong. Without competition, drug manufacturers have no incentive to lower prices when they can make more profits instead.
Spending money on marketing MIGHT lower prices when looking at a single company.
For a market like pharmaceuticals where patients are prescribed by Dr's and are going to be subscribed one thing or another regardless, the lack of any marketing wouldn't really reduce the amount of volume in the industry as a whole, might just switch around which drugs/companies it goes to.
That's fair enough, maybe Europeans should pay more than they do for pharmaceuticals and get away with paying less due to the huge profits Pharma makes out of the US health care system.
That's not really on Europe though. It's for the US to sort out it's horrifically dysfunctional health care system, if it chooses to. Honestly I don't know if what Biden plans to do, particularly in relation to Big Pharma is reasonable. I suspect it's likely to be treating the symptoms with regulation rather than the disease through reform, but maybe that's what you do when treating the disease runs into insurmountable political resistance.
MY understanding (at least in the UK) was that hospitals and universities also do a lot of research (often cutting-edge), and are often the source of innovation. These entities are largely publicly funded.
Most drugs appear first in publicly-funded research, but so does every other compound that can get past a p value of 0.05.
The main value proposition of big pharma is that they take those results, find the ones that actually work (very few of them do), study them for side effects, and characterize them. There is a LOT of work between the published research and an actual drug (there is actually significantly more risk and cost to go from a paper to a drug than to write the initial paper).
Do you have a source for that? It's kinda hard to believe that America happily is paying the research for the world for so long without trump (or anyone) making a huge deal out of it.
China, and Russia, and other countries, are making big breakthroughs in biotech, but we are hesitant on believing their results--now.
They have the advantage of pushing through Clinical trials without much oversight.
I am all for strict Clinical trial protocols, but our biotech companies are testing their drugs in countries that don't have strict protocols on safety.
I don't get the price increase argument anymore. The biotech companies are multinational. It's just Americans give them the most money.
I'm getting afraid of the whole, "American biotech will cure anything because of the financial perks they get" mantra too.
I pay out of pocket for my needs at Costco. Their prices are a bit above wholesale. That said, I pay way to much for certain drugs. I guarantee their are shinagigans going on in the pricing if certain drugs.
Bupenorpine us a generic drug. Why gave I been paying $70 for a decade?
(This drug is America's answer to the opioid crisis. I was prescribed this drug off label for another condition. It's the price that has me scratching my head. It's been the same price for too long. Other pharmacy's price it higher.)
I won't get started on the drugs (new--not genetic) prescribed for depression. And then reading Irving Kirsch's research. His paper can be found, but you need to hunt for it. I'll offer this interview.
I am proud of Biden's promise to lower prices. I am so glad he's at the helm. I'm not being overly political. I just am just at bit hopeful now. Something I haven't been in 4 plus years.
> They have the advantage of pushing through Clinical trials without much oversight.
This isn't an advantage. What you end up with is a lack of clarity on what works well, what doesn't, and why. It makes it easy to go from A to B, a hypothesis to a drug, but it clouds what C, D, and E should be, as that lack of oversight turns into a lack of deeper insight.
To get approval in US and Europe, the trials need to be of the same quality no matter where they are run. Sometimes it may be cheaper in poorer countries because you don't have to pay your volunteers as much. You still need to check all the appropriate boxes regarding informed consent as anywhere else. And, of course, western companies are entirely capable to run trials anywhere in the world. The COVID vaccine trials were run in Europe, the US, South Africa, Israel, and really any place where the incidence was high enough.
And China and Russia are not "making big breakthroughs": just look at the vaccines again: BioNTech/Moderna/J&J/AZ all work extremely well, all things considered. The Russian and Chinese vaccines don't. Just ask/look at the charts of Chile. Or any Russian.
Am Russian, am vaccinated with Sputnik V, would do it again. Yes, the study was rushed and details were missing, but, eventually, all things got in order.
And it's a real working vaccine, effects of which I see basically every day on my friends.
Yes: unless a vaccine is harmful, it’s better to have than not. Higher effectiveness is better, of course, but if there was ever a time to say “don’t let perfect be the enemy of good”, it’s during a raging pandemic.
It is better than nothing. But it’s a far cry from the best vaccines (Pfizer, Moderna, and to a lesser degree, AstraZeneca), which protect against novel variants and can produce some level of herd immunity.
In the context of this discussion, ‘Europe’ doesn’t do ‘R&D’.
Biotech/Pharma are international. Irrespective of the home location of the organisation, virtually every drug trial from phase I onwards will be run in multiple countries. Further, virtually every drug found to work and filed with regulators for a license, will be filed internationally: Europe (EMA), US (FDA), and a whole host of smaller independent country regulators: Japan, Australia, Switzerland, etc.
So within the overall business model of a given company, there’s no link between the countries in which research is performed, and the prices ultimately set in those countries.
Drugs are more expensive in the US simply because there aren’t any pricing controls (beyond maybe some bargaining by providers; I can only assume this is because of the power of lobbying over the political process in the US). Drugs are cheaper where there’s an established process for determining or controlling prices.
> Drugs are more expensive in the US simply because there aren’t any pricing controls...
There aren't any other markets where "pricing controls" are needed. Drugs are more expensive in the US simply because it is illegal for a 3rd party to sell them.
If it were legal, anyone could buy the drugs where they are cheapest and ship them to America. The problem is obviously that competition is banned. If that isn't the problem, the entire population of the world is remarkably indifferent to a really easy opportunity to make lots of money.
And, I suppose almost to obviously to add, if competition is illegal then prices go up.
When I used the term ‘pricing control’, I was referring to the systems that some countries (eg UK, Germany) have in place for determining the price they’ll pay for a drug based on (roughly) the value it brings to patients. (The best known of these is probably NICE in the UK; it’s not a perfect system, but it’s a pretty good attempt.) Other countries in turn ‘reference’ their price from a number of similar countries including those with formal processes.
Broadly, this is why drug prices are controlled and lower in Europe vs. the US.
In the US, even where there are competing drugs in the same disease, there’s no pressure on prices - manufacturers can just keep on racking up their prices almost without a concern.
> In the context of this discussion, ‘Europe’ doesn’t do ‘R&D’.
Ever wonder why it’s the Pfizer-BioNTech vaccine? It’s because the simple nationalist narrative you’re repeating is misrepresenting a far more complicated international research story.
I'm sure they benefit from public research, lost of industries do, but even public Universities are perfectly capable of patenting their discoveries and getting paid by companies using them. Ours here in the UK certainly do this.
Patents are an attempt to protect risk. If you're getting my money to invest without any risk to yourself, you don't deserve a patent.
Here's an easy solution:
Patent and copyright times are limited proportionally by the percentage of government money invested and at the end of that time, the research must be made publicly available.
In 2018, the average insulin price in the US was $98.70, compared to $6.94 in Australia, $12.00 in Canada, and $7.52 in the UK. This is a 100 year old drug.
The price of insulin specifically is largely a consequence of perverse regulatory incentives, particularly the Obamacare-related expansion of the 340B Drug Pricing Program and its mandatory, byzantine, opaque rebate structures. Don't think it's just the manufacturers who are at the center of this price gouging, not by a long shot; hospitals and pharmacies are all too happy to ride that gravy train.
It isn't a 100 year old drug. There are newer formulations that are faster acting, longer lasting, easier to administer, etc. They're newer so they're still under patent so they're a lot more expensive (because the rest of the world makes the US pay to develop the newer formulations). When insurance is paying for it, people prefer the newer formulations.
Then, since most people have insurance, there wasn't enough of a market for the older formulations for anybody to bother making them for the margins you get for making a generic. So the prices were high for people paying out of pocket.
Anyone making the decade-old version of insulin and selling it for 1% of the price would corner a large portion of the market immediately. Anyone without good health insurance, which is a large and increasing part of the population, would immediately jump on the lower priced version.
And since when are insurance companies excited to pay for the more expensive drug with limited extra utility anyway?
You are giving far too much credit to what is on the face of it a broken system.
^ Exactly this. They can sell the premium version for however much they choose to, but the cheaper one - the affordable, the one that should be given out for free - is simply not available enough, it's being suppressed by the pharma industry in favor of their own premium, expensive product.
I mean what are people else going to do, die? Oh wait.
I don't understand commenters in this thread coming out in defense of pharmacy companies using their monopoly or influence to deny health care to people that need it. It should be considered a criminal offense. It's anti-competitive. I mean with insulin it's a massive hole in the market - why hasn't anyone else been able to jump into that gap and make a killing?
Since this month - and it is headline news all over the country... It shouldn't be extraordinary that cheap drugs needed by millions are available cheaply. (See also: Epi Pens.)
> Anyone without good health insurance, which is a large and increasing part of the population, would immediately jump on the lower priced version.
Medicine isn't like a supermarket, people usually just take what their doctor/hospital prescribes. In addition, I think it's likely that those with no/worse health insurance are on average less informed.
I often talk about costs with doctors. Sometimes they offer things my health care does not (fully) cover, sometimes it's about pure luxury (like a arm bandage that is super nice to wear). Or my dentist, I can choose between different pain killers, one of them costs a little extra but goes away way faster.
I would think it's weird if my doc assumes I just want the cheapest available option.
We saw something similar happen during the pandemic. There has to be infrastructure and people with the skill and knowledge to support an industry available, and even if you had those people available you can't just ramp up production in any old place. That's why there were supply chain problems and will continue to be, the UK won't be making its own drugs (designing, yes, making, no) just because it did in the past, the US won't be making computer chips just because it did in the past. There being a profit to be made isn't enough.
> You are giving far too much credit to what is on the face of it a broken system.
The system may be broken but fixing it takes more than a wave of the hand.
That was true at one point, but the newer formulations of insulin are old enough to mostly have biosimilars, aka follow-ons, the equivalent of generics for drugs produced by bioengineering. Humalog/Lispro/Admelog, Lantus/Basaglar and others, in many cases made by the same company as the original.
The prices of insulin have been increased steadily each year by about 11% for the past 20 years. There's nothing about research or costs that justify that for 20 year old drugs.
The old formulations (Human insulin, NPH) can be purchased without a prescription at Walmart for fairly low prices - the price that people pay for modern insulin in the rest of the world.
> Then, since most people have insurance, there wasn't enough of a market for the older formulations for anybody to bother making them for the margins you get for making a generic.
Is there some research confirming that? It doesn't quite match my out-of-us experience with other drugs. I get a choice of 2-3 brands of ibuprofen and another 1-2 generics for it. Why wouldn't the same apply to insulin? I expect that it's also not 100% covered? (please correct me here)
You can buy the original insulins from 80 years ago for $35-50. Those are human/porcine insulin and one called NPH that has an intermediate duration. Some people who used those before the newer long/short/rapid actings were developed still prefer them, and others use them for cost reasons esp. because they can be obtained in the US without a prescription. I only know of one brand, Humulin by Lilly.
For modern insulin, they were indeed patented but mostly generics called follow-ons or biosimilars are available. Lantus has an alternative Basaglar that costs about 1/3 as a much. Humalog can be replaced with Admelog. The manufacturer of Novolog makes a biosimilar of their own insulin and sells it for 1/3 as much, if that makes any sense.
The various types differ a bit... Lantus has a slower absorption and thus longer duration than it's main competitor, Levemir. Novolog differs from Humalog in one protein on one side of the chain or something. Some people can't use one or the other due to allergies to the excipients or unexplained resistance to the effects.
The often quoted prices do not take into account the actual price paid by consumers, the type of insulin being compared, or relative purchasing power of the countries. I don't actually know how if insulin is actually all that much more expensive across the world when taking those factors into account. Seems like cherry picking without controlling for all of those factors
I encourage you to look up evergreening. Pharmaceuticals are playing every (legal and illegal) trick to extend patent protection. The purpose of the new formulations is often only to extend patent protection. Together with extensive advertisement campaigns to get doctors to use the new formula not all.
If it costs a billion dollars to develop a drug and pharma spends 6.5 billion on ads, that would mean an implausibly small number of drugs being developed, no?
I don't see any reason to believe that pharma spends more on ads than R&D. Do you?
The fact that you just reposted your above comment without any change despite knowing it was wrong and despite being called out on that. That seems like a strong point in favor of the opposite of whatever your position is.
It could easily be the case that without the advertising spend they would not be profitable. Do you think these publicly traded companies are wasting tons of money on advertising? Where is the shareholder outrage?
I worked in pharma advertising for a little bit: There are two sides, consumer and clinical which I believe are about equal spends (might be wrong, but it's significant anyway). Clinical advertising is mostly used to recruit doctors to recruit patients to take part in clinicial trials, and is a necessary component of R&D. Think lots of tradeshows with fancy signage, interactive touchscreens, apps, etc.
Isn't part of the problem that the US/FDA trial and certification process is designed to be very expensive? And who benefits from a moat created by high cost of R&D if not big pharma? I seriously doubt that pharma lobby would be thrilled if costs of bringing new drugs to market suddenly fell by several orders of magnitude, so it's not going to happen.
You're putting the cart before the horse here. The reason why the other developed nations get cheaper access to to medicine is because of collective bargaining from more organized insurance schemes (e.g. single payer), or because of price capping by governments. Not 'because' the US subsidizes R&D through high prices. The US pays high prices because it chooses as system in which that's acceptable, and the pharmaceutical companies design their own pricing around it.
If the US stopped the madness, the companies would rebalance their pricing systems. If what you say is true, maybe every other developed nation would have to pay more.
I'm skeptical of this entire theory, however. It's not like major pharmaceutical companies just barely breaking even, and are selling their products at a loss in Europe. There is a lot of room for profit margins to be squeezed.
There is a reason Americans are willing to pay more for the system we have now, though it's not the one you mentioned. The U.S. health system is considered willing to go farther in treatment than socialized systems are. For example, say, giving 10 patients MRIs to detect one disease. If you're that 10th person, it worked out well for you, and if you're one of the other nine, you just had to pay more.
Anecdotally, a co-worker told me he had moved here from Canada so he could bring his father here to be treated for some form of cancer. He was not going to get that particular treatment in Canada, no matter what he was willing to pay. I am in no way saying that this treatment was necessary or helpful, though it might have been. But my friend perceived that he had more options for treatment here.
Second anecdote, a friend died of pancreatic cancer last year. Her doctor told here it was inoperable, and she had 8 months to live. She went to two other doctors and found one who was willing to put her through intensive chemo; she wanted to fight it. She still only lived 8 months.
In another country, she would not have that option, and maybe she shouldn't have had, because it was very expensive and it had less than zero benefit.
People can get more treatment options here, at a higher cost, for better or worse.
Idk why any politicians arent picking up on foreign price controls as a means of lowering costs in the US. It should be a part of the discussion during any trade talks with Europe.
