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Comment by jseliger | Hacker News Reader

we would be better served looking at boring things like medicares 3 million pages of medical claim guidelines, clearing house operations and conflicts of interest, better incentives for state level responsibility, antitrust litigation, lots of practical things that don't make click bait headlines.

It would also be nice to reform the FDA and the clinical trial system: https://bessstillman.substack.com/p/please-be-dying-but-not-...

"Antitrust litigation" covers this, but to spell it out, the increasing monopolization of many local healthcare systems is a huge problem.

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My opinion about the FDA is that it suffers from two major faults, it is always regulating the "last war" and it has the standard federal government incentive structure for policy making which is "do not do anything that according to civil service regulations can get me fired".

In defense of the FDA, which I promise is not an instituion I have much affection for, they are asked to strike an impossible balance. More or less the same regulatory impulse that allowed Richard Sackler to build an empire on the killing of millions of americans is the same one that allows very sick people to access very, at times dubious, drugs and trials that sometimes save their lives.

Most of medicine is very centrally built around the "first do no harm" approach, even at the cost of lives by non-intervention sometimes. With the FDA most people want a "do some harm, some of the time for the greater good" approach which is a really difficult thing for a federal agency to put into practice. I think they do an especially awful job with it but I appreaciate that it is a really hard balance to strike.

Tobacco kills 7x as many people each hour, day, and month as opioids in the USA, and it’s available everywhere without a prescription.

The Sacklers aren’t the problem here, corruption is.

> The Sacklers aren’t the problem here, corruption is.

Why not both?

This is not really a good argument, there are many things that kill a lot of people , The manner and type of lives lost is important also the nature of impact.

People aren’t dying very young with tobacco addiction for the most part. There is cancer in youth sure , but tobacco is not the leading cause of that .

People who die of tobacco related illnesses are functioning adults and contributing members of society for the vast majority of their lives .

The disruption to the lives of drug addicts and their friends and family far exceeds those faced by tobacco addicts.

Not everything is a conspiracy or corruption people only react to what they see, the impact of drugs is far more visceral and immediate than tobacco or say obesity which kills even more, so pressure for legislation is higher

If tobacco killed because the of one wrongly cut cigarette you smoked , it would require prescription too

Do people die from prescription opioids that often? I assumed that most of the deaths occur when people who are addicted lose access to legal sources and are forced to buy illegally (so risk of overdose and other complications is much higher)?

Interesting theory. I would guess that's rare and that more often than not, people are overdosing on prescriptions that they lied to obtain and then abused, or purchased on the street from someone who received the prescriptions but didn't need them. I'm speaking from personal experiences, but of course, it's anecdotal.

That is exactly why legal sources which are prescription exists, because it is easy to kill oneself by taking a illegal pill of unknown quality, such risks are not common with tobacco.

The regulation is a function of that, not how many people are killed by one item or other, it is merely just how easy is it die of OD with a poorly sourced drug, is why we have FDA and regulations etc is my point.

> there are many things that kill a lot of people

The FDA doesn't have jurisdiction over "many things".

I personally think the FDA shouldn't exist, or should not have power to regulate (and should be a toothless advisory/certification authority). That said, if they are to exist, they should do their job. They're not. We're paying the bill but not getting the service.

Same goes with OSHA. Every casino in Las Vegas demands their employees work in rooms filled with tobacco smoke. Why? Money. It's pure corruption.

We have the rules, they're just not enforced, because if you have enough cash flow, you get a special carve-out so that the rules that apply to everyone else don't apply to you.

Big Tobacco gets it from the FDA. Big Telecom gets it from the FCC. Boeing gets it from the FAA. It's everywhere, and once you see it, you can't unsee it. We're paying billions and billions for these huge bureaucracies and they're only pretending to provide us with the service they exist to provide.

Ah a very libertarian take, I don't think we should have rules, of course until you're personally affected and then you'll demand them.

How did you get “I don’t think we should have rules” from my multi-paragraph comment complaining about how the rules we have are not enforced when and where it matters?

It's the "I personally think the FDA and OSHA should not exist part" which makes me get "I don’t think we should have rules" from your comment.

Rules are critically important. We shouldn’t be paying the government to enforce them, because they aren’t, and such money is basically just being lit on fire.

Who enforces the rules if not the government?

You are paying for the rules, not the enforcement. They don’t have 5e budget to enforce, similar to the EPA.

> The FDA doesn't have jurisdiction over "many things".

The FDA has jurisdiction over tobacco[2] and various food products contributing to obesity and those are the only two examples highlighted by OP or me in the thread.

> We're paying the bill but not getting the service.

Don't think we are, there is very little money for Food part of FDA, in the last 5-6 years the money for food has gone from 1,037M(2018) to 1,145(2022)[1] which in real terms considering inflation means it has gone down and last 30 years it has been similar story.

Last Week Tonight had a recent in depth segment on how little resource we have for food enforcement[3] sometimes as little as singe digit inspectors for an entire industry.

We don't really enforce food regulations, because we don't fund the regulatory body for food safety.

[1] https://crsreports.congress.gov/product/pdf/R/R44576, compare that Drugs moved from 1,330 to 2,116M in the same time period.

[2] https://www.fda.gov/tobacco-products

[3] https://www.youtube.com/watch?v=Za45bT41sXg+

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