Every major pharmacy chain giving government warrantless medical record access | Hacker News Reader

Every major pharmacy chain giving government warrantless medical record access

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345 pointsrntn230 comments

I used to work in Drug Diversion investigations, which is basically any time a prescription medication gets used from something other than intended bona fide medical use. Sometimes its doctors selling prescription drugs for non-medical use, sometimes its medical staff stealing.

The biggest thing we covered was prescription fraud. People stealing or forging doctor's prescriptions. Some were more subtle about it. Sometimes you'd see a patient filling a 30mg Oxycodone, 90 count.

Leads would come from either the Doctor, or the pharmacy. 30mg Oxycodone/90 is generally a "You are in massive pain and probably dying" prescription. So when a health 20 something year old walks in and has it filled for themself, it raises some eyebrows. They'd either call the Doctor to verify, who'd call us to investigate, or theyd call us and then we'd call the doctor.

But the state already has access to this information. All prescriptions are logged in the Prescription Monitoring Program, which I believe all states how now. Any Doctor can get a spreadsheet of all prescriptions filled in their name over the last N days, who it was prescribed to, what for, and when. It was an invaluable tool. Doctor Adams tells us he never wrote this prescription for Bill. We lookup Bill and see he has filled similar suspicious prescriptions from Doctor Charles and Doctor Daniels. We talk to Charles and Daniels and they tell us that Bill isnt their patient either. We encourage Charles and Daniels to check their PMP report, and they uncover 4 or 5 more suspicious prescriptions, and we just keep pulling at this thread uncovering more and more.

Of course there is potential for abuse and neglect, but we werent (and couldnt, legally) just go into a pharmacy and ask for random documents, or lookup random names on the PMP. We had to have an initial lead, usually a doctor, or a pharmacist, who saw something suspicious. From there, its just checking state records, verifying what we saw with doctors, and getting paper evidence of the stuff we already knew was false. I had maybe 3 cases where we had a red flag, called the doc, and they doc said "Yeah thats legit" and that was the end of the conversation. I don't need to know why this patient is on this narcotic, I just needed to know if it was a fraudulent. If its not, then thats between the doc and the patient.

State law gave us authority to request pharmacy records, i.e. prescriptions and pickup logs, without a warrant. Most pharmacists did it with no hesitation. A few would want to make sure it wasn't a HIPPA violation (it wasnt) and that it was legal (it was).

Concerningly, I did have a_couple instances where I asked for documents and the employee started to provide them before I had a chance to identify myself.

In summary, if we were to blindly look at someones medical history or records without a bona fide articulable suspicion of a crime, it'd be massively illegal. If we did have a reason to look at the records, its because someone in the medical field saw something suspicious and reported it. From there we were mainly looking at records the government already had, and then finally getting medical records from the pharmacy that was just paper evidence of records we already had.

I definitely appreciate the context here. It adds some color to breathless headlines.

I'm curious what other precedents there are for this. Can a state policing agency of some kind go and pull purchase records for a credit card by name? Could they extract search history, drive destinations, music lists, or something else without warrant? It's not clear to me where the distinction between "warrant-less search/seizure/wiretap" crosses into "Get all data about a person who is outside their home for free".

> Can a state policing agency of some kind go and pull purchase records for a credit card by name? Could they extract search history, drive destinations, music lists, or something else without warrant? It's not clear to me where the distinction between "warrant-less search/seizure/wiretap" crosses into "Get all data about a person who is outside their home for free".

Yes, law enforcement routinely goes to private companies to get data without a warrant, oftentimes in cases where a warrant would otherwise be required.

For example, Google only _just_ changed their internal policy of handing location data to LEO without a warrant - and while this sounds like great news, it's not as big as it seems, because other players (e.g. cell carriers) also have that data and are much more likely to hand it over than Google is. https://time.com/6539416/google-location-history-data-police...

> In summary, if we were to blindly look at someones medical history or records without a bona fide articulable suspicion of a crime, it'd be massively illegal.

It's extensively documented that law enforcement breaks laws all the time. Your comment isn't reassuring at all - in fact, you're just describing how normalized the process for violating the 4th Amendment and patients' privacy is.

> how normalized the process for violating the 4th Amendment and patients' privacy is.

Well thats the rub, isn't it? Right now the courts don't see this as a violating of the 4th amendment. I can see the argument for requiring a warrant. Im not necessarily against the requirement, but this isn't normalizing a 4th amendment violation any more than license checkpoint (which the courts have also ruled isn't a violation)

[Edited to add the rest of the quote]

> Well thats the rub, isn't it? Right now the courts don't see this as a violating of the 4th amendment.

You omitted the end of my sentence in your quote, which is operative in this case. As explained in the article, the Third Party Doctrine establishes a loophole in 4th Amendment case law. The system you're describing is one which was created specifically to exploit this loophole: to violate patients' privacy while still complying with the 4th Amendment on technical grounds, all the while grossly violating it in spirit.

> You omitted the end of my sentence in your quote, which is operative in this case.

My apologies. I've re-added it with an edit note.

I think its a reach to say 'the system' was created to exploit 4th amendment loopholes, especially in this case. Again, the patients privacy isn't compromised by the pharmacies at all here. The state has its claim of a vested interest in prescription activity, much like with drivers licenses and vehicle registration, and has a database of said data, much like with licenses and vehicle registration.