The problem is chemistry isn’t that different from software. Once you publish the idea it isn’t too difficult to derive the chemical composition. Replication is the easy part. Design and testing cost money.
So in essence we’d have to design drugs and not publish the chemistry which would be uncovered soon enough anyways. This leads to a situation where investment dollars go into other things and human health suffers, especially with so-called rare diseases.
Not to mention the USA loses hegemony. The USA provides Europe with a great deal of military technology and protection as well as medicine but it isn’t for free. The EU exchanges agency in many ways important strategically to American interests. It’s mainly a fair deal.
What you're literally saying is: instead of ending predatory pricing, enforce it for the rest of the world.
Here's a novel idea: cut military spending in half, and you can provide all the free medicine to all Americans for the rest of their lives. All the while making the world a safer place.
> Defense spending amounted to $714 billion in FY 2020—and is expected to increase to $733 billion in FY 2021.
A soldier whose leg was blown up in Afghanistan and is still in a hospital - is not part of that $714-733 billion. So the US military budget is only that low if your definition of "defense" spending does not cover that.
The reality is the US spends over one trillion a year in military spending.
Your own link says as much. It puts "Veteran's medical care" under the health care entitlement side of the equation, as opposed to the military spending side of the equation.
> A soldier whose leg was blown up in Afghanistan and is still in a hospital - is not part of that $714-733 billion.
Where are you getting that? From here https://fas.org/sgp/crs/natsec/IF11442.pdf and the link in the comment you responded to it seems that it is only about 80 billion.
Even if you add that to the 700 billion figure for the military, and add 200 billion for the entire VA, Medicare and Medicade alone account for well over a trillion dollars, and that’s not even the majority of healthcare expenses in the US.
>A soldier whose leg was blown up in Afghanistan and is still in a hospital - is not part of that $714-733 billion.
first off I thought it was clear from my comment that I had not believed the original comment that healthcare was greater than defense spending, but some initial investigation seems to confirm it.
The reason that I had not believed it was that I thought there was an ideological axe to grind behind the statement, so I was surprised.
It seems to me that you maybe are thinking the same thing about me, that is to say I have an ideological axe to grind proving that U.S defense spending is not that high. If so a quick examination of my posting history and the posts here should dissuade you of this.
As far as your argument - I agree the medical costs of the soldier still in the hospital should probably be counted in defense costs somehow but not sure how you would do it as I do not believe a veteran out in the job market working 9-5 and going to the VA for some medical costs should be counted as defense spending. Thus I don't think it is possible to just move all the costs of the VA over and get any fairer an accounting than one has now.
although I guess it is true the U.S could cut defense spending less than in half and pay 234 billion for everyone, so the original comment isn't totally off.
> and most of that is on privately insurers overhead.
It’s true that the plurality of healthcare costs are private insurance, but medicare and medicade combine to a little less than twice the entire defense budget.
I always assumed a fairly significant chunk of that research is to find minor modifications to existing drugs in order to maintain patents that are about to expire. It certainly feels like that happens a lot.
I wonder why we don't fund drug development directly, using tax money and then let companies produce the drugs for a reasonable fee. I feel like drug development shouldn't be prioritized by the estimated amount of profit one can get from the drug.
Is there reason to think that government bureaucrats would do a better job at efficient resource allocation? I expect they would channel funding based on politics with little regard for outcomes.
Is there a reason to think that government bureaucrats would do a worse job? I mean, generally I trust the government to run things like building roads, or taking care of security and education reasonably well. At least as well as a private organization would.
"Efficient" resource allocation strongly depends on your performance measure. I don't think that "maximize shareholder value" is necessarily the best measure to use for healthcare.
> This one is particularly prickly because the high cost paid in the US funds medical R&D
Most of those money goes on marketing.
Moreover, I think that US citizens did not signed up to pay medical R&D for whole world while they are sick. In fact, US citizens tend to have issues with paying researcher, social support and so on from their money.
R&D paid from taxes or insurance makes way more sense then paid by those who already deal with health crisis.
That does not compute though. If prices are lowered, sales volumes will go up because people (and insurance companies) can afford it. I'm no economic, but we've seen time and time again that lowering prices boosts volume sold to the point where eventual profit is much higher.
I mean the government can pitch in via subsidies for medicine R&D if it's really necessary, but honestly the pharma companies are swimming in money, they can afford to funnel money into R&D and pay their taxes instead of pushing it upwards to shareholders and foreign bank accounts.
> I'm no economic, but we've seen time and time again that lowering prices boosts volume sold to the point where eventual profit is much higher.
The current system has whoever can afford it pay the high price, whoever can afford less pay a lower price, and whoever can’t pay anything doesn’t pay anything.
Lowering drug costs won’t change the number of people taking drugs. That already based on need. All that changes is the amount of total profits.
The only politically and morally acceptable answer for this is to raise the price of drug costs globally to soften the change in profits.
Amusingly I would have expected the opposite in terms of what people find acceptable. Trying to charge say $200 for HIV medication to subsistence farmers in Sudan would be viewed as unconscionable.
In a period of unemployment I found that my medications basically operated on the afford less lower price - they gave coupons usable without insurance to far more reasonable prices. I can see clear brand promption and price discrimination here - they don't want to surrender market mindshare and brand name recognition by giving up the low end or their margins by cutting the cost across the board. So they give discounts that usually only the low end could or would take. Ironically such slightly sleazy behavior fits with one hypocratic oath vow to only charge what was within their ability to pay.
Or course "globally" probably means more charge other first world nations so it would be more "splitting the check among coworkers" than "demand the penniless man in the breadline pay a dollar". Still a position I expect to be US popular only.
As far as I can tell drug prices are driven by mainly one thing, realpolitik. Hepatitis C cures are targetted based upon organ transplant costs because that is the only alternative so it still helps but they make huge profits as say $75k drug treatments are still a big improvement over $150k of transplant costs. Unified blocs can twist arms to a certain degree, tiny blocs pay more for reasons beyond just spikey risk pools and meta-insurance, and companies will accept lower profits from some sales if it helps maintain higher profit sales.
That is a common talking point, but I don't know of any data actually backing that up.
It just sounds nice like "they hate freedom". No, nobody does, try again.
I've heard of this argument before but I think it really needs some evidence. Is there a study that corroborates this claim?
Even if the US really "subsidizes" medicine for the rest of the world, what motives do pharmas have to sell medicine at lower-than-production/R&D-cost to the rest of the world? Couldn't they just sell to the US exclusively, let the rest of the world rot, and then sit on a bigger pile of cash as a result?
I was under the impression a large amount of medical R&D is paid for by taxes and done by university students. We pay for it and private industry benefits.
I’ve been a fan of increasing tax credits for medical R&D in exchange for price limits along, or simply, with a limit on the ratio a drug can be sold domestically versus overseas.
> This one is particularly prickly because the high cost paid in the US funds medical R&D and extremely expensive clinical trials
This is what pharma wants you to believe because it's a positive spin on their pricing. I suggest watching Rep. Porter grilling these pharma CEOs if you want to understand the true costs:
For vaccines, most major countries want trials repeated with their local population before approving them.
Ironically, in the US, many/most(?) core-science phds and post-docs are immigrants who are used as "cheap labor". For double irony, they're often from countries that have price controls on pharma/biotech products.
If American drug makers fired all the young ladies whose job is to bring coffee and donuts to your internist's office, and they stopped sending your internist away for golf weekends to learn more about why they should be prescribing Rosuvamax instead of Crestulon, I think they could probably bring costs in line with those in other countries...
And the Congress mandated monopoly on residency positions and building new hospitals. We would have a lot more advances in medical science if MD positions were not gate kept by the artificially limited residency positions.
Agreed! Also if residents worked regular hours like normal people instead of going after the cokehead who came up with the whole residency process. This isn't the military there's no reason for that sort of environment.
I highly doubt that even without government intervention prices would be lower.
Healthcare is not a free market and yet Americans still try to pretend it's one. The information asymmetry is huge and nobody's going to negotiate/look around for anything when they think they're close to their deathbed.
Health care was a free market until the following events:
1. requirement for government licenses for doctors, which was done to drive Jewish and Black doctors out of business, and to restrict the supply of doctors
2. the advent of employer-provided health care during WW2, which due to tax policy married health care coverage to one's job
3. the 1962 FDA amendments which required efficacy for drug approval (not just safety) leading to a tripling of drug costs and a corresponding drop in new drug development
4. the introduction of Medicare/Medicaid in 1968
5. ever more regulation and interference in the market, like requirements the emergency rooms treat for free
Regardless of whether one thinks these are good things or not, they detract from health care being a free market.
> I highly doubt that even without government intervention prices would be lower.
Without government intervention , Amazon Basics would assuredly make dirt cheap versions of every major drug.
You can argue that this is bad for other reasons, but theres zero doubt that drugs would be cheap as water without government intervention (including IP protection and FDA mandated trials).
"Cheaper but people die due to lead poisoning" (replace "lead" with your favorite toxic chemical) does not count as cheaper, for medicine. It needs to be cheaper and trustworthy. The Iron Line of medicine, I guess.
vitamins are pretty much unregulated for decades, but doesn't have this lead or toxic chemical problem. Why do you feel so strongly this would happen in medicine?
Do you really think companies (who spend a lot of capital building a business) will knowingly waste it all away by selling medicine that poisons people?
> vitamins are pretty much unregulated for decades, but doesn't have this lead or toxic chemical problem.
Check out John Oliver and see how many problems we're having due to unregulated vitamins.
Also vitamins are used by a ton fewer people than medicine, and for purposes far, far less risky than medicine.
> Why do you feel so strongly this would happen in medicine?
Because it would happen for sure without regulation. Maybe not to the degree I pointed out, but if they wouldn't be forced to go through all those clinical trials, etc., I'm 99% sure that bean counters in a company would decide: "you know, maybe we could reduce the dosage of that super expensive ingredient by 10%, the side effects will only be known after 10 years and we're here only until we cash in our checks in 2 quarters".
> Do you really think companies (who spend a lot of capital building a business) will knowingly waste it all away by selling medicine that poisons people?
There are companies that periodically change their name to "cleanse" their image. Telecom companies, for example. Plus, they'd only have to persuade doctors, not regular people. Regular people don't really know who makes their specific medicine anyway (don't believe me, go ask your grandpa who makes each of his 10 drugs he's taking).
> vitamins are used by a ton fewer people than medicine
Really? Every supermarket has plenty of them for sale. The local drug store has whole aisles devoted to them. They don't stock items that don't move.
> Because it would happen for sure without regulation.
Poisoning people is not something allowed by the free market, any more than hitting people with a baseball bat is. Free markets require government to proscribe fraud and abusing peoples' rights.
> Regular people don't really know who makes their specific medicine anyway
They do when it turns out to be a problem, like the Tylenol murders.
The rise in health care prices at a faster rate than inflation started in 1968, coincidentally with the arrival of Medicare/Medicaid (an attempt to reduce costs).
What are you saying was the cause though? And either way, people still got healthcare and negotiated payments thinking they were close to their deathbeds prior to that era of increase.
Also 1986 was the emergency room mandate, which used Medicare payments as leverage. And of course the obesity epidemic and the low-fat diet (blaming fat for heart disease) started around then. The ACA started in 2010 but phased in over four years.
The government's 1940s intervention that ensured white collar professionals would be removed from the problems for 60yr is generally considered the root cause of the current healthcare debacle. Without it we'd likely have a system that's more akin to what's the norm internationally.
What the public does not see is how the patent system is gamed by generic sellers. How this works is not something that can be easily explained in a single paragraph.
The problem is specifically mentioned in the Fact Sheet/Order. This is a legitimate antitrust issue but it is exceedingly difficult to succeed in the courts.
Another line of research would be PBMs (Pharmacy Benefit Managers). These are another primary means through which drug prices are manipulated by Big Pharma, away from public scrutiny. Some Big Pharma companies have actually formed their own PBMs to provide better secrecy.
Understanding what's really going on, i.e., exactly how it works, would require reading and understanding a significant amount of case law or working for Big Pharma. Note that understanding how it all works will not necessarily lead to change, unfortunately. PhRMA does a reliable job of making sure things stay the same year after year. These problems with gaming Hatch-Waxman have been around since the 90's. IMO, Big Pharma's lobbyists are far more skilled than Big Tech's lobbysists. Time will tell.
There is no single factor that is wholly responsible for higher drug prices. It is many factors. This is probably why it is such a difficult problem to solve.
Here is one example of one Hatch-Waxman "loophole." This is the one with antitrust issues that I had in mind when making that comment.
These are all mostly non-issues outside of the US where virtually all countries have implemented some form of universal healthcare. The US is really unique in this respect, being so affluent and having an almost unbridled capitalism with a huge influence on politics.
It's always strange to me to read discussions about healthcare on somewhat 'global' forums like this, because this is a US specific issue. It's healthcare system is such a deviation from what is the norm globally.
There is, of course, 'Big Pharma' everywhere. However I think in the eyes of non-US public it's rather about large corporations wielding a disproportionate power. A power that is incentivized by profit motivates which don't necessarily align with the public health interest.
Some people do though. Imagine someone who just lets this stuff lapse and they are still being regularly prescribed stuff that should have been cancelled 8 years ago.
Just like how we require people to check in with their accountant every 6 months to make sure their finances are doing well, check in with a teacher and take a test every year to make sure our education is still up to date, and we have the cops investigate us biannually to catch any signs of legal trouble early.
We don't and we shouldn't require everyone to be nannied just because some people might benefit - they can seek those services on their own if they wish. Requiring someone else's permission to maintain your personal health would be considered just as absurd if it weren't the status quo.
Please, sign a notarized document saying you, your family or the DA won't sue because you were (a) lost to follow-up, (b) developed a medical condition as you grew older, (c) got a side effect because of long term medical use.
Then, don't waste ER time if you have a stroke or heart attack because government can't tell me not to eat trans fats.
And, by the way, if you have an accountant, you should check in more than once a year. It's not fair to them to dump stuff only during tax time. Also, I do have to do regular tests to make sure my medical knowledge is up to date.
If we could sue hospitals into paying out because we developed medical conditions as we aged, there wouldn't be any hospitals.
You have to qualify your statement with "if you have an accountant" because I don't have to have an accountant, it is an optional service I can seek if I want. In my case, I do my own taxes, and if I don't get as big a tax return as I could've back, it hurts nobody but me.
The requirement for you to do regular tasks for the privilege of practicing your profession is forced upon you because the the consequences of any lapse in your knowledge are borne by others, not you. I too have professional requirements, but I can choose a different profession and be absolved of all of them.
