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Comment by dmurray | Hacker News Reader

> we should not accept any health care reform proposal that any of the American Medical Association, the Pharmaceutical Research and Manufacturers of America, or the American Hospital Association are generally supportive of.

That seems like a lot of people to piss off to get any reform done.

Wouldn't an actual smart negotiator play off one against the other, and make the doctors support the initiative at the expense of the pharma industry, or vice versa?

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Coal miners, car companies, and sears catalog were not consulted when their industry was disrupted. No one is entitled to a gravy train, especially when your entire industry is cartelized.

Middle men jobs, no matter how good, need to be on the chopping block if all they do is be extractive pests. They can't both be protected from the pressures of the free market, and not have any accountability from an improved service standpoint.

As for the actual workers, Doctors can charge what they like, but they shouldn't be able to limit the supply of doctors within the nation. That is NIMBY mentality.

Those companies weren't disrupted by a democratic government for which all of their employees have a vote.

The government acts at the behest of the governed so they need to get support from at least some of those groups because a lot of families rely on someone working in one of them.

The government has been directly interfering with this industry since the ACA (“Obamacare”) was enacted; forcing everyone to purchase health insurance.

And not before? This industry exists because of government

Before as well, of course. But prior to the ACA there was no requirement for every individual filing taxes to show they had coverage, or most businesses (even relatively small ones) to offer benefits packages.

It also changed small medical practices because suddenly everyone wanted to use this insurance they were paying for. No longer could it just be a doctor and maybe a couple of medical staff; they needed medical coders, specialized software, and so forth. Some decided to join large hospital networks (for worse, from what I have generally heard).

And this cascaded into multiple sub-industries developing around this revenue stream and the medical system. Everyone trying to sell something and grab their piece of the pie.

It was not great before, but you could go see a doctor and literally pay a small amount of cash for an appointment. Many won’t even accept anyone without insurance now.

Edit: as mburns@ pointed out, the IRS no longer asks individuals about their health insurance status since 2019.

The government has been interfering in the industry since at least the imposition of wage controls during World War 2 that drove employers to offer non-cash benefits to attract and retain employees.

Small correction: No one was forced, and the provision you’re thinking of hasn’t even existed for the last 5 years.

It is hard to argue against this comment, because it is not even factually accurate if we accept framing as valid ( it isn't ).

Can defend why Obamacare marked government interference and , for example, not medicare?

At least since sometime around WWII.

Perhaps, but this is also a great example of tyranny of a (demonstrably corrupt) minority. It’s fundamentally anti-Democratic to say “everyone has to suffer worse health outcomes and pay more money because this small group of people has established a quite profitable scam and pays politicians to keep it that way.” This is why most developed democracies don’t allow this to happen. That being said screwing over the majority people to benefit a corrupt, self-serving minority, is about as close a definition of American “democracy” as I can think of, so I expect little of this to change.

> The government acts at the behest of the governed

US here. I remember a Princeton Study from 2014 that found no correlation between public opinion and public policy.

https://www.cambridge.org/core/journals/perspectives-on-poli...

That's absolutely true, but the direction in which public policy fails the will of the govern is predictable. Reforma that hurt a few people a lot, and help most people a little, tend to fail in politics. Things like tobacco legislation are minor miracles in a long line of lobbyists winning. So the way in which the US government will keep failing to match the will of the governed here is, if anything, towards the insiders that are ruined by anything resembling health care efficiency.

I suspect that the disruption will come outside of the regulatory realm: As prices go high enough it's cheaper to get the same treatment in Mexico, or have an AI be your primary care provider, the US system will fall. It will not be this year, and probably not this decade, but eventually such level of waste crashes big.

The US government is arranged to ensure that, the Senate and Electoral College both give significant electoral weight to rural areas in the Midwest. Reading the writing from the time that's intentional and by design.

I feel like "piss off a lot of people" is a general prerequisite to any substantial reform on any topic. Almost anything that requires reform is going to be at the point where it is being abused and (inordinately) capitalized on.

There's always winners and losers with any type of change. Look at COVID. Some companies thrived and had their best years ever and others went bankrupt and closed down.

A lot of negotiators talk about win-win agreements which may be true with just two parties. I think once you get beyond that, no true win-win agreement is possible and some people are going to lose out. Trying to appease every single interest group is what leads to a lack of progress.

> make the doctors support the initiative at the expense of the pharma industry

(Full disclosure: family member works for Big Pharma)

You might not get them to admit it out loud, but Big Pharma sees the USA as the cash cow that funds R&D for everyone on the planet. If a potential product can't or won't ever make it to market in the USA, or if there aren't enough potential patients in the USA to be prescribed said product, then it might never get off the drawing board.

It's (unfortunately) that simple.

If the capitalistic system doesn’t produce results, we can do like India and have state-funded drug R&D and so on.

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

Frankly this system is already deep into market failure in the US and should be reformed anyway. We are not getting important drugs approved here because they can’t make it through approval despite track records of safe and efficacious use in hundreds of millions of people. That’s an intense life-wasting market failure.

Yes, a lot of people don't understand the sheer amount of labor and time that is required to bring a new drug to market. (Edit: Or the number of things that are tried but don't pan out for one reason or another. The success rate is very low.) I myself have only the vaguest understanding. Someone has to pay for it all.

We need India to get rich ASAP, so Indians can start paying for it. :-)

Surprise, surprise but a huge chunk (maybe even the majority of?) of drug research is conducted by academic institutions using government funded grants. Then the drug companies come swoop up the research, refine it, mass produce, and market. They shouldn't be able to get such a free ride from all this government funded research imo. The taxpayers already funded the research so why are they getting the short end of the stick?

Research is the least labour- and time-intensive part of the system.

Trials are punishingly expensive.

Edit: protocol development. Drug interactions. Poisonings, Doctor education -- er, marketing. Incorporation into manuals. There's a lot that happens after the research talent has strutted its stuff.

Edit edit: oh, yeah developing manufacturing and logistics as well. The 'D' part of "R & D" is usually over 95% of the total for a reason.

The challenge is that Pharma companies still spend huge sums on marketing, both to patients and to doctors. While I could probably be convinced that there's some role for spend on physician education about new drugs or spreading awareness, it should be a small fraction of the spend on R&D and manufacturing.

https://www.raps.org/news-and-articles/news-articles/2019/7/...

So the cheap part is government funded but the expensive and risky part is private and you take that as them getting a "free ride".

You’re right it’s a lot of “people” to piss off, but in this context it’s like being a sheep trying to negotiate what’s for dinner with a wolf.

Speaking of negotiators. These groups have very skilled so they wouldn’t just let themselves be played off against each other to their own detriment.

I think most of the issues in the US are due to a sizeable amount of people are systematically ripping the rest off.

Healthcare? Doctors, hospitals, insurance, etc all are taking a bigger cut than they should. You'll get a ton of pissed people if you want to solve it.

Housing? Nimbys are just regular homeowners that block housing to implicitly (or explicitly) protect their property value. Solving that gets a ton of homeowners pissed.

Universities? Tons of university admins and loan programs that benefit from restricting tertiary education supply. Fixing is pissing lots of people.

So much of our economy is captured by large cohorts of people that are not explicitly conspiring to do so, but their incentives moves them to behave like that.

I’d rather piss off a single generation of these workers and get true hard reform for all future generations.

Hm. That’s a good point. Provide government care and it pays more than private insurance (which it should if economies of scale are employed). That would basically gut the private industry entirely.

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