If I start running tags to see where someone lives to stalk them, thats bad, and illegal. If I start running prescription data for someone to see what they're on and stalk them, thats bad and illegal.

If a car dealer says "These VINs on the car dont match, we think something was stolen" we can investigate it by accessing the state database. We will likely see some personal information of someone who isnt guilty of anything in the process of this investigation. If a doctor says "This person filled a prescription under my name that I didnt write" we can investigate it by accessing the state database. We will likely see some personal information of someone who isnt guilty of anything in the process of this investigation.

My assertion here isnt "Everything is fine, change nothing". Its "If you're concerned about privacy here, you are looking at the wrong target". Warrant requirements could be reasonable. Whether we get them or not, I think a good start would be auto-redacting Prescription Monitoring Program reports. If Doctor Adams says Bill filled a fraudulent script, because Adams doesnt write for percocet, I shouldnt see every name for every prescription on Adams' report. That should be redacted. Then if I see a script for percocet, which we've established is fraudulent, we then un-redact the "patient" name.

Again, CVS handing me a copy of a prescription that I already know is fake is the least significant issue at hand.

I've been here, aka worked at Google and became confused why people didn't trust it, since I now trusted it.

Succinctly:

- you described an _excellent_ process

- the key part is "concerningly sometimes ppl handed me stuff before I identified myself"

- there's nothing you can say or do to alleviate that

Furthering the Google analogy, with intent to clarify:

The Google version of this is "you can have all the data behind 20 locks and and 32 keys and 5 biometric measures and never let human eyes actually see it. Now let's turnover all Google employees. You sure they'll do the same thing?"

(the answer is no, after The Great McKinsey-ification and the corner-cutting and self-justification of lies demonstrated since ChatGPT)

> any more than license checkpoint (which the courts have also ruled isn't a violation)

Personally, I think that was a terrible ruling. Any suspicionless stop and check/investigation/search in a place everyone has a right to be should be treated as an unreasonable search.

The pharmacy records checks you're describing here are based on evidence that would likely hold up as probable cause in court.

In the US, driving checkpoints are only allowed to check for compliance with driving laws only for the driver: drivers license, car registration and insurance, and sobriety of the driver. It is part of what you give up to drive in public roads. But checkpoints can't search passengers or the car, unless something else that is illegal is in plain view.

My understanding of the case law on checkpoints is that it started with inland immigration checkpoints, and similar reasoning got applied to checkpoints meant to catch drunk drivers. I consider it an evisceration of the fourth amendment, as did Justice William J. Brennan when he wrote as much in his dissent.

https://en.wikipedia.org/wiki/United_States_v._Martinez-Fuer...

To play devil's advocate: sounds like a "bona fide articulable suspicion of a crime" doesn't necessarily mean there is a documented reason for the release of records that has been authorized by a judge. Wouldn't that leave too much space for abuse?

Yeah, it could. People can also lie on affidavits for warrants, but it does leave more of a paper trail to catch the guy. Honestly I don't think I'd be against a warrant requirement, but I also think we need a way to speed up the warrant process a _lot_. Right now it often involves a 1 hour + drive to a magistrates office, 30-45 minutes of filling out paperwork by hand, plus the hearing, getting the actual warrant printed+signed+logged, then 1 hour + drive back to where you need to be. I think you'd see less pushback of warrants in general if it leveraged the technology we have. We should absolutely be able to file an affidavit electronically, facetime a magistrate, and get a warrant approved/denied that way.

But again, getting records from the pharmacy isn't really the issue. The government already has the records of the doctor that "wrote" the prescription. All the pharmacy is giving you is the physical copy of the record + data of who picked it up.

3hrs seems like a small price to pay for patient privacy

Everything is cheap when you aren't the one paying for it.

Without a warrant requirement, all patients collectively pay their privacy away without knowing it. Is the collective benefit worth it? (Remember, the "benefit" is the additional harm the government prevents when not constrained by a default warrant requirement, not the total harm the government prevents with and without getting warrants.)

At this point, some legitimate patients may find it less concerting to just buy their medicine on the black market and avoid all the surveillance.

Our entire system is built around the fundamentally American belief that adults need to obtain permission to consume anything that isn't Alcohol or Tobacco (Unless you're an Indian living on a reservation where alcohol has been banned as well).

American pharmacies take special care to put our full names along with our doctors names and phone numbers just to make sure that nobody gets away with possessing drugs that the aren't allowed to have.

A big country like Iran banning alcohol seems unimaginable until you remember that for whatever reason alcohol is the only thing a big country like America hasn't banned.

Actually America did ban alcohol at one point, but it did not go so well...

Warrants are regularly issued based on electronic filings and phone conferences are they not? Everyone spent an entire year plus doing almost all court processes entirely online/over zoom.

> State law gave us authority to request pharmacy records, i.e. prescriptions and pickup logs, without a warrant.

This is good to know.

It is proposed that this arrangement be modified to require a warrant.

Although I am comfortable accepting that your agency demonstrates the integrity you indicate, there are ~18k other law enforcement agencies in the US. A not insignificant number have long and well-documented histories of excessive and inappropriate record access. (And many, many other LEA have similar histories, even if they don't overreach as often.)

A warrant provides some judicial oversight. When accessing our private and confidential information, this is the reasonable default.

> It is proposed that this arrangement be modified to include a warrant requirement.

