Biden launches action on "Big Tech, Big Pharma, and Big Ag" – can it be real?
mattstoller.substack.com
mattstoller.substack.com
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.
The high cost of medicines that are low cost to produce, and are sold at low cost elsewhere
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.
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.
Half the US defense budget is no where near the amount spent on healthcare in the private sector.
Healthcare:
The federal government spent nearly $1.2 trillion in fiscal year 2019. In addition, income tax expenditures for health care totaled $234 billion.
https://www.taxpolicycenter.org/briefing-book/how-much-does-...
Defense:
Defense spending amounted to $714 billion in FY 2020—and is expected to increase to $733 billion in FY 2021.
[1] https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
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.
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.
damn, right again. That sure is a mind blowing situation the U.S is in.
https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
Medicare spending grew 6.7% to $799.4 billion in 2019, or 21 percent of total NHE.
Medicaid spending grew 2.9% to $613.5 billion in 2019, or 16 percent of total NHE.
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.
At least 34% of that is spent on admin alone: https://time.com/5759972/health-care-administrative-costs/ and most of that is on privately insurers overhead.
> Half the US defense budget is no where near the amount spent on healthcare in the private sector
It would be way more than enough if there was some political will behind it.
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.
The US government could cut significantly into the out of pocket expenses if they halved the defense budget. This link is interesting: https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...
You really think that nobody outside the US are making drugs? Like no drugs are ever developed in Europe??
Cost can be shared among the US and Europe populations. So per user cost would come down by a lot.
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.
It’s available. It’s just far less convenient and much easier to fuck up in a life-threatening way.
The insulin price meme is a particularly bad one.
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)
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.
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.
That's 6% not 1% of the cost of new ones, though.
>McInnis explained since 2000, Walmart has sold ReliOn insulin, the only private insulin brand on the market retailing at $24.88 per vial.
https://www.wfmynews2.com/article/news/verify-yes-walmart-do...
Walmart just started selling analog insulin(the newer formulation) just recently. https://nypost.com/2021/06/29/walmart-to-launch-its-own-low-...
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.
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 would think it's weird if my doc assumes I just want the cheapest available option.
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?
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.
https://www.businessinsider.com/insulin-price-increased-last...
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.
How does the rest of the world make the US do that?!?
According to the CBO pharma R&D was $83 billion in 2019.
References:
https://www.fiercepharma.com/special-report/top-10-ad-spende...
https://www.statista.com/statistics/817534/annual-novel-drug...
I don't see any reason to believe that pharma spends more on ads than R&D. Do you?
No.
> 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.
Pull a public filing for these companies and take a look at their balance sheets; it's pretty straight forward.
It seems to me that US people have been sold FUD by there own pharma companies, if I’m honest.
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.
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.
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.
https://www.aarp.org/health/drugs-supplements/info-05-2010/d...
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.
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.
And it's a real working vaccine, effects of which I see basically every day on my friends.
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.
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.
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).
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.
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.
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.
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.
Every European drug firm also sells in the US, so I suspect that's taken into account in their business model
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.
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.
If that was legal, someone would do it and make bank. And it is the US that is responsible for those laws.
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.
"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.
Yes. Government institutions (academia, DARPA, CERN, etc.) created the original internet!
And then companies messed it up.
If this is true then surely it would be in the US’s interest to stop doing it! Stop us freeloaders from mooching off your drug development!
Personally I’m doubtful that this claim is broadly true though. I think it should at least be backed by some decent analysis.
The US represents less than 34% of global research. https://pubmed.ncbi.nlm.nih.gov/17354441/
and yet, the US has about 5% of the world's population. So proportionally, they are punching way above their weight.
https://en.wikipedia.org/wiki/List_of_countries_by_total_wea...
Healthcare, especially in older population, starts to behave like a luxury good at upper ends of cost / care.
I thought they were still higher.
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.
Ofc bs...
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.
Maybe that's part of the reason medicines cost multiple times more?
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.
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.
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.
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.
There is zero need to advertise drugs to potential patients which need a doctors prescription.
They bought smaller Pharma co's, gutted R&D, and jacked up prices of the medications they sold.
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?