A chronic condition is not a choice. Dealing with your pain is not a privilege, it is a right. The idea that people should be forced to forego their right based on the idea that some others will benefit (a dubious claim for which I can find no evidence supporting) is absurd.
Thanks for your response. I think I was unfairly attacking you after a rough day. I'll just say that preventative care is very important and you have a right to receive the proper medication.
I think the idea is that the doctor is actively intervening in your medical treatment, so they have a responsibility to make sure they're getting it right. This person is free to stop taking their meds and die alone whenever they like.
Visits to the doctor should be cheaper and more efficient, but people shouldn't stop going to the doctor.
I find it fascinating that the HN crowd complains about doctors being too expensive. I mean what is the comparative value that software developers add to society compared to doctors that justify their salaries (which are often on the same level or higher)?
False equivalence. Software developers "charge" companies (that are very much able to pay) for their services. Doctors charge everyone, from the rich to the poor, for their services. The poor (and even not-so-poor) get screwed by this, more often than not. I haven't heard of a bunch of software developers bankrupting people in exchange for their health...
Why is it always "doctors" and not "administrators" in these threads on HN? They don't set the price of the drug. They don't set the price of an ER visit. If their hourly rate seems high, have you seen the hourly rate of a plumber who absolutely did not go to school for ten years?
That's not a normal range for most of the country doing SWE. If you know where to get that type of job let me know. I've done blind, sent out tons of applications, whatever. Hurts to know I'm potentially screwing myself out of tens of thousands of dollars, but nobody is contacting me back.
My professional contacts have told me I'm doing senior level work but nobody will respond even for positions below that.
Yeah, I've seen it. Not many companies seem to pay well. An issue (on the employer side) is my lack of degree, but as stated I'm doing senior level work and have plenty of experience.
I personally prefer a proactive doctor. Life gets busy and I don't always find time to get checkups and such. A small nudge from the doctor's office to get a checkup pays dividends. People with chronic conditions do need monitoring. It shouldn't be absurdly expensive.
I take a medication for a rest-of-your-life condition I've had since childhood. The simple blood test used to calibrate dosing is about $10 in saner countries. In order to get the blood drawn and tested it costs me >$100 out of pocket and I also have to see a doctor for a half hour ($250) before they'll update my prescription, regardless of if there is any change. This is with insurance, and must happen every 2 years or so. Medication cost is $10/mo or so.
This is completely ridiculous, and yet my situation is downright reasonable compared to what a lot of people have to deal with.
I shouldn't have to take permission from anyone to be able to buy the medicines I need. This is a cartel-type situation where your pharmacist won't sell you meds unless you pay a doctor.
Been there done that but from a different continent flying in. Nobody cares in general unless you're importing scheduled substances. You need to do your research but it's a way to beat the racket.
Drive up to the border and walk across on a day trip to the pharmacy. I believe the first few miles into the country are a NAFTA special economic zone with very relaxed paperwork requirements.
You can buy prescription drugs online from India without a prescription for super cheap. They arrive in your mail.
This is probably illegal, but not enforced.
I’m insured so it’d actually be cheaper for me personally to go in to the doctor and ask for a prescription. But I got tired of taking time out of my day for this - these are just beta blockers for fuck’s sake.
Gas chromatography-mass spectrometry (GC/MS [1]) by an independent third-party lab [2]. For unscheduled substances they'll even email you the mass plot.
Nearly all of our (US) pharmaceuticals already come from India anyways. Manufactured there from Chinese bulk precursors.
I trust a third-party GC/MS plot way more than any brand slapped on a package.
I'm confused. Are you saying that every time you receive a package of medications from India, you send a sample off to for spectrometry?
That seems extremely arduous.
The point is that you don't trust this specific supply chain/manufacturer, which is part of the approval process.
"India/China" is not some monolithic entity that is either good or bad, there are some manufacturers that you can trust, and some you cannot.
Quality control in drug manufacturing is what ensures that every single pill has the correct dose, and not some random batch accidentally having 100x the active drug you need - or 0.01%.
the good pharmacies in India have started asking for prescriptions..
so, one is left to go the sketchy/tinier ones, where quality can be expected to be lower as well.
Contact lens prescriptions change though, and bad contacts can do subtle damage to the wearer’s eye. I have permanent scarring in my eyes because I over-wore my 2 week contacts, my fault I know, but without an eye doctor appointment I would have done even more damage.
Wow, no kidding? I used to wear mine for months, maybe even close to a year. Anytime I had my eyes examined I asked how my eyes looked due to the constant wear and the optometrist told me they looked great but frowned at me doing so. I figured the disposable contact thing was mostly a racket, but I had some doubts. I wear glasses now.
These were the 2 week variety that were on sale between 2008 and 2012, after which I changed to 1 month lenses. It’s possible that newer lenses are better when worn outside the recommended range.
Sorry to say but you'll have to find a better doctor if all you're getting is refills without being seen. It's a sad state of medicine but primary care is being rapidly replaced by NP/PAs who do a good job but are very regimented in their thinking.
I don't see most physicians being an issue. Many of them are fed up with the insurance, pharma, and regulations. Most are forced to work for large providers instead of being independent just due to the overhead of dealing with digital record systems, legal, insurance billing, etc.
I've heard they're fed up w/ insurance, billing...but the few times I've asked "hey what if I pay cash, not through insurance, is it cheaper?" (I knew I wont meet deductible...)
It was actually more expensive. I've stopped asking and feel it's a urban myth.
The list price will nearly always be a multiple of your cost with insurance. The issue here is that insurers have provisions in their network contracts that prevent providers from publically advertising lower prices than what's charged to the insurer, which mandates discounting. In many other industries, these most favored nation arrangements are considered anti-competitive and, thus, illegal.
Large hospital systems totally separate business and care, so it can be difficult to negotiate a discount. Smaller and independent providers are often more accommodating. However, you need to ask for a discount, you can't simply offer to pay cash (i.e. "If I pay cash, can I get 40% off"). The providers can counter your offer, but can't discount you off the bat or else they invite legal action from insurers.
And what was the legislation? How was it monopolistic in favor of physicians?
The AMA does not really represent physicians. Less than 1/4 of doctors belong to the AMA. Many of them do not feel the AMA represents them. The AMA also accepts substantial donations from other sources, including corporate donors and foundations.
"Limit medical care to being provided by these people"
Who else would provide this care? This licensure is similar to other professions, like lawyers, and really doesn't take very much lobbying since the majority of the public want oversight of these sorts of professionals.
Residencies simply haven't kept pace with medical student numbers. They have gone up though. The main question is "where does the funding come from for residency training?". Medicare provides most of that funding, but that is a constrained resource. I find it hard to believe that the AMA lobbied for this provision.
>>the majority of the public want oversight of these sorts of professionals.
The majority of the public wants whatever they are lobbied to believe they need. The majority also supports the War on Drugs and criminalizing the sex trade, and for the same reason: fear tactics used to convince them that the mere option of doing an ostensibly harmful activity, is to the detriment of themselves and society at large, even though the activity would harm no one but the party engaged in it.
Plenty of medical procedures could be done by nurses and other non-physician medical professionals, yet this entire option is barred to the public. There should be a free market, with consenting adults free to choose for themselves who to hire to perform services for them.
"The majority of the public wants whatever they are lobbied to believe they need."
Ok, can you show me the lobbying that swayed their opinion on this topic then? If they are just gullible like you claim, then do you think these incapable people will have the capacity to choose well after removing license requirements for providers?
"Plenty of medical procedures could be done by nurses and other non-physician medical professionals, yet this entire option is barred to the public."
This is not banned at all. Physician assistants and nurse practitioners exist and can perform some medical procedures/tasks. Even pharmacists. Granted I've personally had some negative experiences with some PAs and try to choose actually physicians for most things.
"There should be a free market, with consenting adults free to choose for themselves who to hire to perform services for them."
That would be nice in many ways, but I can see a downside too. Once someone is found to be incompetent, fraudulent, and harmful, how would they be barred from the profession to prevent the issue from happening to others? Usually things like insurance and bonding are requirements to cover any issues for people in this and other licensed fields.
>>Ok, can you show me the lobbying that swayed their opinion on this topic then?
I only deduce it happens.
I mean the lobbying happens in ordinary conversations like these, where people with a vested interest in gatekeeping argue it's in the public interest. I'm deducing it happens based simply on the incentives that exist for concentrated interests, in the form of insiders, to engage in it.
It also manifests as major political representatives legitimizing said licensure, and rationalizing the principle behind it to the public, in exchange for support from insiders within the regulated industry.
>>If they are just gullible like you claim, then do you think these incapable people will have the capacity to choose well after removing license requirements for providers?
Yes, because people do far more research for personal consumer choices, where their level of knowledge has a substantial personal impact, than for political positions where their level of knowledge has a minimal impact, or minimal likelihood of impact, on their personal life.
>>That would be nice in many ways, but I can see a downside too. Once someone is found to be incompetent, fraudulent, and harmful, how would they be barred from the profession to prevent the issue from happening to others?
I don't see how the absence of licensure would prevert courts from issuing restrictions on individuals found guilty of criminal misconduct.
The government requiring a conviction in court before restricting someone's right to free association is how it should be. That is what the principles of a free society demand.
"I don't see how the absence of licensure would prevent courts from issuing restrictions on individuals found guilty of criminal misconduct."
That might cover fraud, but that doesn't cover incompetence or other harm.
"The government requiring a conviction in court before restricting someone's right to free association is how it should be."
That is one way to look at it, yet is is not how the legal system works today. The courts have determined that licensure is a lawful restriction on association.
"Yes, because people do far more research for personal consumer choices, where their level of knowledge has a substantial personal impact, than for political positions where their level of knowledge has a minimal impact, or minimal likelihood of impact, on their personal life."
It may have a more direct impact, but that does not mean they will have better outcomes. For one, you will be taken to the nearest hospital in an emergency - you have no choice. The important part is "their level of knowledge". Most people do not possess the level of knowledge to evaluate a medical professional and the information given to them by that medical professional. Most people accept it as truth and do not care to do any research on credible sites like PubMed.
>>That might cover fraud, but that doesn't cover incompetence or other harm.
If someone acts non-fradulently, and honestly conveys their lack of experience, their lack of competency in carrying out the service is no one's fault than the consumer.
>>The courts have determined that licensure is a lawful restriction on association.
I'm arguing this legal framework, not saying that's how it currently is.
>>It may have a more direct impact, but that does not mean they will have better outcomes. For one, you will be taken to the nearest hospital in an emergency - you have no choice.
Only 8% of healthcare spending is on emergency services, which can and should have government involvement to avoid abuse of geography-based monopoly by service providers.
But the remaining ~92% of healthcare spending is made through non-time-sensitive decisions where an individual has plenty of to assess the market options.
>>Most people do not possess the level of knowledge to evaluate a medical professional and the information given to them by that medical professional.
Just as people delegate this analysis to a cadre of politicians in the current monopolistic system, people would be able to delegate analysis to reputable experts in a free market.
"If someone acts non-fradulently, and honestly conveys their lack of experience, their lack of competency in carrying out the service is no one's fault than the consumer."
You're ignoring the part where it cannot be conveyed, like when people are mentally ill, incapacitated, etc.
"But the remaining ~92% of healthcare spending is made through non-time-sensitive decisions where an individual has plenty of to assess the market options."
Just because it's non-emergency does not mean the person is capable if choosing. You have people who are mentally ill and incapacitated who are treated in settings other than the ER. The highest spending happens at the end of life stage.
"I'm arguing this legal framework, not saying that's how it currently is."
Do you actually have more details for how that framework would work? So far all I'm hearing is that we should nor have licenses for medical professionals. How does that work with medical professionals powers to suspend drivers licenses, commit people, help in emergencies (good samaritan laws), etc. How does this affect malpractice insurance and torts, especially if you're saying that any incompetence can simply be stated by the provider to avoid court intervention? How would this system work in relation to controlled substances and expensive equiptment maintenance/procurement? How are the safety programs legally enforceable or logically possible without training? We already see that VEARS has terrible quality data. There are many adverse events that go unreported, especially by the lower trained PAs/NPs (my experiences).
"Just as people delegate this analysis to a cadre of politicians in the current monopolistic system, people would be able to delegate analysis to reputable experts in a free market."
You keep calling this a monopoly, but it is not a monopoly. There are numerous providers competing with each other. There's simply a training/licensure requirement. How are reputable experts foing to be any different than the current system? My guess is that they will create their own license system and force people through that too. Insurances, which cover the vast majority, will still require licenses to ensure that people aren't getting care that will be ineffective and cost them even more. This includes stuff like Medicare and Medicaid that the government controls.
Do you have a thesis paper or something that we can see? We really need more information about what exactly you are proposing beyond 'remove licenses, free market will work', how that will affect the numerous aspects of the system as well as it's integration with other systems, and what research there is to support it.
>>You're ignoring the part where it cannot be conveyed, like when people are mentally ill, incapacitated, etc.
We already have provisions for when someone cannot make decisions for themselves, like guardianship. We do not need to subject the entire population to guardianship-like subordination.
>>You keep calling this a monopoly, but it is not a monopoly.
It is a monopoly: the licensure rules have a monopoly over all providers. Your argument seems to be that people cannot choose for themselves, so it's better we impose this monopoly on them.
But if they can't choose an effective delegate in the marketplace, who says they can choose an effective politician to vote for in an election, who will then appoint the regulator that vets their market options? It's better to go with a decentralized approach, where each individual is free to choose their own delegate, rather than a centralized one where the entire population votes every four years for one delegate that gets the power to vote for every one, whether they consent or not.
>>Do you have a thesis paper or something that we can see? We really need more information about what exactly you are proposing beyond 'remove licenses, free market will work',
I think the burden of proof is on those who advocate for continuing to limit people's right to freely contract and purchase the goods/services they want.
I showed you a source earlier in the thread and you didn't respond. It is the website of AMA, where they celebrate their success in lobbying against any bill that would allow other professionals expanded capabilities.
"For over 30 years, the AMA’s state and federal advocacy efforts have safeguarded the practice of medicine by opposing nurse practitioner (NP) and other nonphysician professional attempts to inappropriately expand their scope of practice."
So this is a source just saying they oppose inappropriate expansion. That they want PAs and NPs to practice as part of a team that includes a physician.
I don't really see this
as an issue. I also see PAs, NPs, and nurses as falling into the medical profession and subject to licensing, etc. So I see them as being on the inside of the system, not one of the "other people".
What I was specifically looking for was a source about the second part of this thread - the restriction of residency by the AMA.
When asked on the street people always say "yes I want healthcare to be safe" but if you actually see who is lobbying for certification requirements it is always incumbents.