That defeats the entire point of this arrangement, which allows them to investigate in situations where the legal requirements for obtaining a warrant are not met. (Which is the elephant in the room: the entire premise of this system is to bypass established legal thresholds).

> Although I am comfortable accepting that your agency demonstrates the integrity you indicate

I'm not sure that's a safe assumption. As you mention, system abuse by law enforcement is incredibly common at agencies across the country. If you talk to any person at one of those agencies, they will almost invariably tell you that their coworkers take their job seriously, that they never abuse their own power, and that they can't imagine their coworkers doing the same.

> That defeats the entire point of this arrangement, which allows them to investigate in situations where the legal requirements for obtaining a warrant are not met. (Which is the elephant in the room: the entire premise of this system is to bypass established legal thresholds).

This is just 100% false. If im pulling a prescription from a pharmacy its because Doctor Adams told me "I never wrote a prescription for Bill Barnes for percocet, but this state maintained record says that he filled a prescription for percocet at CVS #12345 on main street". That statement alone is enough to get a warrant for said pharmacy records.

> That statement alone is enough to get a warrant for said pharmacy records.

Great, then get a warrant.

The entire reason this story exists is because people are surprised and - rightfully - upset that law enforcement is able to access this information without one.

>> That statement alone is enough to get a warrant for said pharmacy records.

> Great, then get a warrant.

I agree with my whole heart. This is the meat and bone of the discussion.

And an important side note: The assertions "can't access without a warrant" and "can't access at all" need to be clearly distinct at all times. Once the 1st gets translated as the 2nd, the good faith portion of this discussion is lost.

>> Although I am comfortable accepting that your agency demonstrates the integrity you indicate

> I'm not sure that's a safe assumption. As you mention, system abuse by law enforcement is incredibly common at agencies across the country.

I feel a benefit of the doubt costs us little in this instance and I feel we need a familiarity with what responsible policing looks like. To me, the OPs recounting provides that.

Past that, I believe that the widespread bad behavior of other agencies is insufficient reason for mistrust here. And casually using others' bad behavior to justify mistrust - this is something we reasonably criticize police for.

> I feel we need a familiarity with what responsible policing looks like. To me, the OPs recounting provides that.

The point is that nearly every cop you talk to will sound like OP. That doesn't mean anything about the integrity of them or their coworkers; it just means that they're capable of articulating their own behavior in a way that makes them sound reasonable with no context. That's an incredibly low bar, one that nearly every abusive cop will clear.

To repeat what I said in a separate comment: Having worked extensively in this area, I'll be blunt and say that anytime someone who works in law enforcement says that there are no abuses of power in their workplace, that means either they were so oblivious that they never saw abuses that are occurring around them, or they were so mired in the system that they are incapable of recognizing the abuses of power that they themselves are participating in.

> Past that, I believe that the widespread bad behavior of other agencies is insufficient reason for mistrust here.

On the contrary, that's exactly what "systemic abuse of power" means. It means that the bad behavior is so ingrained in the operations of the system that individuals' actions contribute to its operations, whether or not they recognize or even understand it.

And you may well have the right of it.

I'd agree that federal and state LEO serve their govs, unilaterally and universally. They exist to advance the interests of the party in power and campaign contributors.

As a public-of-individuals, our best interests may get occasionally get served by accident but our actual welfare is never, ever, not-ever the primary focus.

All that said, I still avoid Cops Suck as the default. Broadly speaking: The more local the force, the less certain is the system-serving corruption. You can get to a place with an ethical+competent commissioner/chief/sheriff. Under them, officers can be allowed to focus on being ethical+competent. I have personally witnessed this.

Where those officers might exist, I want to be fair.

> Past that, I believe that the widespread bad behavior of other agencies is insufficient reason for mistrust here. And casually using others' bad behavior to justify mistrust - this is something we reasonably criticize police for.

The government, and any authority, should be mistrusted. Period.

That doesn't mean they aren't sometimes necessary, or that the lack of trust should turn into fear, but any person or organization on the winning end of a power imbalance should not be trusted. The lack of trust there is what leads to checks and balances, we need systems in place to make sure those with the power can't abuse it even if they wanted to.

The best scenario is that (a) the powerful aren't trusted (2) proper guardrails are in place and (d) the powerful actually do act honestly and the guardrails may slow them down a bit but don't prevent them from doing the job they were given power to do.

> The government, and any authority, should be mistrusted. Period.

I mostly agree with that but we're talking about a response (mine) to a post, by someone who's communicating from the interior of an LEA.

His narrative could be propaganda or false or curated by agenda or unhelpfully incomplete or meaningfully representative. We don't know which of those it is. We do know that communication outside of PR channels is useful, even if we have to heavily qualify it.

And valuable info sometimes comes out of informal channels. We're not gaining anything by crapping on it here.

Past that, we risk nothing by assuming good faith of the OP's post - even if our good faith turns out to be misapplied. No judicial precedence is in play. No hearts are swayed to dark sides. No mass readership is being fed a pregurgitated conclusion. No agenda needles get budged.

In this place and at this time: We are safe letting one LEO-adjacent individual feel - well maybe not welcome but at least a lower level of mob noise. We don't have to put their haunches up by pushing back with everything we have.