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:
* https://www.youtube.com/watch?v=wpdhD4ZLBxc
* https://www.youtube.com/watch?v=n0L0XbnvJ6I
TLDR: marketing alone outweighs R&D investment, and stock buybacks often account for more than both combined.
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.
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.
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.
After 1980 US really took off though. In 1980 US spend 8.2% of GDP, Germany 8.1%, Denmark 8.4%
By 1990 US was 11.2%, Germany and Denmark 8%
US plataued in 1993 about 12%, lasting until 2000 when it took off again, reaching 16% in 2009, then was mostly flat (slightly reducing) until 2013.
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.
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.
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).
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.
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.
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.
https://en.wikipedia.org/wiki/Health_care_systems_by_country...
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.
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.
Where can we find the explanation?
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.
https://en.wikipedia.org/wiki/Pharmacy_benefit_management
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.
https://en.wikipedia.org/wiki/Reverse_payment_patent_settlem...
I have no idea why these groups have survived scrutiny for their literal multi-hundred million dollar lobbying/bribery of politicians.
My closest guess is that we all know "My" physician or a well paid nurse that benefits from the bribery.
"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?
[0] https://thehill.com/business-a-lobbying/536082-us-chamber-nu...
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."
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.
https://www.physiciansweekly.com/is-the-ama-really-the-voice...
A. Limit medical care to being provided by these people
B. Limit number of residencies
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.
"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."
Here it is again: https://www.ama-assn.org/practice-management/scope-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.
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.
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.
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.
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.
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.
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.
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.
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.
https://www.ama-assn.org/press-center/press-releases/ama-fun...
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 was actually more expensive. I've stopped asking and feel it's a urban myth.
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.
I should add that the same thing applies to glasses.
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.
https://www.fda.gov/industry/import-basics/personal-importat...
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.
And what guarantee do you have of their contents?
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.
[1] https://en.m.wikipedia.org/wiki/Gas_chromatography–mass_spec...
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%.
Maybe you can find someone that'll do telehealth.
Visits to the doctor should be cheaper and more efficient, but people shouldn't stop going to the doctor.
I suspect the sentiment is from commonly interacting with absolutely useless doctors. There are a lot of them.
My professional contacts have told me I'm doing senior level work but nobody will respond even for positions below that.
Edit: sorry it was site https://www.levels.fyi/company/Google/salaries/Software-Engi.... No idea how real it is.
By many measure: if you see a doctor, cross the street.
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.
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.
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.
This is completely ridiculous, and yet my situation is downright reasonable compared to what a lot of people have to deal with.
https://www.rand.org/news/press/2021/01/28.html
> Prescription Drug Prices in the United States Are 2.56 Times Those in Other Countries
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.
https://pharmanewsintel.com/news/insulin-prices-8x-higher-in...
Source: https://www.kqed.org/stateofhealth/205822/northern-californi...
What do you think? - Is this something tech CAN do today, with an open source application and publicly available data?
https://www.whitehouse.gov/briefing-room/presidential-action...
https://www.whitehouse.gov/briefing-room/statements-releases...
In the Order, the President:
* 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.
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.
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.
0 - https://www.politico.com/newsletters/morning-tech/2021/07/07...
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.
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.
You're the one who seems to not understand.
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.
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.
Wasn't this already put in place by the previous administration?
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).
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).
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.
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.
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
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.
There is no price transparency. Sure would like it since I have a high deductible plan.
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.
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.)
https://en.wikipedia.org/wiki/Oregon_Medicaid_health_experim...
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.
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.
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.
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.
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).
https://www.healthcare.gov/coverage/preventive-care-benefits...
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.
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.
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 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 :(
So this is me saying "Thank you."
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.
The lifespan is indefinite. If crystals start to form, you can heat the honey and it'll return to it's normal(?) state.
That said, yes, fintech and banking are conspicuously absent. Which kind of lets you know that they are just too powerful.
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.
https://www.whitehouse.gov/briefing-room/presidential-action...
> (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:
> (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:I read through the whole thing, there are some decent ideas but a lot of filler.
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.
> 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.
0. https://foundation.mozilla.org/en/campaigns/facebook-stop-gr... 1. https://www.vox.com/recode/22319681/vaccine-misinformation-f...
https://newrepublic.com/article/137798/important-wikileaks-r...