If people wanted and needed licensure for health, hair cutting, whatever, you'd expect that they would be at the state house. But they're not.
Haha this is exactly why point source information is so damaging. The AMA spent years keeping this tightened down by spending money and then they started issuing press releases asking for the opposite (but this time, conspicuously leaving off the money spending).
This naïveté is typical of HN. You’d read a press release from ISIS and conclude they’ve built a paradise. You need more knowledge than you can Google up. You need to be aware of what they did and do over the last 30 years.
But it’s okay, you can believe falsehoods. No skin off my back.
It is just amazing to watch people in the US defend the price gouging in healthcare in the US.
The medicine prices are MUCH lower in other parts of the world - including in places where the cost of living is much higher than in the US such as Norway and Switzerland.
The cost of Insulin is 8x higher in the US than in comparable countries around the world.
We're talking western countries, not places where you would expect it to be less like Mexico, India, Brazil. Basic domestic services are going to be about the same across various western countries. Drugs and health services in general are 2-4x what other western countries pay AT A MINIMUM. Most have free health care.
Maybe I'm weird but I don't have a nanny or landscaper and neither does anyone I know or any of their relatives that I'm aware of. But I pay a flat €5 for most prescription drugs (the rest are free) and my public health insurance costs are capped at about €700 per month (and I get to keep it for free if I become unemployed).
No it's not. Lobbying in that reported sense is also a very small slice of persuading politicians and regulators and bureaucrats.
PHRMA plays big in politics, 501c4 space etc.
They also are known for the revolving door which is hard to quantify, but surely it makes a big difference on regs. Look at the Purdue, they got the regulator responsible for approving the label to actually sit in a hotel room and help write their oxy label together...
Here's an article shows "in the US from 1999 to 2018, found that the pharmaceutical and health product industry spent $4.7 billion, an average of $233 million per year, on lobbying the US federal government; $414 million on contributions to presidential and congressional electoral candidates, national party committees, and outside spending groups; and $877 million on contributions to state candidates and committees."
I double checked -- another source[0] mentions amounts that are a bit higher:
"The Chamber [of Commerce] spent nearly $82 million on lobbying in 2020"
But generally in line with the list posted by the GP:
"Facebook and Amazon were the only companies in the top 10 spending list and spent nearly $19.7 million and more than $18.7 million on lobbying in 2020, respectively"
I too, am surprised as how little this is for these gigantic companies ($20M for FB? 1/1000th of their quarterly revenue?) and more generally, how little money this is... in comparison with the entire US government budget?
Sorry, this is probably all obvious? Just a bit.. sad?
Really. Who doesn't get how cheap our politicians come? Old joke about Spiro Agnew (Nixon's VP who had to resign because he took around $30,000 in bribes while Governor of Maryland years before): When Armstrong set foot on the Moon he would have been set for life if his first words had just been "Coca Cola!" Of course if it had been Agnew he probably would have said something like, "Fred's Tailor Shop, Baltimore!" Point is, US politicians really do come cheap. Political favors are a wholesale business, they make out on volume.
It was purposefully written to mislead, hence the lack of commas or the M suffix. So yeah, it is definitely not a lot. For comparison, Facebook alone spent $17M on lobbying in 2019.
Sutter Health is one of those hospital cartels. They've made it so that giving birth in Sacramento is now one of the most expensive cities in America. It's all a racket.
I think pretty much all players in the US health system are a problem. They all benefit to some degree from this corruption. If I had to pick the worst I would name hospitals. But everybody else profits handsomely too.
I would think tech is now at the point to undermine micro-exploiters who extract punitive payments from people who feel that there is no viable alternative provider (e.g. a specialist who requires completely unnecessary monthly visits, gives a cursory glance, keeps treatment unchanged and charges hundreds in the process).
What do you think? - Is this something tech CAN do today, with an open source application and publicly available data?
* Encourages the FTC to ban or limit non-compete agreements.
* Encourages the FTC to ban unnecessary occupational licensing restrictions that impede economic mobility.
* Encourages the FTC and DOJ to strengthen antitrust guidance to prevent employers from collaborating to suppress wages or reduce benefits by sharing wage and benefit information with one another.
* Directs the Food and Drug Administration to work with states and tribes to safely import prescription drugs from Canada, pursuant to the Medicare Modernization Act of 2003.
* Directs the Health and Human Services Administration (HHS) to increase support for generic and biosimilar drugs, which provide low-cost options for patients.
* Directs HHS to issue a comprehensive plan within 45 days to combat high prescription drug prices and price gouging.
* Encourages the FTC to ban “pay for delay” and similar agreements by rule.
* Directs HHS to consider issuing proposed rules within 120 days for allowing hearing aids to be sold over the counter.
* Underscores that hospital mergers can be harmful to patients and encourages the Justice Department and FTC to review and revise their merger guidelines to ensure patients are not harmed by such mergers.
* Directs HHS to support existing hospital price transparency rules and to finish implementing bipartisan federal legislation to address surprise hospital billing.
* Directs HHS to standardize plan options in the National Health Insurance Marketplace so people can comparison shop more easily.
* Directs the DOT to consider issuing clear rules requiring the refund of fees when baggage is delayed or when service isn’t actually provided—like when the plane’s WiFi or in-flight entertainment system is broken.
* Directs the DOT to consider issuing rules that require baggage, change, and cancellation fees to be clearly disclosed to the customer.
* Encourages the Surface Transportation Board to require railroad track owners to provide rights of way to passenger rail and to strengthen their obligations to treat other freight companies fairly.
* Encourages the Federal Maritime Commission to ensure vigorous enforcement against shippers charging American exporters exorbitant charges.
* Directs USDA to consider issuing new rules under the Packers and Stockyards Act making it easier for farmers to bring and win claims, stopping chicken processors from exploiting and underpaying chicken farmers, and adopting anti-retaliation protections for farmers who speak out about bad practices.
* Directs USDA to consider issuing new rules defining when meat can bear “Product of USA” labels, so that consumers have accurate, transparent labels that enable them to choose products made here.
* Directs USDA to develop a plan to increase opportunities for farmers to access markets and receive a fair return, including supporting alternative food distribution systems like farmers markets and developing standards and labels so that consumers can choose to buy products that treat farmers fairly.
* Encourages the FTC to limit powerful equipment manufacturers from restricting people’s ability to use independent repair shops or do DIY repairs—such as when tractor companies block farmers from repairing their own tractors.
* Encourages the FTC to prevent ISPs from making deals with landlords that limit tenants’ choices.
* Encourages the FTC to revive the “Broadband Nutrition Label” and require providers to report prices and subscription rates to the FCC.
* Encourages the FTC to limit excessive early termination fees.
* Encourages the FTC to restore Net Neutrality rules undone by the prior administration.
* Announces an Administration policy of greater scrutiny of mergers, especially by dominant internet platforms, with particular attention to the acquisition of nascent competitors, serial mergers, the accumulation of data, competition by “free” products, and the effect on user privacy.
* Encourages the FTC to establish rules on surveillance and the accumulation of data.
* Encourages the FTC to establish rules barring unfair methods of competition on internet marketplaces.
* Encourages the FTC to issue rules against anticompetitive restrictions on using independent repair shops or doing DIY repairs of your own devices and equipment.
* Encourages DOJ and the agencies responsible for banking (the Federal Reserve, the Federal Deposit Insurance Corporation, and the Office of the Comptroller of the Currency) to update guidelines on banking mergers to provide more robust scrutiny of mergers.
* Encourages the Consumer Financial Protection Bureau (CFPB) to issue rules allowing customers to download their banking data and take it with them.
My understanding is that the "encourages" part relates to agencies that are independent and are therefore not directly under the control of the president. He therefore cannot directly order them to do anything.
However, from what I could gather from news interviews, this has not been published without the collaboration from those agencies, who in general are on board with the changes.
Correct, the President is actually fairly limited in how much control they exert over regulatory agencies -- such agencies are created by Congress, commissioners are nominated by the President and confirmed by Congress, and commissioners report back to Congress.
It's an executive order, there is only so much the President can mandate outside of the organizations he controls. Look at most of Trump's presidency, feckless EO's that in the end were reversed anyway or were blocked by a court. My guess is that the goal here is to have the regulating authorities be "encouraged" to put the screws to some of these big-X companies. In other words, have them set their policies based on the general direction given by the President. I think that's probably normal operation.
A more cynical view is that the goal is to make it seem like the administration is trying to follow through with some campaign promises while not doing much of legwork to actually do it.
It takes very little to issue an EO. It takes more to work with colleagues in congress to actually implement some of the stuff laid out here. Biden's predecessor really laid the framework here and turned it into an artform - issue a worthless EO, get a great photo op and some feel good stories in the media, then everyone forgets why they can't figure out hospital prices in a few weeks again.
For some more context, it is within Biden's power to appoint an assistant attorney general for antitrust, but as of last week, he still hasn't [0]. I'm not sure how serious this rhetoric around strengthening antitrust guidance really is, in light of that.
I'd love to be proven wrong, but I think this administration has earned my skepticism. Time will tell.
> * Encourages the FTC to restore Net Neutrality rules undone by the prior administration.
This is the worst thing in the list. The politicians still don't seem to understand how the internet works and how different service types cost differently and have different effects on the network. A new Netflix-like service is a very different thing than a new social-network-like service.
You don’t seem to understand. If I have 100 mbps down speed, my ISP should have no say in how I use it. If it is Netflix of Facebook, it doesn’t matter. It’s my 100 mbps. That is like saying that my electric provider should have a say on what I use my electricity for. That if I use a GE brand washer it costs less per kwh than a Samsung, or that electricity for a computer is more expensive per kwh than electricity for a refrigerator. No. They give me the electricity, I decide how to use it. They give me the internet bandwidth, I decide how to use it.
Net neutrality never was about you though, it's about the companies sending content to you.
Electricity has absolutely no comparison to network traffic. That's a fundamental misunderstanding of how networks work. A packet coming from the other side of the world costs, fundamentally, a very different amount from a packet coming from nearby.
> A packet coming from the other side of the world costs, fundamentally, a very different amount from a packet coming from nearby.
But you were not talking about the distance a packet travels. You specifically said “A new Netflix-like service is a very different thing than a new social-network-like service” which, other things like location being equal, is not true. Getting 100 mbps of “Netflix like” traffic is not different than getting 100 mbps of “social network” traffic. The content doesn’t matter.
I was wrong about you not understanding. Clearly you do understand and are arguing in bad faith and attempting to misrepresent the issue. Since “packet distance” has never been part of the issue of ISPs trying to be able to discriminate based on content, either the company providing it (Netflix vs Hulu vs Prime Video) or based on the category of content (music vs social media vs messaging). None of those have anything to do with packet distances, which you clearly understood when you were originally were speaking about content categories. But you then tried to use a more technical and pedantic, but irrelevant, issue to obfuscate the actual argument.
I'm not going to bother to exlpain anymore. The FAANG companies have twisted this conversation so much into knots that the average person doesn't know that they're actually been turned into sock puppets for the FAANG companies to argue for legislation that is purely for the benefit of those FAANG companies so they are not required to pay the ISPs for data transit.
You never explained anything. You made assertions you couldn't support and just accuse everyone else of not understanding. Also, your argument is ridiculous on its face. Tech companies already pay for internet. Their datacenters don’t have free hookups. ISPs already get money from FAANG companies to get their data in and out of their data centers, and from me to get my data in and out of my house. If you need more bandwidth, you pay more money. Netflix spends hundreds of millions of dollars a year on bandwidth. This is one of the weakest and most nonsensical arguments yet against net neutrality. I’d love to see some of your sources because that’s a rabbit hole of misinformation I’d love to go down.
A couple years past, def under Obama, I went in for a retina exam. They absolutely could not tell me the price for the appointment. "It depends on services rendered" - "what if it is a standard appointment with no extra services, how much (ball park) should I expect? $50? $500? $5k?" - "I couldn't tell you, I can't imagine that high."
There is no price transparency. Sure would like it since I have a high deductible plan.
Price transparency plus high deductible plans would drive the cost of health insurance down.
Health insurance is supposed to cover you for catastrophic health issues that were previously unknown. For some reason it changed to also cover all your recurring or minor illnesses.
Part of that is because it’s far cheaper to catch (say) cancer at an early stage and treat it than it is to catch it at stage 3 or 4 and spend potentially millions on a possibly preventable catastrophe.
There is fairly strong evidence that if the cost of routine preventative care isn’t paid by insurance, quite a lot of people opt to skip it because they can’t afford it, leading to worse outcomes.
Do you have evidence of this part specifically? Because the Oregon Experiment found no improvement in health outcomes in a large randomized trial of low-income recipients of Medicaid. (Partly because their health was generally good in the first place.)
I had no health insurance so put off on a specialist i needed to see until i could sign up for medicaid (can only apply at the end of the year for some retarded reason). Just putting my issues off for 4 months turned an easy thing to fix into needing to spend the past 8 months in and out of the doctors and hospital.
If the plural of anecdote is data, when the ACA was first rolled out, someone close to me discovered they had colon cancer. They had been having symptoms for quite some time, but had been managing them with home treatment, the first day the had insurance they went to get it checked out. Lucky they did, as devastating as it was (and continues to be, turns out your chemo is brutal and having large sections of your colon removed isn't great either) their doctors already weren't sure they could treat it effectively.
While they credit the ACA with saving their life, had we had some form of socialized medicine from the start, this likely would've been caught much earlier, treated much more easily, and with significantly less long term effects.
I couldn't easily find studies on preventative care leading to better outcomes, but given how many diseases (like cancer for example) can go from easily treatable to a catastrophic nightmare depending on how early they are detected, I find it hard to believe that easy, cheap (or free) access screenings would have no effect on outcomes, though I realize how treacherous it can be to rely on instinct instead of data.
Counterintuitive as it may be, the Oregon Experiment showed increased costs.
It did show an improvement is psychological outcomes, I presume due to peace of mind, because their wasn’t a corresponding increase in psychiatric medication.
I imagine this test isn't sufficient because just like with me and this other commenter, many would be going to the doctor to catch up on care they've been missing. Over a longer time period and with having this from the start of your life, I'm sure the costs would end up lower m
Did the increase in cost also come with an increase in outcomes? I don't think it's counterintuitive that people who couldn't afford healthcare see a doctor, you'll see a lot of issues; did we see a decrease in medical issues across the population?
It is part of large complicated model. If it was their entire model they wouldn't be operating medical offices and hospitals. It is the whole package that helps them control costs.
It is my understanding that obligatory routine care is a major component of Kaiser’s model. In the experience of those I know who use Kaiser, effectively, if they come in for something and their routine checkups are out of date, they’re obligated to get that routine checkup (at the same time due to streamline of service), before they can get what they came in for.