> In this place and at this time: We are safe letting one LEO-adjacent individual feel - well maybe not welcome but at least a lower level of mob noise. We don't have to put their haunches up by pushing back with everything we have.

Totally agree. This thread did go off the rails quite a bit. My main point wasn't actually even whether any one LEO can or should be trusted, I assume a vast majority of them are in the job with good intentions. My aim was more so at the power structure of any LEA or government in general, they should never be trusted IMO even when we're willing to take the risks of centralizing power for some greater good.

You should mind your own business and let people put whatever they want into their bodies

Yeah, don't know why are you being downvoted. According to OP's description it is just big waste of money and erosion of privacy to catch some people who don't really hurt anyone.

To be fair to the system the OP describes, a doctor who's prescription was forged and the pharmacist who filled it could both he considered harmed when someone fills a bogus script. Both are licensed professionals that have a lot to lose if there is reason to believe they may be involved in writing or selling bad prescriptions.

Given that we've already empowered law enforcement agencies to enforce the law, its reasonable for them to step in here to catch those forging prescriptions and risking direct harm to others' rights. What is unreasonable and the main discussion above is the process of dodging the 4th amendment to investigate these people without a warrant.

> To be fair to the system the OP describes, a doctor who's prescription was forged and the pharmacist who filled it could both he considered harmed when someone fills a bogus script. Both are licensed professionals that have a lot to lose if there is reason to believe they may be involved in writing or selling bad prescriptions. Given that we've already empowered law enforcement agencies to enforce the law, its reasonable for them to step in here to catch those forging prescriptions and risking direct harm to others' rights.

IMO desperate person who tries to buy 90 pills of Oxycodone with forged prescription (OP's example) needs help, not a criminal record.

> What is unreasonable and the main discussion above is the process of dodging the 4th amendment to investigate these people without a warrant.

Fully agree with this.

Agreed. I don't think doctor shopping is as much of a thing as it used to be and that's why there's so much demand for counterfeit oxycodone tablets

> IMO desperate person who tries to buy 90 pills of Oxycodone with forged prescription (OP's example) needs help, not a criminal record.

Sure I definitely don't have a strong opinion on this. I don't have nearly enough first hand experience helping someone with a serious drug problem, or dealing with one myself. The debate over the best way to help people in this situation is firmly in the space of one that I'm happy to weigh in on but would heavily lean on those more experienced to share what they've found to work best.

Unrelated to drug charges, I was involved in helping a close relative through a criminal case that was entirely based on the testimony of one individual, with no hard evidence and other witnesses directly refuting the claim. I have very strong opinions about the legal system in general that would land me pretty squarely on the "provide help not a criminal record" in a vast majority of cases. Our legal system is a complete shit show.

Surely this all becomes unnecessary with mandatory e-prescribing for controlled substances?

If one is to fill a rx meant for someone else (c2), ie someone diverts their legit RX to an addict who pays them and fills it

Does this data get linked with the addicts other rxs in their name

Some meds require the person picking up to show ID, and they record the ID, so maybe?

all of this for 90/180/270 pills?

This seems deeply antithetical to a free society

I used to be analyst in a related area. I was impressed by the difference in the treatment of commercial databases (e.g. LexisNexis) and government databases that had data that was controlled under laws.

As far as the commercial databases were concerned, I don't think we were told much more than this costs money, so don't waste searches.

But as for things like criminal history searches ("RAP sheets") we had training that stressed the illegality of looking up anyone without a justifiable legal reason. We were told to log the reason for doing every search. The training materials included news clippings about former police officers who were in prison for invalid use of the criminal history database. Once a year we were audited and asked to justify a selection of lookups we had done.

All systems are faillible and can be misused by bad actors. All systems are subject to cost-benefit analysis.

But I think it's valid that we have a system of law enforcement, that it be able, under appropriate circumstances and laws and checks and balances, to gain information that is sensitive and not publicly available.

Hi, I'm a former Federal LEO that has gotten warrentless access to medical records - a long time ago.

I can't speak for every agency (there are more than 100 Federal agencies with sworn officers and arrest authority, and thousands of state and local agencies), but the few times I did this in the early 2000s, even most of the HN crowd would have thought it reasonable.

I was an officer in the Coast Guard and had LE powers under two different branches of law - one public safety and one criminal. When Bad Things happened on federal waterways, my job was to first investigate threats to public safety. This comes with the power to issue a subpoena. This means we can 'compel speech' and then if you lie to us, you are in trouble.

This has more to do with what you might think the NTSB or FAA might do following an accident. The government has the right under current law to understand threats to the public. If a shipping company is currently doing something that could dump a barge full of Xylene into the bayou next to an elementary school (this is not a made up scenario, and you should look up Xylene) then there is a public interest compelling enough that we can tell people they have to sit down and tell us the truth, and the 4th amendment is not a barrier.

However, if a public safety investigation moves past 'understanding if something is a risk to the public', and individual criminal culpability appears possible, we are then required to disclose to the individuals involved that we have moved to a criminal investigation. In this case, the 4th comes back in play and warrants are required.

For me, this really only came up a couple times with individuals involved in an accident that were either using medical prescriptions ("I missed my medications, I'm not drunk") to delay us investigating a scene. Or, for a couple of injured mariners who were in the hospital at the time we showed up. We needed to go to the hospital get their version of the story and to confirm an injury; grave injuries would increase the 'level' and thus mandatory resources involved in an investigation. Also, we would need to get a witness testimony from a deckhand or something that was on a boat or facility and saw what happened (did the boat really slam into the terminal coupling or did the guy just mess up attaching it because he wasn't an officially trained Tankerman who shouldn't have been operating the equipment).