Also maybe relevant: https://ksr.hkspublications.org/2021/05/18/can-conservatism-...
> 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.
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.
Or something.
The gap between "too soft, doesn't help you hear" and "too loud, damages your hearing" can be narrow.
Usually it's more of a problem in the other direction, with doctors playing it safe and tamping down the aid to the point of uselessness.
https://www.npr.org/podcasts/381444600/marketplace
https://www.bose.com/en_us/products/headphones/earbuds/sound...
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.
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.
There was an IndiGogo project aiming to produce 2-in-1 earbuds/hearing aids, it was funded in 15 minutes...
https://www.indiegogo.com/projects/olive-pro-2-in-1-hearing-...
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.
[1] https://c1.iggcdn.com/indiegogo-media-prod-cld/image/upload/...
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.
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.
And why wouldn't someone be able to sue successfully?
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.
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.
The entire point of patents...
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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?
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.
Seems to have worked out poorly for them.
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
A consumer shouldn't chhose the second if they don't want to. But governments should step in to ensure that the market remains competetive.
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.
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.
I think that was better for most cases.
There are already dozens of companies making them:
https://www.amazon.com/Hearing-Amplifiers/b?ie=UTF8&node=377...
Top 10 spenders on lobbying in 2021:
"Lobbying Client","Total Spent"
"US Chamber of Commerce","$17590000"
"Pharmaceutical Research & Manufacturers of America","$8664000"
"National Assn of Realtors","$7985521"
"American Medical Assn","$6520000"
"American Hospital Assn","$5852623"
"Blue Cross/Blue Shield","$5774300"
"Raytheon Technologies","$5360000"
"Amazon.com","$5060000"
"Facebook Inc","$4790000"
"Northrop Grumman","$4610000"
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.
Explain.
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.
"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'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).
A lot of it comes down to tribalism: "I'd rather pay higher drug prices than lower drug prices your way."
Career politicians do not betray those who fund their campaigns, especially in the highest office.
The political support is definitely there. But if you’re talking about rich Silicon Valley donors, yeah they might have a problem with it.
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.
[1] https://en.wikipedia.org/wiki/Great_Famine_(Ireland)#Causes_...
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.
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.
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 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.
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.
You mean like chopping off a limb/finger for every violation?
Unfortunately, that won't work for a certain lizardman CEO who is purported to be able to regrow limbs.
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.
Makes me think of an abusive relationship where the abuser is very jealous and protective of the abused.
“If anyone spies on my citizens, it’s gonna be me!”
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.
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.
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.
- 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.
[1] http://web.archive.org/web/20210206212101/https://www.nytime...
It is not unreasonable to assume those same realizations are happening or being expressed by government officials as well.
[1] https://abcnews.go.com/Politics/wireStory/biden-offers-tax-d...
I get the complaints, but so much of these actions feel like they don’t start with an understanding of the benefits large can bring.
Say what now? That doesn’t seem right.
Why is that a head scratcher? 40% the us population lives in just 100 counties (of 3000)
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.)
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?
[1] https://misenategopcdn.s3.us-east-1.amazonaws.com/99/doccume...
Presumably you're talking about this fact sheet?
https://www.whitehouse.gov/briefing-room/statements-releases...
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.
Where is the evidence?
https://theintercept.com/2021/07/06/westexec-biden-administr...
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.
Wealth and Democracy: A Political History of the American Rich [2003] https://www.amazon.com/Wealth-Democracy-Political-History-Am...
Here's a more recent account:
Lobbying America: The Politics of Business from Nixon to NAFTA [2015] https://www.amazon.com/Lobbying-America-Politics-Business-So...
Edit: I changed "Last decade" to "Around 2005". Time flies. My bad.
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.
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?
https://www.federalregister.gov/presidential-documents/execu...
https://www.presidency.ucsb.edu/statistics/data/executive-or...
Barack Obama (D) Total 276 Avg/year 35
Donald J. Trump (R) Total 220 Avg/year 55
Hardly "dwarfed". If anything Trump issued 60% more executive orders than Obama on an annual basis over his one term.
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.
Looks like Trump's average is lower than a lot of previous presidents'.