From this, I derived the argument that routine checkups are a *major* component of Kaiser’s system, to the point that, given the flow of discussion, I felt it appropriate to call it “their whole model”. I’m sorry my hyperbole was too far.
Kaiser has no specific preventative care requirements and does not withhold care if you are not up to date on some schedule. In fact Kaiser works pretty much exactly like any other HMO with the main difference being that insurance is in-house (but a different department, so insurance screwups still happen, but at least the hospital and the insurance are not constantly fighting each other with you stuck in the middle).
Well that and with Kaiser it's a lot easier to tell who is in network (they never commingle in and out of network care).
That's interesting. The person I'm familiar with wasn't allowed to get meds for their strep throat until they went through their regular exams since it had been a year or over one or something. It was all very, very quick, but they were quite serious about getting their regular checks in. The patient in particular was in her 50s at the time, so perhaps that's where the difference comes in?
You're not getting the whole story from that person. Competent providers will strongly recommend preventative care services but patients can always refuse.
If we had socialized medicine like my local Kaiser, I would be so excited. I honestly haven't been treated anywhere else with the same level of care and concern. I used to hate doctors because of bad experience, but the Kaiser system convinced me to take care of myself on a routine basis. Just one opinion, but thought I'd share.
Glad it worked for you. I've had both good and terrible experiences at Kaiser (in pretty serious circumstances such as major op and post-op experiences), and a similar spectrum at other HMOs. I don't think Kaiser is a panacea, although I agree single-payer looks like the only way to fix the systemic economic issues and Kaiser is a bit closer to that model than other HMOs.
It’d help a little but it’d still be a long way from an Econ 101 market. Preventative care is hugely effective at reducing costs but high-deductible plans ensure that many people will not get it.
Many people simply aren’t capable of shopping around, either: emergency care, cognitive impairments, limited geographic options, and the conflicts of interest inherent to for-profit medicine all make it hard for people to know what they need and whether it’s worth the money. As with preventative care, making it harder to get treatment is certain to lead to many people not getting problems treated prior to them becoming major.
Kind of like how list price means everyone pays the same price for a car? What would happen is more of what we already see: tons of addons being pushed, rebates or other ways to adjust prices for some people without lowering them, random specialists and unnecessary services being pulled in relying on the fact that most people don’t realize they can and should say no, and a whole industry of people finding ways to say you had some obscure complications not covered by the standard price.
Look at it from an economic incentive standpoint: Americans pay 2-3 times more for the same service. That is a huge amount of money, and it ensures that rooms full of smart people will be working to ensure that their employers continue to get it.
Exactly - it’s not a normal market and there are hard limits preventing it from ever working like that, no matter how many people desperately try to pretend otherwise because it’s personally profitable for them.
I agree with your take. I work in the industry. The for some reason has partly to do with the U.S. tying insurance to your employer and not charging taxes. It makes sense to offer as much as possible pretax.
I'm not so sure. There's a lot of waste in all of our health care system, and many areas are served by few care providers. Transparency on prices without effective competition won't change much.
That's an excellent point! It can't hurt, and might help. I don't know why I felt negatively about it at first, anything to start disrupting the bad parts of the system should be welcome.
Of course it was, also see “value based care”. It’s all bullshit.
Hospitals have zero incentive to be transparent, and all the incentives to be opaque. So long as you’re a non-Medicare/Medicaid patient you’ll continue to suffer.
The American healthcare system is completely fucked (there’s no better word).
Is it fscked for physicians and various healthcare professionals (e.g., paid higher wages than other countries with different systems). Is it also fscked for wealthy patients who do not really care about costs.
> Is it fscked for physicians and various healthcare professionals
It's an underappreciated point. The US healthcare system is one of the largest wealth transfer systems ever invented. It's a heavily protected cartel that plunders wealth from the top 2/3 and lines the pockets of a few million employees in the system.
There is an excess cost bounty of $1.2 trillion (or more) being plundered and redistributed every year to the healthcare cartel.
There are millions of people working artificially high paying jobs in the healthcare cartel in the US courtesy of the hyper inflated costs in the system. From nurses to doctors to pharma sales reps to scientists to management and everything inbetween.
Nobody ever talks about the need to slash the pay of nurses & doctors though, it's far too unpopular of a subject, it's downright taboo. Just a notch below slashing the pay of teachers. They'd all go on strike tomorrow morning if a serious attempt were made to bring their pay in-line with other developed nations.
The US has to remove a minimum of $1.2 trillion in cost from its healthcare system (which would produce an end cost structure still far above that of eg Britain). Only about 10-15% of that can come from slashing costs out of the pharma drug price side. The bulk of it has to come out of inflated salaries of millions of workers in healthcare across the board.
When politicians talk about universal healthcare in the US, they always, without exception, go far out of their way to dodge this epic scale problem of inflated salaries in healthcare and of where to find $1.2 trillion in costs to slash (they primarily focus on high drug prices as a matter of political convenience; that segment by itself won't remotely cut it though). This is why every time a state decides it's going to look at doing universal healthcare, it immediately runs away after the cost study is completed, it's impossible until you remove a dramatic amount of cost from the system. Now someone go tell all the nurses and doctors in California they get to make 25%-35% less money (good luck).
Do you have some sources where I can read up more on this? I have always believed that the cost of front line worker salaries (Doctors/Nurses) was a relatively small % of the total cost of healthcare.
Studies like this [1] led me to believe that massive rises in administration costs and inefficiencies due to insurance structure are bigger culprits than doctor/nurse salaries. But I am admittedly not very well informed in this area.
I see your point, but I will raise you that medical training in other countries doesn't also put you in hundreds of thousands of dollars of debt before you've even begun to practice. The cost of a medical education has a large impact on why salaries are "artificially" inflated.
Sure, high salaries are justified for this minority.
The people mentioned specifically in the comment are of more concern; sales, admin, etc. salaries in this field are also inflated compared to other industries.
Removing insurance companies from the equation saves billions. There are hundreds of thousands of insurance employees working on complex payer software, business workflows, payments, clearing houses, membership, plan negotiations, sales, actuarial, claims, member support etc. Also on the hospital side all the people that interface with the insurance companies.
There would be some overhead for single payer but it would be much more efficient and simple.
Massive insurance company dissolution might also be an unpopular reality for folks to come to terms with as well though
I mean, someone is paying the price anyways, right? Why cant we as a society continue to pay the same (inflated) price now, but give the government the leverage it needs to fix the problem over several decades?
Only for billing cost of procedures. It's still a mess.
Did you know that hospitals make money by using name brand medications? They will get a contract with a brand, like Motrin, and charge you full price at $8 a pill. Then Motrin will will evaluate how much the hospital used and give them a big rebate to bring the hospital's cost down under $1 per pill. You can literally buy a bottle of ibuprofen for what they charge for a single pill, but of course in the name of safety (and really kickbacks too) they won't allow the cheaper outside medication. It's effectively an internal monopoly.
As far as pricing goes I view US hospitals basically as money grabbing scam operations. What they are doing is just insane. It’s hard to believe Americans are putting up with this nonsense or even defend it.
I’ve actually tried to “shop around” for hospitals and it’s basically impossible. Just about everything is hidden behind some barrier and there’s just no way to effectively compare prices. Additionally, you really have no idea what products or services you’ll end up receiving while at the hospital.
Most importantly, ALL of this planning and sense of choice goes out the window when you have a true emergency. When that happens all that matters is getting to an ER, fast.
Not to mention that for scheduled procedures nearly every doctor will require their own imaging for 40-50k a pop at list price before even discussing treatment options and cost.
> Most importantly, ALL of this planning and sense of choice goes out the window when you have a true emergency. When that happens all that matters is getting to an ER, fast.
Yep. I was a victim of this in the -worst- way. 11 years ago I was hospitalized, and it 'just so happened' that the only doctor that would take me while I was admitted was out of network.
BCBS of Michigan in fact later settled out of court in a class action over this behavior, although the 50 or 100$ I would have gotten certainly did not make up for the hundreds of dollars that the out of network provider cost me.
The hospital you end up in is not a free market and usually it's not even a choice. Anyone who who gets in a car accident, falls off a roof, has a heart attack will be lucky to still be conscious when the ambulance picks them up, much less in a state of mind to be considering the relative merits.
Yet emergency care is relatively small portion of health care costs - so maybe deal with that last. It'd be hard for hospitals to make the case that emergency care is substantially more costly than similar procedures they offer.
Even for ER visits alone, it's not true that patients are "usually" incapacitated or on the verge of death. Something like a third aren't even urgent and only a small percentage are admitted to the hospital. And the most common reasons for visits are mostly pain complaints with a conscious patient. On average people get triaged to the waiting room to wait for 40 minutes or whatever.
There was a thread here a while back about something like an emergency-mode uber for replacing ambulances for most ER trips. Something similar might also be done for shopping for cheaper urgent care too perhaps. Say a clinic that is open late and will check out your scary rash/cough/pain without charging so much.
In Czechia we have sufficient capacity of ambulances and other emergency services. What happens is that off peak they serve to help move old people to hospital, like a super expensive taxi. In these cases I can see how "emergency Uber" could help. On the other hand the doctors serving in these ambulances are usually extremely well prepared, the best MD students go to study to serve there. Even if it is one in a hundred cases, they will recognize the stroke from a random chest pain. Replacing them would surely increase the death rate in these cases...
Sure but you can make such an argument about every single medical issue. People can drop dead in a few days due to an unexpectedly aggressive toe infection. At some point we need to compare risks to costs.
There will always be a trade-off between quality and cost. If you accept nothing less than highest quality (enforced by law and an extremely litigious society), then you get the US hyper-inflation of healthcare prices.
Also in the US, I think ambulances typically only have EMT's and paramedics. Though sometimes it can cost as much as the ER itself.
Not everywhere has multiple hospitals to choose from. Even if there are multiple hospitals, your insurance might influence your choices too. And at the end of the day, if you're incapacitated, they will just take you to wherever is closest.
The point was that the hospitals are doing things behind the scenes that are not well known that affect the pricing. In this example, they charge you more for using name brand medication and then get a kickback to make money for themselves.
I love how conservatives still make this argument. You're arguing for the free market in a system that literally isn't, and doing it in such a way that it tries to be a thought-terminating cliche.
If you get into a car accident tomorrow driving to work, the ambulance/paramedics aren't going to ask you to do your research prior to shuttling you to a hospital to get life saving treatment. Even if you could how would you be able to tell which hospital has what price structure, what services you'll actually need given your medical condition, and what arrangements they have with various drug manufacturers and how that relates to what you require to help your condition. Save it.. "no one to blame but yourself" is so incredibly idiotic is comical.
Take something even more benign, like someone falling and breaking/straining something. Wanna still do your research first? Is it a sprain, fracture, break? How do you know? Is it clear cut? What pain medication will you need? Will you require surgery? What lab work will you need? How many tests will you need? X-rays? CAT scan? MRI? What kind of surgeon? How many nurses? Will you require blood? Whats the recovery like? What about follow up visits? Do you expect us all to practice free market principles and know all that crap in advance for price discovery before deciding to seek treatment?
True free market principles require an asymmetry of information for the system to work, and even "fathers" of the theory understood that and acknowledge the need for regulation when its absent.
> and even "fathers" of the theory understood that and acknowledge the need for regulation when its absent.
I would emphasize that traditional forms of conservatism were never opposed to all regulation and never embraced this libertarian worship of the unregulated market. They were opposed to collectivism, but the only remaining option isn't radical individualism. Neither are good for the individual or for society.
The basis is so completely obvious though, if your health is badly compromised then you will be much less able to make good decisions in any circumstances, let alone dealing with the current for-profit healthcare system in the US.
You Americans are getting so screwed... I got 4 separate X-ray scans done for $40 recently, modern machine, sent home with physical copies and USB, etc.
Price transparency regulations could also be used to implement public price controls or public fines on monopolies engaging in price discrimination.
For instance if a provider billed a patient over 100% of their stated price or over 120% the minimum price for the same item published by comparable providers, there might be some public fine or tax on the biller and rebate to the patient in proportion to the entire amount by which the patient was over-billed regardless of their insurance status.
This would possibly amount to something similar to universal public price negotiation.
But yes the idea of using pricing transparency to suppress over-billing by monopolies could possibly be interpreted as suggesting a rejection of the alternative idea of centrally fixing all consumer facing prices using a public office and then determining all government facing prices from external suppliers providing necessary inputs for the public healthcare system through minimum bid.
Parent is not labeling the poster as conservative; he is labeling the argument as the underpinning of the same argument conservatives often make. That's a nuanced difference.
If we are concerned with nuance, there's probably at least 2 different conservative arguments.
There is the hyper-libertarian argument which says that if someone arrives at a hospital unconcious, and the hospital bills them the maximum amount they estimate the patient can pay before bankruptcy, so the hospital can maximize initially reported earnings before writing down unpaid debts, that this is somehow a voluntarily market price as long as the hospital is private and not owned by the government, because value is purely subjective and has no relation to cost.
Then there is the other argument which says if hospitals are over-billing people which are under duress, that this is bad and we want to do something about it, but we don't want to immediately nationalize healthcare and ban private health insurance. This second type of conservatism usually focuses on price controls or regulation of monopolies.
With pricing transparency regulations, it's probably possible to implement universal public price negotiation by fining non-elective healthcare providers which bill patients over 100% of their previously published price or 120% of the minimum price published by comparable providers. Then rebate patients the entire amount they were over-billed regardless of their insurance status.
With over-billing rebates there is less need to collect payroll tax to finance social insurance premiums. Need based assistance could be financed from more progressive property taxes on the rich, and the actual price controls could be implemented relatively cheaply by randomly auditing providers to ensure compliance, by allowing patients to manually submit invoices whenever they felt they were over-billed, and by financing rebates to patients entirely from fines on providers.
It's certainly possible that other systems would work better. However if we want to be nuanced there are many different strands of U.S. conservatism. Historically U.S. conservatives subscribed to some form of cost or labor theory of value. The kind of hyper-libertarian conservative movement which says private prices are always fair is probably less than 100 years old.
They mean lock you in to their services only. Once you're in there you're forced to pay for whatever services they provide, which could be a lot in an emergency or if your unconscious. I think they were also referencing the idea that you are forced to pay a high amount for Motrin, when an alternate source would be much cheaper.
Well, I hope this does some good, but I'm a bit skeptical. I think we need more focus on how to help freelancers, gig workers and microbusiness actually succeed as a counterpart to preventing big business from preying upon small business.
It's something I personally try to promote but I feel I have little in the way of success. I still struggle to make it through the month myself and my various projects intended to help others seem to mostly kind of languish, with one exception and I have no hard data on how much good that is doing.