Being in the hospital or at the doctors was an excuse used more than once my companies trying to slow down inquiry into their mistakes. And yes, I think for our use case, it was completely reasonable for us to be able to call the hospital and ask "was so and so admitted last night?", just for us to find out that they were not, and went back home to mom's house to hide under orders from their captain.

Anyway, with all that said, it seems unlikely these powers are not frequently abused, even if most of the LEO community is just trying to do their job. So, tin-hat away, friends.

As someone who also has a lot of experience in this area, I'll say that your comment is a classic example of the tactics that that LEOs use to minimize or defend abuses of power. It's actually a great case study, because it exemplifies the way that abuses of power are adopted structurally at an institutional level, while also drawing the line to how that is internalized and effected in practice by individuals. (This process is a key component of any stable system for abuse; that said, it's rare to see it illustrated so plainly).

> Being in the hospital or at the doctors was an excuse used more than once my companies trying to slow down inquiry into their mistakes. And yes, I think for our use case, it was completely reasonable for us to be able to call the hospital and ask "was so and so admitted last night?", just for us to find out that they were not, and went back home to mom's house to hide under orders from their captain.

Just because it made your job easier doesn't mean that it was legitimate. Constitutional rights, privacy laws, and case law have been created specifically to limit police power. Yes, it would be easier if cops didn't need warrants at all. No, that is not a valid argument for bypassing them.

Similarly - yes, it's common for LEOs to talk to witnesses to try and get them to incriminate themselves, either by engaging them in interactions that don't legally require a Miranda warning or by ignoring Miranda requirements altogether (which happens frequently). That doesn't justify it, either legally or ethically.

> Anyway, with all that said, it seems unlikely these powers are not frequently abused, even if most of the LEO community is just trying to do their job.

The assumption that "most LEOs are just trying to do their job" is itself questionable, given how much documentation there is of systemic abuse of police power. Even if it weren't, that isn't a valid defense when the government has explicitly placed restraints on the ways LEO can do their job (to say nothing of the broader question of the legitimacy of that job in the first place).

> Just because it made your job easier doesn't mean that it was legitimate.

So, I suppose that the main point. In these cases, we weren't investigating the individual as a suspect, we were trying to understand the nature of an incident that could affect the safety of others in a relatively linear fashion.

Imagine it's 20 years ago, there's no cameras everywhere, GPS is limited to multi-meter precision - did the 50-barge tow coming down the Mississipi river with millions of tons of cargo hit the interstate bridge broadside or did it just scrape it? There's a big pylon-shaped dent in the side of a naptha barge with cement dust on it, but the captain swears he just glanced it with the grain barge at the head of the tow. It's ancient and looks like it's battered 100 docks in the past year.

So, Mr. Deckhand, what hit the bridge?

In this scenario, he is not responsible for navigating the vessel, so we assume that it's unlikley that this would evolve into an investigation that would jeopardize him. And thus are free to issue a subpoenea if needed to find out if we need to shut down the only passage over the Mississippi for 100 miles.

I think it's fair that the public has the right to his honesty in this scenario.

Of course, these powers present the potential for abuse, and I'm sure it happens. Just not in the world I ever operated in; our powers and obligations were taken very seriously internally.

> So, I suppose that the main point. In these cases, we weren't investigating the individual as a suspect, we were trying to understand the nature of an incident that could affect the safety of others in a relatively linear fashion.

That doesn't matter. You're still talking about accessing private, sensitive data about an individual.

> I think it's fair that the public has the right to his honesty in this scenario.

Yes, and that's exactly why warrants exist. The courts are specifically responsible for determining the outcome of cases in which private rights potentially conflict with public ones (or with private rights of other parties).

> Of course, these powers present the potential for abuse, and I'm sure it happens. Just not in the world I ever operating in; our powers and obligations were taken very seriously internally.

Having worked extensively in this area, I'll be blunt and say: anytime someone who works in law enforcement says that there are no abuses of power in their workplace, that means either they were so oblivious that they never saw abuses that are occurring around them, or they were so mired in the system that they are incapable of recognizing the abuses of power that they themselves are participating in.

Out of charity, I'll assume the former. But to be honest, every time I've spoken at length about this with LEOs, it's inevitably turned out to be the latter.

> Out of charity, I'll assume the former. But to be honest, every time I've spoken at length about this with LEOs, it's inevitably turned out to be the latter.

I am sure this is often true at the local LE level. But remember, they deal almost entirely with criminal investigations about individuals for things that do not present a broader risk to the public (beyond their continued individual behavior).

In our case, we are not reifying 'the drug menace' to a public level; we are trying to find out if a barge is full of vegetable oil or an explosive polymerization agent. And in those cases, no, I don't think your rights to privacy supersede our obligation to understand if there's a major threat to other people.

> That doesn't matter. You're still talking about accessing private, sensitive data about an individual.

This is true and I can assure you I know quite a bit about what can be in people medical records (I am a MD who has worked extensively in medical records exchange and machine learning). I don't think accessing this kind of data should be possible without genuine need.

> Yes, and that's exactly why warrants exist.