I think my efforts aren't pointless or fruitless, but it never seems to be enough to actually resolve my chronic poverty and I don't get enough feedback affirming that the lives of others suck less thanks to me.
That kind of thing is maybe part of what helps drive a concentration of money and power.
I think we overregulate small business. You need to know a lot of laws and regulations to operate at all and if you are one or a few people, that's a big burden. It's less of a burden for big business to play that game because they make enough money and have enough people that it's a relatively small part of what they do and I think that regulatory burden is one of the things hampering small business, just like it tends to impede the development of affordable housing.
I don't know the answers. I just am skeptical that focusing exclusively on breaking up monopolies and putting a break on big business actually breathes life into small business. It's perhaps a necessary but insufficient precondition.
> I don't get enough feedback affirming that the lives of others suck less thanks to me.
I have always liked your posts a lot over the years here.
I'm in the same boat, I have created a few things that are used by actual people but I have not yet thought about trying to make a living that way. Ideally I would open source everything and go the Patreon / donation route, but I want to get some of my work in order and nail at least one of my bigger ideas... then it might be feasible, but for now money is absolutely the limiting factor and I don't even need much relative to some :(
I did see your comment and I appreciate you leaving it. I didn't reply immediately because I had hoped to do something more meaningful with it than just say "Thank you" but that seems to not be gelling.
Sort of good, but we'll see how it plays out without other policies supporting it. Frankly, many consolidations are not malicious but necessary for survival. Economies of scale and verticle integration are required to complete with foreign companies with lower costs. Look at domestic steel production. No way the market can support numerous domestic options that can compete with the low cost of foreign imports.
Then there's vertical integration. I don't know if this will effect vertical integration. If it does, I wonder how domestic companies will compete without it.
As a beekeeper, it's vastly cheaper foreign imports (some of it fake) that are more damaging than large domestic producers (although there's a healthy variety). The low prices have been forcing consolidation, or for some people to switch from producing domestically to packing imported honey. It's tough to market local honey for even $12/lb when walmart sells honey for less than $5/lb.
What are some uses for honey by the pound? Off topic but curious, I only ever put it in tea rarely or simmiliarly rarely use it as a sugar alternative when cooking.
Price per pound is mostly just a standardized measure used to compare prices regardless of container size. The most common container size is a one pound jar, but 8oz jars are fairly common too. You would buy a jar and use it in tea, other drinks, on waffles, etc. You can buy larger quantities to do things like baking, making candy, making mead, etc.
I see, yeah I only ever get a the little honey bear ones lol, but the big jars at farmers markets look interesting but they're always huge and I almost never use honey
As long as they're airtight they stay good for years. Some local producers sell small jars too. I mostly sell pint jars (1.4 lbs). I will probably switch to standard 1 lb jars soon.
As long as it's air tight, sort of. They found honey that is safe to eat from the pyramids. I wouldn't recommend eating it as it probably doesn't taste good at all. The flavor will decrease after a while, but that generally takes years. Eventually it will taste bad, but that should take decades.
Honey stays good for an amazing time. It is due to two things. It is mainly sugar, which means that it has a high osmotic pressure which kills other organisms like bacteria and fungi. The bees make their own antibiotics to fight of infections and some of these are present in their honey as well.
This executive order is really comprehensive, it touches literally every economical areas where competitions are withering away. To be specific, I think this part addresses your concern on big telecoms.
> (l) To promote competition, lower prices, and a vibrant and innovative telecommunications ecosystem, the Chair of the Federal Communications Commission is encouraged to work with the rest of the Commission, as appropriate and consistent with applicable law, to consider:
The following also partially addresses big banks, though I'm not sure it's sufficient enough to tame them. Better than nothing though.
> (e) To ensure Americans have choices among financial institutions and to guard against excessive market power, the Attorney General, in consultation with the Chairman of the Board of Governors of the Federal Reserve System, the Chairperson of the Board of Directors of the Federal Deposit Insurance Corporation, and the Comptroller of the Currency, is encouraged to review current practices and adopt a plan, not later than 180 days after the date of this order, for the revitalization of merger oversight under the Bank Merger Act and the Bank Holding Company Act of 1956 (Public Law 84-511, 70 Stat. 133, 12 U.S.C. 1841 et seq.) that is in accordance with the factors enumerated in 12 U.S.C. 1828(c) and 1842(c).
> (t) The Director of the Consumer Financial Protection Bureau, consistent with the pro-competition objectives stated in section 1021 of the Dodd-Frank Act, is encouraged to consider:
We need to bring back the Glass-Stegall Act, which kept banks and brokerages separate. It's not really about competition, though; it's about isolating broker failures from bank failures. That was in Trump's plaform, by the way.
If you think Google, apple, Microsoft, and Facebook are evil, then other kinds of business like Pharma, insurance, bank, agriculture are 10x Satan reborn combined.
> Facebook and Amazon are now the two biggest corporate lobbying spenders in the country.[9]
> Big Tech has eclipsed yesterday’s big lobbying spenders, Big Oil and Big Tobacco. In 2020, Amazon and Facebook spent nearly twice as much as Exxon and Philip Morris on lobbying.
> Big Tech’s lobbyists are not just numerous, they are also among the most influential in Washington. Among the 10 lobbyists who were the biggest contributors to the 2020 election cycle, half lobby on behalf of at least one of the four Big Tech companies. Together, just these five lobbyists contributed over $2 million to the 2020 elections.
This is more about power and reach. I'm going to pick on Facebook since they are easy to dislike. They are the medium of disinformation that is hurting the US and the world. First, people are joining extremist groups due to FB recommendations [0]. Second, vaccine misinformation has been spreading on FB. [1] Those are two horrific examples, but there's more.
Or that you really, really need to establish precedent (and ideally, a pttern) by first successfully going after the "easier" targets. It's much easier to go after fintech and banking if you can go "what's the problem, you're just next in line, your industry's hardly getting singled out"
Banking is getting impacted in this series of executive orders, there’s a mandate that banks make customer financial history portable so that customers aren’t locked into continuing to use their current bank to keep their financial records. Aside from that issue that stops customers from being likely to switch banks, there’s a ton of competition in banking. There are many consumer banks, they all provide essentially the same services, and they compete on things like branch density, customer service, and saving/loan rates. Aside from that, consumer banking is already one of the most regulated industries.
Fintech consumer products and services are rare with the exception of tax preparation. E-trading is becoming more popular, but existing consumer banks and brokerages are stepping up to compete across the board. Intuit’s TurboTax product is really the only example I can think of in the fintech industry that needs antitrust attention.
Well, the Obama admin that included him was fully in the pocked of the bankers as revealed by Wikileaks. They chose 29 of 31 cabinet positions. Seems that not much has changed there.
Yes and that's a good thing. Politics is mostly a game of pretend and therefore bullshit, as uhh.. engineers we like to be more practical. We simply see the bullshit they are selling regardless of political affiliation. If they wanted to actually solve problems the approach and results would be totally different.
Politics is mostly a game of pretend and therefore bullshit, as uhh.. engineers we like to be more practical.
I've found that when engineers talk about politics, they're no more practical than anybody else. On HN I see a ton of uninformed and simplistic overbroad solutions. They imagine it's pragmatism, but they don't actually know any of the real problems.
Worth noting that the Pharma industry, as well as Big Tech and Wall Street, supported Biden. As a Biden supporter I’d like to believe that this is because he’s an old school Democrat and not afraid of biting the hand that feeds him. More cynically, this could be seen as posturing to keep together what is a very weird coalition (Occupy Wall Street and Wall Street under the same tent).
> The best answer, in my view, is that the Republican Party’s remaining connection to the dominant sectors of the American economy occurs through its usefulness as a tool to selectively balance and discipline the members of the Democratic coalition. Big Pharma, for instance, will throw money at the Heritage Foundation to rant against “socialized medicine” whenever talk of the government negotiating drug prices surfaces, but pharma is hardly interested in repealing Obamacare, much less dismantling Medicare. Financial lobbies will rent the Republican Party to ward off troublesome regulations or taxes, but are hardly interested in “sound money” policies or big spending cuts that would derail financial markets, never mind social conservatism. Big Tech will team up with Americans for Prosperity to oppose legislation limiting app store developer fees, all while more aggressively controlling conservative speech online, and so on.
"Hearing aids cost thousands of dollars apiece, for no other reason than there is a cartel established by government that prevents firms from selling hearing aids without a prescription."
An example of how many (most?) monopolies are able to exist because of some sort of legal authorization or protection. Regulatory capture.
There are dozens of companies who would no doubt start making inexpensive hearing aids tomorrow. Absent government regulation, they already would be.
>An example of how many (most?) monopolies are able to exist because of some sort of legal authorization or protection. Regulatory capture.
To be clear this "legal authorization or protection" is not necessarily over regulation. Depending on the market, sometimes monopolies are the result of too much government regulation and sometimes they are the result of not enough government regulation. For example, most of the big tech monopolies do not exist because of regulatory capture. They exist because the government never put in enough effort to stop the monopolies from forming.
> For example, most of the big tech monopolies do not exist because of regulatory capture. They exist because the government never put in enough effort to stop the monopolies from forming.
Is it possible they exist because the immense economies of scale and near zero marginal cost that software provides makes for a winner take all market?
As a customer, why would one use the 2nd best option, when the best option is available at no extra cost or very little cost?
I don't know if I would argue it applies to tech, but the economic term for this is a "natural monopoly", a market where the most efficient outcome is to have a single supplier. A common example is electrical transmission, since it wouldn't make sense to have 3 separate overlapping distribution networks. These are typically allowed to exist by regulation and controlled in some way, for example there is the common carrier concept for electrical transmission.
That assumption doesn’t go well with what we saw in the case of Instagram and then Snapchat. Both took significant share out of Facebook but Facebook was able to buy Instagram and copy Snapchat to retain its monopoly. The Instagram acquisition shouldn’t have been possible is what the parent seems to be alluding to.
Instagram had 10mn users and a one week old Android app at the time it was acquired.
Their ad system was pretty much ported from FB, one assumes, and their ads were sold by FB reps as part of a package.
I honestly don't know if they would have made it independently (and we'll never know, I guess).
The snapchat thing was different. Snap had a policy of focusing on iOS, while FB, IG and Whatsapp (all of which cloned their core feature) were available on Android. I personally think Snapchat shot themselves in the foot with bad product strategy.
And look at TikTok. They are definitely the biggest competitor FB have ever faced, so I'd imagine that the future competitive landscape for them looks much more difficult than the past.
Well yes, that is the "Depending on the market" part I mentioned in the sentence before the one you quoted. Some markets have traits that are more likely to lead to natural monopolies. A government acting in the best interest of its citizens would usually work on creating regulation in these markets to discourage monopolies.
You make an implicit assumption that a monopoly can't be the best way to organize an industry, and that competition is always better.
I'm not convinced by this assumption as i've seen contrary evidence. I've seen monopolies doing a great job, and i've seen competition destroy quality of service and price.
I would agree that the government needs to mitigate private actors. This regulation can take the form of splitting a monopoly but it can also take the form of keeping it a monopoly and regulating it by having a presence on the Board or through law.
The idea that we need multiple groups of people working on solving the same goal concurrently doesn't strike me of a one-size-fits-all approach. Multiple competing restaurants in a town is probably the way to go. Having virtual operators on the back of one physical infra as is the case with phone carriers for instance I would say is probably causing lots of overheads. I've seen it first hand from the inside. Turns out it's really complex to virtualize infra and have tenant-based billing. The only real difference is now you have 5 companies competing on marketing and offers on top of the same physical reality. Marketing costs can't vanish so the consumer is losing that money one way or another
Big tech wouldn't have the silos or platform lock downs (ie power/user capture) they have today without the ip legal framework. People would be able to legally circumvent their bs and offer services around gaps in their platforms and would encourage more competition and result in a less monopolistic practice.
I think all monopolies are violence enforced or they are competitive otherwise somebody would step in and undercut their costs and the government has a monopoly on violence so...
It's reasonable to conclude that Facebook and Twitter have benefitted greatly by not having expenses to properly monitor their platform due to section 230 safe harbor exemption. They are able to get away with selective enforcement on their platform and not pay a monetary penalty for doing so.
The only problem I see with allowing anyone to offer hearing aids is the hypothetical problem that a malfunctioning product may harm someone's hearing further.
That's a real issue to be addressed, but generally I agree that making it easier for people to help other people is better than throwing up obstacles.
A huge number of everyday products have the potential to cause serious harm if they're defective, but they generally aren't regulated to the extent that hearing aids are. As a sibling comment points out, the threat of law suits keeps manufacturers in check.
> There are dozens of companies who would no doubt start making inexpensive hearing aids tomorrow. Absent government regulation, they already would be.
And with the lack of certification requirement, someone will start cutting corners to make an extra chunk of profit. Just imagine a faulty hearing aid that fails while a person is driving, and the person causing an accident as a result. Good luck suing anyone over that one. Or people mis-tuning hearing aids leading to more damage than before.
Another thing I can easily imagine is unscrupulous manufacturers using banned chemicals to manufacture the hearing aids. We have enough of this sort of shenanigans with nickel allergies in jewelry.
They're not, but it's still illegal to drive with headphones.
Deaf people still are unable to properly hear so are more unsafe when driving. They're legally allowed to do so because of deaf people lobbying legislators to force them to be allowed to do so.
Even assuming that’s true, if your hearing suddenly cuts out, and you decide to pull over in response, the chance you’ll encounter one of those objects in the few seconds it takes to pull over is rather low.
For this to be a real danger, either the driver would have to not notice that they suddenly couldn’t hear anything, or the faulty hearing aid would have to pass through some sounds but not others. Both of those scenarios seem pretty unlikely.
Meanwhile, from some quick googling, it seems to be common for completely deaf people to drive; apparently there are devices that can translate sirens and such into visual cues, but such devices are not universally used. To be fair, it’s a bit different if you’re not expecting it or practiced at it.
Bose’s hearing aids were recently approved by the FDA, and they’re only $850. The APM Marketplace program recently covered this development and the hearing aid monopoly. The sky isn’t going to fall.
> Bose’s hearing aids were recently approved by the FDA, and they’re only $850.
Only $850? That is a new use of the word only as far as I'm concerned. These things, which are in many ways similar to if not identical with bluetooth earbuds should not cost more than those - and given the fact that Apple managed to convince people that $200 is a normal price for these things that should leave more than enough margin for an unhealthy profit margin seeing as how the ones I'm using cost ⅐ of that while achieving a longer battery life.
The only progress needed here is for the protection racket to be broken down, this can be done with the stroke of a pen. Allowing it to "take time" only gives those who seek to extract as much money as possible from the artificially limited market more time to do so.