In our case at least, warrants wouldn't even make sense. We were not conducting criminal investigations and asking for access to pursue a person against their will, in response to a crime. We were trying to find out about near-term threats to other people.

I think you and I probably agree on the spirit here - it's just that in our case (and cases like the NTSB or FAA) there are compelling public interests that supersede someones right to privacy. Finding out if you were prescribed benzos so I can charge you for some garbage possession misdemeanor is not one; finding out if there's 30,000 barrels of explosive leaking under a highway is.

No?

Yes, No.

  there are compelling public interests that supersede someones right to privacy.

This is road to hell path paved with good intentions. All crime has compelling public interests to be prevented. Using that logic, cops should be able to search everywhere. It's compelling public interest to stop people who do bad things.

> In our case at least, warrants wouldn't even make sense. We were not conducting criminal investigations and asking for access to pursue a person against their will, in response to a crime. We were trying to find out about near-term threats to other people....Finding out if you were prescribed benzos so I can charge you for some garbage possession misdemeanor is not one; finding out if there's 30,000 barrels of explosive leaking under a highway is.

Nothing you have said, in this comment or in the rest of the thread, refutes the point that warrants are the mechanism by which the legal system intermediates this power. It's quite telling that even in a completely constructed example chosen for the discussion at hand, you're not actually making a case that cops need access to people's medical information without a warrant.

> I think you and I probably agree on the spirit here - it's just that in our case (and cases like the NTSB or FAA) there are compelling public interests that supersede someones right to privacy.

No, I'm saying that it is literally not your job as a member of law enforcement to decide when the public interest "supersedes" someone's right to privacy. That's what a judge is for. That's why warrants exist.

> And in those cases, no, I don't think your rights to privacy supersede our obligation to understand if there's a major threat to other people.

> No?

No.

Just because you couldn't think of a tool to "understand the nature of an incident that could affect the safety of others" doesn't mean it legitimizes your department policy or personal tactics

I would be 100% fine with stripping that group of this discretion, sanctioning them, and sending them back to the drawing board on how to "understand the nature of incidents that could affect the safety of others", aka investigate.

Checks and balances are essential to the American way of government. Law enforcement should have to follow the Constitution, which means dealing with the check of obtaining a warrant. If the reason is really that compelling you’ll have no problem convincing a judge or magistrate.

I guess that's the point I was trying to make - in our case we were not conducting a criminal investigation. And if we were headed that way (which only happened every once in a while) then yes, we'd have to go in to Criminal Mode rather than Public Safety mode, and 4th and 5th Amendment obligations where back on.

Wouldn’t 5th amendment self-incrimination protections be in place even if the compelled questioning is purely part of a public safety investigation? Those protections are not about whether the particular kind of questioning is itself a criminal investigation but instead about whether the person is being compelled by the government to give answers that could tend to incriminate them.

For example, maybe your concern is just how fast and recklessly a boat was going with the goal of figuring out if they are a threat to fresh into another boat, but maybe the person doesn’t want to open themselves up for Boating Under the Influence or Controlled Substances Act criminal charges (whether or not they are legally guilty).

5th amendment self-incrimination protections apply even in compelled congressional testimony and routine tax return filing obligations, which are definitely not criminal investigations.

4th amendment protections also apply well beyond the criminal context, although I can well believe that your public safety investigations may have fallen into a judicially recognized exception. For a legally very clear example, no law can constitutionally authorize an LEO to nonconsensually conduct a warrantless suspicionless search of someone’s home to see if they might have failed to pay any applicable taxes or duties on any imported cigarettes which they may happen to have present there.

(Emphasis on suspicionless - the legal answer would probably be very different if the LEO sees someone transporting a pallet of imported cigarettes from the home into a truck in their driveway following having received a tip from the FedEx customs clearance people, even if there’s no time for a warrant. But there’s no constitutional reason for any investigation like this, whether about criminally intentional tax evasion or merely noncriminal accidental tax underpayment, to be occurring without suspicion.)

While all those are cases where LEO had legitimate reason to have access the information, none of them provide a compelling reason why a warrant couldn't be required.

The third-party doctrine has become far too broad. There are so many situations where people share information with a third party, but also expect and deserve a right to privacy regarding that information. The fact that HIPAA doesn't provide a reasonable expectation of privacy in information shared with your doctor/pharmacist is just absurd. The law does explicitly carve out these LEO exemptions, but reasonable expectation of privacy is a constitutional right, and those carve-outs should be deemed unconstitutional. And we should extend those lines with good privacy laws all around - any information that a company is required to protect under civil privacy laws should also be exempt from the third-party doctrine and require a warrant.

I won't belabor points I've made below, but I do want to agree with you about 3rd party doctrine in general; the modern world makes it almost impossible to live a normal life without non-consensually making your self available for full time monitoring by everyone within eyesight of you.

I think the point of this article is actually being elided over some by the conversation here though; it appears that these agencies are largely following the law. The question is, how broad should the reach of LE go given their legitimate authority?

In the current scenario, should a LEO from Idaho be allowed to see prescription records from a pharmacy in California? Should they have the right to get data from CVS about things that didn't happen in Idaho? Every prescription ever? Every doctors note?

The law as it stands allows states to determine the reproductive rights of their citizens and investigate violations thereof (note that I don't agree with the law, or the Supreme Court here). I think the question being raised by this letter is, what breadth of access should some Sheriff have over your medical records, and really, what the heck is even going on with this now?

The Dobbs case has opened up a new frontier of potential abuse, and I think the letter and article are appropriately exploring that frontier.

It's not just with LEOs where patient privacy gets dodgy.

I've helped get a number of tech companies HIPAA compliant, so I've become very familiar with the workings and requirements of the act. My wife, a nurse, works in medical claim management. Lots of healthcare knowledge between us.

I've had some very interesting conversations with her because of a tool she's described being used by insurance companies: medical canvassing. It's an "interesting" tool used by investigators that doesn't technically request PHI, but can paint a picture of one's past medical care.

Basically, an investigator can ask a health care provider a bunch of yes/no questions - "did the patient receive care between $DATE1 and $DATE2?" "yes" "was the patient treated for $THING_RELEVANT_BUT_UNRELATED_TO_CLAIM?" "yes" "okay, thank you, that's all we needed." No "PHI" requested, none provided, but a picture still painted... and HIPAA allows for it.

I'm very curious to know what other interesting methods exist that allow for the circumvention of patient privacy.

I am aiming to help get companies HIPPA compliant and aware this next year, both changing tech stacks and educating. Would like to connect with any resources / checklists / firms / anything that could help me help others understand.

Contact in profile if willing to chat.

>Basically, an investigator can ask a health care provider a bunch of yes/no questions - "did the patient receive care between $DATE1 and $DATE2?" "yes" "was the patient treated for $THING_RELEVANT_BUT_UNRELATED_TO_CLAIM?" "yes" "okay, thank you, that's all we needed." No "PHI" requested, none provided, but a picture still painted... and HIPAA allows for it.

How is that not PHI? You asked for treatment information and it was provided. Asking it roundabout way doesn't sidestep HIPAA.

I think the interest here is less about how it was used in the past, and how it might be used in the future.

With changing landscape of laws related to things like abortion and transgender rights, people are rightly worried that a zealous prosecutor in one state will subpoena for records of things like abortion drugs or hormone blockers, and use that data to start harassing or prosecuting people.

It sounds like it would be feasible for a prosecutor to ask for a list of all patients currently prescribed hormone blockers and then open child welfare cases against all those families across an entire state.

Why do I get the feeling this (xylene) happened in southern Louisiana?

Big thread last week

https://news.ycombinator.com/item?id=38719918

and last last week

https://news.ycombinator.com/item?id=38615841

Thanks! Macroexpanded:

Police get medical records without a warrant - https://news.ycombinator.com/item?id=38719918 - Dec 2023 (258 comments)

Pharmacies share medical data with police without a warrant, inquiry finds - https://news.ycombinator.com/item?id=38615841 - Dec 2023 (46 comments)

Just adding for audience clarification and context:

Techdirt is mostly about post-reporting analysis. They tend to come in when a story is a few days old and understanding has some percolation time.

We can get a differently ordered picture than in the instants after news has broken.

I'm sure that's true. From a HN moderation point of view though, the question is whether two articles about the same underlying story are different enough to support substantially different conversations. If not, then the resulting thread will be largely repetitive of the original, and repetition is one of the main things we're trying to reduce here.

In the present case the answer is pretty clearly 'no', because the comments aren't reacting to the OP's specific analysis, they're just responding to the general topic. This is pretty much what we'd expect since that's mostly how internet comments work.

That doesn't invalidate your point, it just means that unfortunately the 'nuanced analysis' article that comes later is usually going to get downweighted as a follow-up on HN when the 'hot news' version of the same story already had significant attention.

The story in TechDirt stems from https://www.finance.senate.gov/imo/media/doc/hhs_pharmacy_su...

Please explain why this is bad for anyone except RX re-sellers?

They probably van get that information 3 other ways also...

The government can violate your rights so long as they go through a 3rd party...

The consolidation of the medical industry has been one of the most terrible things I've witnessed during my lifetime. What is the end state for all this?

One company owning everything?

To be fair, some of the consolidation is purely because the costs of business have been raised so far that both doctors and pharmacists can't operate independently. From mountains of school debt, to requirements for IT services and compliances, to the insane cost of real estate everywhere.

This country is heading towards one of those cyberpunk endings where corporations own people.

HIPAA was a stupid mistake by the Clinton administration. I really don’t care who has my medical history and the field of medical study would be infinitely better off if it was public.

Now that's a take I've never heard before. It'd be interesting to have an opt-in for sharing your medical history with entities, but there is no way in hell I'd be sharing information that is so easily weaponized against me.

But do you use pharmacies?

"Yet you participate in society. Curious!" https://knowyourmeme.com/memes/we-should-improve-society-som...

> It'd be interesting to have an opt-in for sharing your medical history with entities

That already exists. It's baked into HIPAA (if you're talking about medical history collected by Covered Entities).

All "medical" data collected by direct-to-consumer products that aren't providing clinical care (think 23AndMe, or third-party services that allow you to book appointments with doctors in a Yelp-style interface) are not subject to HIPAA, so they already can legally collect (and sell) that data without additional consent.

Would you like employers to be able to pull medical history (using "background check" type firms) and able to deny employment based on your medical condition? Some employers may prefer not to hire anyone who has ever been on antidepressants, for example.

Don’t I have a right to avoid crazy or lepers?