Being European I think they will pay even less attention to me than they would to their constituents. Hearing aids are expensive on this side of the Atlantic as well though - although less expensive than in the USA - so it is still worth finding a way to open up this market. Just like intrepid hackers managed to turn routing appliances into versatile network components by creating OpenWRT, DD-WRT and similar "hacks" it would be refreshing to see something like this happening by someone creating new firmware for earbuds. While this would not be a real solution - hearing aids need longer battery life than earbuds for starters - it would give lie to the defence of high hearing aid prices. Any earbud with active noise cancellation probably has enough DSP capacity to implement the equaliser necessary to function as a hearing aid so the hardware should be available for such a hack.
There was an IndiGogo project aiming to produce 2-in-1 earbuds/hearing aids, it was funded in 15 minutes...
The high price for hearing aids in the US is due to that independent providers need to mark up their hearing aids to pay for their overhead. So a $4k/pair hearing aid might have cost $2k/pair for them. Here Costco also sells hearing aids so they private label the same top end hearing aids for $1.4k/pair. They are a lot cheaper because they make profits through their overall membership base. Also they can negotiate a volume discount. Based of talking to the audiologist, I'd say the supplier sells them for $1.3k/pair tops.
Having hearing aids myself, the big thing is amplifying the sound without the noise. The device needs to figure out what to focus on. If I'm in a restaurant with lots of background noise and people talking, what should be amplified. Most hearing aids use multiple microphones and program settings to identify what to focus on. And there are different kinds of noise like car engine noise or HVAC noise. And don't forget the wind noise on the microphone when you are walking. Also hearing aids compress the dynamic range and frequencies to extend the range of hearing to improve comprehension. And if there is a sudden loud noise it shouldn't go beyond a comfortable power level.
Yes, a hearing aid is not the same as a noise-cancelling earbud, they use different algorithms and the former needs to be more configurable than the latter. Then again, this functionality is implemented in firmware and uses common audio processing algorithms on off-the-shelf low-power DSPs, just like those noise-cancelling earbuds. The IndieGogo example I mentioned seems to be able to sell a pair of multi-purpose buds for around $250 a pair, $600 for 3 pairs. Assuming they are actually making a profit on these sales - and I don't see why they wouldn't, the hardware seems quite standard for noise-cancelling earbuds - this is proof of what I stated before and gives lie to the "overhead" excuse for the high mark-up, especially given the small size of the company behind the things. Of course I do not know whether the buds sold through IndieGogo are as capable hearing aids as "regular, overpriced" ones and I do notice that the stated running time (18 hours) is that of the buds and the charging case together - the buds themselves last for 7 hours between charges. They're specified for "mild ~ moderately-severe hearing loss" and seem to have the required amplification and equalizing capabilities [1]. Maybe give them a try? I don't need hearing aids myself but my mother does use them so I'm thinking about getting her a pair of these once her current pair is in need of replacement.
Hi, I wear hearing aids full time and have been wearing them all my life. They are not identical to Bluetooth earbuds. The sound is completely different. Hearing aids need to be able to be adjusted to the wearer’s particular hearing loss. For example I need more amplification on high frequency pitches and less amplification on lower pitches.
Good hearing aids are also environmentally aware. They will adjust the amplification to be different in a car, bus, and quiet conference room. Cheap hearing aids rarely do this well. There is a very drastic difference between 800 dollar hearing aids and 10,000 aids. Trust me, I’ve tried both of them.
At best these Bluetooth headphones / earbuds you mention can just make all noises louder, across all environments. That helps a bit but it is not the same as what a good pair of hearing aids can do today.
$850 each and as of a month or so ago only available in 3 states.
At Costco you can get what seem to be high end hearing aids for $699 each. The current generation are rechargeable and support bluetooth. This includes the free hearing test free fitting ("real ear", which is current best practice) and followup so long as you have a membership.
The key thing that is lacking is a decent app or api for me to write my own. Oh, that and phone conversations using the hearing aid's bluetooth is pretty bad.
Cue rating agencies passing anything because hearing aid companies can go to another rating company if they don't, like what happened with mortgage securities in the 00s...
If it’s true that hearing aids shouldn’t need a prescription and can be made cheaply, shouldn’t it be easy for anyone who needs one to buy online from overseas? The same way you can get grey market viagra.
The problem is that you don’t want zero regulation. That’s how you get fire hazard USB chargers from no-name Amazon sellers. You want minimal safety regulations — and no more.
Well, if that were so, you would expect them to be secret and to never expire. The fact that are published and expire after a relatively short period belies the simplicity of that statement.
In today's world, 20 years could mean the patented object is obsolete by the time it is public domain. Having exclusive use of the technology for the duration of it's useful life expectancy seems like a monopoly to me...
Yes, there is probably a good argument to be made that many patents should have a shorter protected period. Also the "non obvious" requirement for an invention seems to need more emphasis, when an idea like "one click ordering" can be patented.
Ever greening patents is standard practice today. This is why insulin is so expensive. Another good example is Disney's bs. They have kept thinks out of public domain for over a hundred years.. The 20 years thing is for the little guy, if he can ever afford the 50k patent and legal fees in the first place.
Yeah, that used to be the point of patents. Now it seems it's mostly to squeeze as much out of people by capturing the majority of the market by not allowing similar products.
I mean, we have CEOs of biomedical companies admitting that they aren't basing prices off of what it costs to research, develop, and deliver a therapy, but rather base it off of what a deaparare person is willing to pay for it. This is the very thing antitrust laws were supposed to prevent, but the patent system is used to create a similar environment.
Agreed? Patents are being misused. We should fix that. Patents fixed gross injustices when they were created, and we shouldn't forget that, either. Software is probably the worst example of a field for patents and I think the case for patenting algorithms or design is dicey. But if you sink 100M into drug R&D, a novel type of medical device, or a new type of semiconductor CVD process you should have some protection against reverse engineering from competition for a period of time.
Since the problem seems to come a lot, maybe the problem is the role of money in politics and we should address the root cause. Just a thought.
Drug companies spend more on marketing than on R&D. Much of the research is done with grants and government money. The vast majority of medical devices use the 510K process for approval, which means they are substantially similar to existing device (to bypass testing).
Sure some protection is necessary. You could make it based on development costs and have much shorter times for things that were cheap to do.
"maybe the problem is the role of money in politics and we should address the root cause. "
There are a lot of problems in politics that should be fixed - rules for thee but not for me (rule of law ignored), basically insider trading, high lifetime pensions, long careers, two party system, media bias/lies, and even problems in the voter base (us v them). Money is an issue, but it's really only good if the constituents are gullible or believe in the ends justifying the means. The real root of all of this is that politicians are a separate class from the rest of us and aren't accountable to anyone unless their transgressions are egregious, and then only sometimes. Rule of law has become a joke.
Drug companies are just similar to software in that regard. They acquire a bunch of companies that do basic R&D and get drug pipelines. Those founders get rich because they have patent protection. Just look at biosimilars for a taste of what might happen without patent protections.
I am more familiar with the 510(k) that most people are. It bypasses some testing, but there is still a fair amount of work. It has nothing to do with R&D expenditures that may or may not be behind an submission.
510K is faster and cheaper in regards to studies given that it doesn't necessarily require human data nor clinical trials, which can be fairly large costs.
No you shouldn't.. The idea that your idea is so novel it should be legally enforced as "yours" is pretty egotistical imo. How do you credit the millions of ideas you are basing yours off of. It's also information, it's not "stolen" in the sense that multiple people can't use it at the same time.
Benefit of rnd is being first to market. You will capture much of the market while everyone else catches up and you are in a better position to innovate.
Also without these legal barriers if somebody can improve on it and make it better that's better for the community and consumer at large and allows for constant iteration.
Also there is a lot of bad behavior and things encouraged by the patent system. You have judges giving patents over technical nuances they can't possibly learn in a courtroom. You have companies like Intel spending millions on legal teams to enforce things rather then engineering innovation, which is great until you are no longer the dominant player and global players don't play by those rules.
As someone who started a business only to get a bullshit suit that I was unable to afford by one of the largest re insurance providers in the world (#1/2), the idea that the ip/patent legal framework as it is today helps the little guy is a slap in the face.
They preemptively sued me in a state I've never worked in or entered for that matter because the favorable corporate law there, and that is why they have their hq there. They would file a bullshit motion, get everyone in front of the judge. Somebody would point it out, they would retract it, and immediately file a new one and request everyone have time to review it. All the while bleeding me dry at 500$ an hour for litigation on top of travel expenses plus the regular legal fees of multiple lawyers across two states.
The whole thing was bullshit, lots of red flags but I lacked the capital to assert my agency legally..
The ip/patent framework as it is today helps nobody but big co and promotes regulatory capture. It prevents the kind of reverse engineering you see in China and why we don't have things like removable battery cell phone mods and other "hacks" here. It's why the right to repair is an issue at all, if they didn't have this legal framework they wouldn't be able to enforce any of it legally. Somebody would come along and offer a service to do it at a fraction of the cost. Why do I have to keep buying the same media over and over again on different formats. It's amazing to me seeing the most authoritarian regime in modern history leverage the free market better than the "capitalists".
Sorry for the rant but this shit is imo the reason for most of the corporate bullshit today. It's what empowers the lawyers.
If you tossed out the patent system, would you get any less screwed? Or just screwed in a different way, or worse?
I really don't know. Your experience is awful and clearly unjust and an abuse of the system. You didn't mention Texas, but I'm guessing Texas. What happens there is a national disgrace.
The court system is a joke. It has nothing to do with justice. On the criminal side, you can get a citation for a $500 fine and it's better to just plead guilty because a lawyer will cost you at least that much. It's a financial punishment even if you are innocent. If you don't hire a lawyer the judge won't take you seriously and call you names like "sovereign citizen". The number of mistakes and the amount of ignorance by the people running the system is repulsive and leads to violations of rights.
As just one laughable example, I had a magistrate think that requesting the case to be dismissed with prejudice was me calling him prejudice. You dont even need to have a law degree or pass the bar to be a magistrate.
Now they just file the patent before inventing it, let you do the R&D for them to make it a reality, and sue your for patent infringement when you go to market.
Plus, Biden is the last person to be trusted with this. The overall lockdowns in the US are basically a joke. Your government let big pharma abuse the entire society for more than a year and people are still so discombobulated by what happened that they've started to develop a stockholm syndrome.
One of the principles of public health is that you can't just look at one disease isolated, you have to look at public health as a whole. With lockdowns there's been a lot of collateral public health damages: Cancer treatments and scanning that were not provided, worse cardiovascular disease outcomes, diabetes not being properly taken care of, tragic mental health situation, education of kids going to school, and other unintended side effects. One of the things known from the beginning is that, even though anyone can get infected with covid, there's a 1000 fold difference in the risk of mortality.
A lot more people support action than support any given outcome. I worry that the majority will be disappointed by the outcome because of this.
Take the big tech action: some people support it because they want less censorship (that's me), others because they want more. The same applies in other aspects of peoples' issues with big tech (fake news, hate groups, grooming and CP, privacy, foreign election meddling etc). We can't all be happy with whatever the FTC does to social media sites can we, given we mostly want different things.
"The most interesting pushback was by Google, Facebook, and Amazon, as well as Chinese giants DJI and Alibaba. All of these firms speak though the trade association Netchoice, which has them as key members. Netchoice didn't bother to try and convince Democrats. Instead, the big tech trade association used the order to lobby Republicans, making the case that Biden's actions against monopoly are opening the door to a larger more powerful government. Here's the key part of Netchoice's statement:
"Sen. Lee and Rep. Jordan's warnings were right - when Republicans back progressive antitrust proposals because of concerns about tech, they open the door to progressive antitrust activism... By backing hard-left proposals, like nominating Lina Khan to the FTC and Rep. Cicilline's antitrust legislation, anti-tech Republicans bear responsibility for the damage that will result from importing a European-style antitrust framework to all sections of the American economy."
Netchoice represents mostly American giants, but also Chinese dominant players. So it's interesting is to see the Chinese tech giants through their lobbying proxy coming out against Biden's anti-monopoly actions, and praising conservative Republicans Jim Jordan and Mike Lee in the process. It's clear that both big tech, and China's own tech giants, do not want to see anti-monopolists like Lina Khan succeed. But conservative Trump-supportive ranchers, by contrast, do."
It is almost as if these "tech" companies are trying to sow divisiveness. Divide and conquer.
> It is almost as if these "tech" companies are trying to sow divisiveness
It's worked in their business model for over a decade. Their actions over the last five years have shown they have built up operations as core competencies in helping divide our country. Although one could argue they are just delivering what their customers want (otherwise customers would leave said platforms).
So why do we a accept that VC's invest in software tech but we don't expect them to do the same in biotech (obviously some do I am generalizing) but instead expect Americans (mostly, I live in Canada though) to subsidize Big Pharma through taxes and, in many many many cases outrageous costs for decades old drugs?
Apparently, because Americans tolerate it. A bunch of factors lead to higher drug prices here and an almost complete inability to agree on a way to fix it.
A lot of it comes down to tribalism: "I'd rather pay higher drug prices than lower drug prices your way."
Here's an article from the NYT about how they are trying to ethically sell Hunter Biden's artwork. "Ethically sell" was a term I chose specifically because Hunter Biden is not an artist, and the question of why his paintings are being sold for half a million dollars and to whom is substance.
No. In what world does buying setting from an adult relative consist of a donation?
And if a foreign government overpaying for hundreds of thousands of dollars worth of hotel stays in properties owned by the politician is not considered a donation, I can't imagine anyone thinking the painting thing would be.
That's anonymous - there's no way for the Biden's to ever know the buyer. Of course, the buyer can just show them a picture of the painting in their house or whatever but that would be unethical.
I can understand them going after Ag and Pharma in a big way, but I'm skeptical about the Tech part. There is just too much to lose in political support from that industry for any politician to attack them too aggressively.
I hope it’s real. We need modern anti trust laws, big tech is out of control. You’re right though.. sadly. Most importantly, we need to get money out of politics to free our government from the grips of these corporate conglomerates.
If there is no viable alternative then it’s censorship. Put the power of moderation in the hands of people, create a market for it, that’s a winning strategy.
What are some of your opinions that can't be shared freely on at least some platforms? "Conservative opinions" don't count, because if they were actually censored then I wouldn't have to have them rammed down my throat every minute of every day from every angle.
What does Ag do? "Efficiency Is Everything" eats for $500/year. Compare that to medical which is a minimum of a few thousand dollars a year if you are perfectly healthy and $20000 if you have a 1 day stay at a hospital.
Big Ag is responsible for horrible factory farming practices growing the wrong crops and producing food lacking nutrients while destroying the environment and torturing animals. They take huge subsidies and use them to support these unsustainable practices.
Economies of scale, when viewed from the perspective of a cattle beast in a feed lot are a horrible thing in agriculture.
Modern industrial agriculture with its expensive inputs, ruination of land, and abuse of live stock is a quite horrifying thing and is impoverishing the people responsible for the base of our food supply.
It is the most efficient in terms of output per input, but not by most other measures.
What you say is true in theory but not in aggregate. It's no different from any other business in that respect. Look at companies in a field you are familiar with and you will find that the very large ones are a lot more impersonal, ruthlessly efficient, and amoral.
That's the huristic I'm pushing back on: Big = bad, efficient = bad, ect. Some problems are indeed exaserbated at scale, others are not. I think this is especially true for the ag industry and the issues mentioned up thread. You can bust up the biggest factory farms into 100 smaller companies, but they would still have the same practices. Same with monocrop farming.
But at least the concentration of wealth would not occur, and right now wealth = power, which often means anti competitive practices like simply buying competitors.
if you have 2 big companies they’re “too big to fail” and can better whether lawsuits with massive legal teams, settlement money, pr firms… if you have a thousand smaller companies you can bankrupt 100 and be ok
a lot of it can be rolled into “diversity is better” IMO - lots of diverse types of leaders, diverse strategies, perspectives, risks, failures, etc… mega large companies don’t give us as much benefit as they’d like us to think… I’d even argue that they’re worst in most ways for 99% of the people involved
I prefer a more competitive, dynamic, and diverse market for almost all products as well. However, most of this thread is pie in the sky wishful thinking that busting big corps will solve all of societies ills. Attribution of these ills to mega corps often ignores the actual problem and obfuscates the real solutions.
I think it could help with some issues, and perhaps hurt with others.
I grew up in a farming community and even mom and pop farms paid into national associations with a strong lobbying arm. on the up side, at least these associations favor policy that is usually good for the industry at large.
That said, I think the real solution is making sure that government officials are accountable and not for sale. No amount of big company busting would fix that problem.
The fact that one of the largest famines in the Western world as of late was caused by an economic system that led to people relying on monoculture crops to feed themselves[1], the fact that ours results in monocultures, as well, should be worrying.
I think for tech, the forks/knifes are out from both parties, for different reasons. As for the other industries, I am much more skeptical anything significant will be done.
This administration as pushed lots of 'agendas' just for political show even though it new it had 0 chance for them to pass and wasting everybody's time.
Time will tell if this is just another political show, or they will actually accomplish anything.
But, see, if I'm a politician, it's exactly "there is just too much to lose in political support from that industry" that worries me. I've seen how much weight they can throw against a politician they don't like; I've seen them decide to go from "not throwing that weight" to "throwing that weight" very abruptly; and I realize that such a move can be made against me at the drop of a hat. That would worry me. Would it worry me enough for me to risk triggering their wrath right now? I don't know.
As a non-politician, here's what I think needs to happen. They either need broken up, or they need heavily regulated. (We didn't break up the power companies. But we did create the Public Service Commissions to heavily regulate them.) I could see a Public Network Committee or something, saying: "No, you can't make that change your UI to make it even more addictive. No, you can't gouge advertisers. No, you can't directly sell personal information..."
The Republicans will never go this route because of the risk it would work and be used on other industries. The Democrats will never go for this because it would open up social media to 1st amendment claims which would prevent the censorship they depend on.
I hope they take a look at VeriSign's monopoly power over .com/.net. We saw how dangerously close .ORG got to being turned into a rent seeking tax on non profits. .COM/.NET are a licensed rent seeking monopoly with increasing prices and decreasing costs to serve and no contract competition. Those contracts need to be made competitive, there are plenty of registry providers who can do it cheaper and VeriSign as a company exists because of those no-compete contracts.
The reason we can afford universal health care in my country is because there are hard caps to the prices health professionals can legally ask, be it for fees or medication prices. If the prices are kept closer to their real value, and not inflated prices, then it's already much more affordable to consider paying for universal health care.
Yes there's a good argument that insurance in the US has artificially increased prices. College loans have done similar. This is why the ACA (obamacare) kinda failed to fix most of the issues. Care is much too expensive.
This would be a good move, but don't most people get insurance through their employer? To me that would really be the thing to break asap. Can people really shop around? It's either getting an expensive insurance on your own or a much cheaper one via employment but extremely limited choice.
The main barrier to getting rid of insurance via employment seems to be the very high cost of premiums. Employers are able to get much better deal for their employees than a single individual would be able to negotiate with a carrier. Maybe we would need an electroshock including banning employment based insurance and allowing carriers to operate anywhere. This would immediately kickoff the competition between carriers.
I think you misunderstood GP. I don't think he was claiming that the insurance company was literally buying stocks, he is saying his manner of insuring his health is buying hospital stocks (in the hope that their value will go up high enough to pay off any medical procedures he needs in the future).
Finally, they've started attacking big tech on the privacy front. The whole "monopoly" and "anti-trust" thing was going nowhere. But privacy orders like this are a step in the right direction.
And to put the nail in big tech's coffin, congress should pass a law forbidding the sharing of any personal information on any resident of the US for any commercial reason whatsoever. With draconian penalties assessed per user infraction. That would stop these tech companies in their tracks.
> And to put the nail in big tech's coffin, congress should pass a law forbidding the sharing of any personal information on any resident of the US for any commercial reason whatsoever.
At this point, a huge number (majority?) of Facebook et al users know what Facebook are doing. They value their own data less than Facebook do and are happy to trade it in return for free social media service. You may not like it, but free people should be able to engage in a transaction if it’s not infringing on other peoples’ rights.
I’m not sure why you would know what’s better for them than they would.
Facebook shares lots of data about people who have never signed up for a Facebook account. Everyone is a Facebook "user" whether they want to be or not.
> Facebook shares lots of data about people who have never signed up for a Facebook account. Everyone is a Facebook "user" whether they want to be or not.
Same with Twitch/AMZ, YouTube/GOOG, Target, Wall Street Journal, etc. It's basically the state of digital advertising today, which is not remotely limited to or monopolized by FB. I've worked on the adservers, across multiple companies, for over 15 years now.
It is infringing other's peoples rights. Shadow profiles are and even if you paid for subscriptions everywhere in the net, you could not get away untracked and being targeted for ads you neither want nor need.
Source because I’m pretty sure that’s not true. If that was true GDPR wouldn’t exist in the EU. California has CCPA in the works which is similar/same. People don’t like how big tech is using their data and actions are being done to counter it.
Some people buy an iPhone just because Apple imposes draconian rules on Facebook. People do put a price on privacy, thousands of dollars probably.
When you reduce the value of interconnecting people to a linear scale, it’s unfair. How much value do you put on a friendship? How much value do you extract from belonging to a Facebook group? It’s probably a million dollars per person. It doesn’t mean the privacy part isn’t extracted by coercion, taking friendships as hostage, threatening to remove you from participation to a lot of the social life if you revoke your Facebook account.
> How much value do you extract from belonging to a Facebook group? It’s probably a million dollars per person.
No idea what you’re on about. The average person doesn’t buy Apple products, they have a small percentage of market share. You’re just throwing absurd numbers around.
You’ve argued my point: people value socialization (millions, according to you) more than they value privacy (mere thousands, again according to you).
Nobody forces anybody to use Facebook. Yet billions use it. It boggles my mind when people feel they should dictate other people’s personal choices.
While ultimately a ban on sharing personal information for commercial reasons would be good in the long term, in the short term (many years, certainly, maybe forever) it would serve to entrench existing big tech companies. Google, for example, doesn’t directly share personal information with advertisers. Where side-channels exist that would enable advertisers to extract data from Google, Google has the scale and the resources to create technical solutions like having advertisers send their entire software stack to run in Google datacenters so that Google can ensure nothing is being logged, and force advertisers to comply. Facebook, Amazon, and Apple likely have the resources and scale to pull of the same feats. Anybody else would be put out of business. Hardly a mandate that would make sense in the context of encouraging competition.
I was thinking more along the lines of heavy fines.
I'm not a big supporter of violence against pharma, tech, and Ag CEOs. I'm not a big supporter of violence against anyone where massive fines will serve the same purpose. In fact, the fines would work better.
I feel there is nothing the government is going to do about that. This doesn't mean that I throw up my hands and say, OK, I'll let everyone have all of my communications logs since the government has them.
I personally believe being targeted with advertising is much less intrusive than the government having unfettered access to my daily interactions with people and various institutions. I would prefer to not have to worry about either.
I'm generally skeptical about all such news but a few things make me cautiously optimistic:
- Lina Khan: I had heard about her a long time ago before she even got into politics. She is known for her academic work on antitrust and big tech so she definitely understands how monopolies work and how they are unfair.
- Biden saying "Capitalism without Competition is Exploitation"; simply the acknowledgment by a sitting president that what we have today doesn't look like capitalism anymore is in itself a huge achievement and lays the groundwork for real improvement. Now, everyone knows that something needs to be done and everyone knows that everyone else knows that!
- Biden is getting old and probably doesn't care about a second term in office. It's possible that he decided to make as many powerful enemies as necessary to secure a great legacy for himself.
That said, I think that people have such low trust in government and media nowadays that I don't expect anyone from the right to warm to Biden until we see actual results.
here [1] they say that Kamala Harris is seen as a friend of big tech and silicon valley, that would imply she is a friend of big tech corporations. Does this step signify a rift between Biden and Harris, or is that not the case?
That’s possible but the article is a year old. This past year and a half I think if you polled the HN crowd you would even see a dramatic shift in perspective on proper policy for big tech antitrust legislation.
It is not unreasonable to assume those same realizations are happening or being expressed by government officials as well.
it makes sense that Biden wants to tax big corporations to finance his infrastructure projects. [1] that would make sense if Biden is a big fan of president Franklin D. Roosevelt, i am not sure if Roosevelt is as attractive to someone from the generation of Harris. (however i don't know if the generation aspect is a matter of importance, in this context)
The sentence "Capitalism without Competition is Exploitation" immediately makes me think about the many monopolies held by the government. Will he do something about those too?
Is he really in a position to keep doing this?
Biden recorder the most votes in history, while winning the fewest counties. That's a head scratcher. The fact remains most of the geographic area of the country voted red. If he keeps this up, states are going to start ignoring his executive orders. That's not how democracy is supposed to work. Laws get passed by legislature, not by dictate of the King.
The stacking of improbabilities is a head scratcher. 12 million vote increase over Obama with 300+ fewer counties.
Must be wildly more popular. Yet was losing the nomination of his own party. Can't 10k views on youtube, but somehow more black people turned out to vote for him in Detroit than Obama. I, like 40%+ of Americans have doubts about this Election.
> The stacking of improbabilities is a head scratcher. 12 million vote increase over Obama with 300+ fewer counties. Must be wildly more popular.
Counties are a meaningless, nonuninform unit, and even if they were the exact same counties minus 300, so what? That just means bigger margins in the counties he won, which would be consistent with greater regional polarization.
> Yet was losing the nomination of his own party.
Biden was the clear winner much sooner in the process than Obama was.
> more black people turned out to vote for him in Detroit than Obama.
Why is it surprising that more black people turned out to vote against Trump than McCain? (That votes in a two-party system are quite often more against the oppoaing major party than really “for” the partt marked is well-known.)
I just don't understand why you're focusing on the counties. Obama's win was over a decade ago. People move around and concentrate in cities.
What would have been wildly improbable was Biden's opponent winning. The man was deeply unpopular, failed to win the popular vote twice, couldn't crack 50% approval for 4 years, was impeached, was being blamed for the terrible US government pandemic response, and had some of the deepest most consistent unpopular ratings of any president since that kind of sentiment has been tracked. Talk about stacking improbabilities.
> I, like 40%+ of Americans have doubts about this Election.
I can understand having some doubts after the election -- it was a very tumultuous time. But why do you still have doubts today? The dust has settled, the results have been looked at in Wisconsin, Michigan, Pennsylvania, Georgia, and Arizona, and no systemic fraud was found. Just read this report by Michigan Republicans [1]. They earnestly looked at everything alleged and found nothing. Absolutely nothing. What exactly are you having doubts about except vague feelings of improbability related to counties? Improbable things do happen, yes?
Since my other got flagged, you’re clearly a confused person. You post videos of trumps lies and defend some narrative that does harm to our democracy. The election was won by Biden.
"Biden won 81 million votes and 509 counties in the Nov. 3 election, while Trump won 74 million votes and 2,547 counties, according to data aggregated by think tank the Brookings Institute. Obama won 69 million votes and 873 counties in 2008. "
https://www.usatoday.com/story/news/factcheck/2020/12/23/fac...
If a lobbying firm is behind official White House communications, and not WH-employed staff, that alone would be a serious allegation. But to say that tech is behind this is even worse.
Me: According to your book, America's political parties have flipped every ~70 years. It should have happened around the time of Ross Perot, so I guess we're overdue. Do you think another realignment is emminent?
Phillips: No. It won't happen while Wall St. and finance remains in control of our political discourse.
--
It'll be amazing if Biden Admin is able to uncork the next cycle. But I'm not holding my breath.
It's about control. These "Big" companies are in a position to collect plenty of data about the market - companies and individuals. They are now able to do what previously was exclusive (read: monopoly) to the government.
I'm not defending "Big *", simply noting that historical context is mostly irrelevant. The game is different now. The rules also different. It's not about markets and dominance. It's not about economic monopolies. It's about control. Control of the future. Control of the narrative.
Executive orders were a constant theme of the previous administration. It was the first time that I’ve really heard about them consistently as a presidential technique and similarly as much in the media.
The lower executive order numbers from the previous 2 administrations before made me think that these were tools used for media attention when I kept hearing about them.
Now the current administration is using them (for causes that I hope will benefit) and I’m wondering are these going to hold weight or is this another media ploy?
Obama dwarfed Trump’s number of EOs. Bush Jr. and Clinton were extremely high as well. This seems to be a response to congressional stonewalling (with varying outcomes).
By your own source, this is so misleading as to be blatantly false. Trump issued 220 EOs in 4 years. Obama issued 276 in 8 years. I wouldn't call that "dwarfing" even looking at the raw numbers, and as a rate, Trump was the highest in history, nearly twice Obama.
Of course, that's only relevant if you believe a priori that (a) EOs are a bad thing, and (b) that all EOs are created equal. Neither of those is true, obviously.
The second one seems like a much easier thing to get rid of using hard government power, and should be the low-hanging fruit.
The first will require a decade of masterful leadership, co-operation from competing interests, and delicate undoing over time that I don't think any country in the west has right now.