Freedom of association shouldn't end just because I want to hire an assistant.

Individual rights vs. societal responsibilities.

Jobs are touted as necessary as being part of modern society. Judges, legislators, and commmunity leaders expect you to have a job and consider whether or not you have one as judgement of your character. The health of society and a community are measured by the percentage of adults that have jobs. As long as this is true, then strict freedom of association should have lower priority than making sure everyone is employed.

An alternative is UBI.

No, but health is already a protected class in employment laws. Any employer pulling or seeking that information in any way would open themselves up to a class action lawsuit by everyone who had ever been rejected from that company.

The US government does that for security clearances.

So, treatment for an STD, for example, should be public information?

What if that treatment occurred while the spouse was on a six month military deployment?

Mental health records should be freely available?

Would you enjoy having potential employers review all of your conversations with a counselor before deciding whether to hire you?

There's a very good reason why society has placed a high value on the privacy of health care information above almost all else, including financial.

So, treatment for an STD, for example, should be public information? What if that treatment occurred while the spouse was on a six month military deployment?

There has to be a better example of why privacy is important than keeping infidelity and having an STD secret from your military deployed spouse.

Marital infidelity rate is about 50% - and that's just for self-admitted [1]. Actual rates are likely much higher. A large majority of people of both sexes admit that they would have an extra-marital affair if they believed they wouldn't get caught.

Anecdotally, when I was I the military I saw much, much higher than 50% when spouses were deployed. This seems to be a pervasive issue [2].

Seems like a culturally relevant health issue to use as an example.

[1] https://worldpopulationreview.com/country-rankings/infidelit...

[2] https://pubmed.ncbi.nlm.nih.gov/28054799/

While divorce may be culturally relevant, I read the phrasing

> What if that treatment occurred while the spouse was on a six month military deployment?

as indicating that the STD treatment would be kept from the spouse. While each individual has a right to privacy, cheating on an away spouse, getting an STD and treatment, and then keeping it secret from the spouse is pretty shitty, and is especially bad under the guise of "right to privacy". "I'm not going to tell my spouse I had an STD, they have no right to know" is not what medical information privacy is about.

We can talk about the value of someone's medical information not being public without evoking a spousal relationship as some kind of reason for privacy.

And when we're talking about keeping medical information private, we're trying to avoid harm to the person the information is about. Someone who is cheating and/or getting STDs without telling their spouse is harming the spouse.

> is not what medical information privacy is about

It is exactly what medical privacy is about. Embarrassing and potentially life changing issues come up routinely with medical privacy. These are things that primary care physicians and staff grapple with on a daily basis (and that I did as a medical guy in the military).

The infidelity example I used was actually part of one of the many HIPAA training classes that I've attended over the years. In the (real life) example the nurses were gossiping about the case in the elevator. It happened that a family member was in the elevator with them.

> Someone who is cheating and/or getting STDs without telling their spouse is harming the spouse.

Someone who has the flu and goes to a restaurant is actively harming the staff and other customers. Should we have a public registry for anyone who gets the flu?

Someone who has HIV and has unprotected sex is actively harming/killing their partner (and has been prosecuted as such). Should we make everyone's HIV status public?

I'm sorry you find the subject of infidelity distasteful, but if you work in healthcare at all you'll quickly come to realize that many personal health issues that are commonly treated are deeply embarrassing and potentially socially devastating to the patient.

Hence the need for stringent medical privacy protection.

> The infidelity example I used was actually part of one of the many HIPAA training classes that I've attended over the years. In the (real life) example the nurses were gossiping about the case in the elevator. It happened that a family member was in the elevator with them.

As I said, I read the original line as being specifically about using medical information privacy protection to keep the information from the spouse, and I think that's a less-than-robust example. I now understand that that wasn't your intent. Mentioning nurses gossiping and discussing patients in an unsecured location adds detail that makes it more robust.

> So, treatment for an STD, for example, should be public information? What if that treatment occurred while the spouse was on a six month military deployment?

My position is that the answer to the first question should be "no": treatment for an STD should not be public information. The answer to the second question has no bearing on the answer to the first, but it is presented/worded as if it should.

That the infidelity and STD treatment occurred while the spouse was deployed distracts from the fact that nurses shouldn't be gossiping in crowded elevators at all. Medical professionals shouldn't be gossiping in crowded elevators independent of the if the spouse is in the military or not or is deployed or not.

I sort of agree with you on the surface (who cares if some rando knows I take thyroid meds?), but the ways medical data can be used against you are very insidious. Even now that preexisting conditions are history (AFAIK), if your data were public, people could target you (or the elderly) for snake oil cure scams, financial scams (especially if they knew you were dying of cancer), identity theft scams (send you fake bills and steal your money). Anything sexual or psychiatric could be used to blackmail you, all sorts of cruel things could be done, it just takes some imagination.

Imagine being a woman with a miscarriage or a trans kid in Texas.

Healthcare info being public invites all sorts of abuse by people going for political or "culture war" gains.

One of the catalyst for that were that insurance companies were kicking people off coverage as they knew about increased risk.

I have a female family member who never got a genetic cancer lab test because a positive result came with risks of her getting kicked off private insurance. Even though her sister had cancer at 30 and her paternal line had tons of history of women dying young for “woman issues” as it was called back then.

Anyway she assumed she had the genetic mutation but never could get the preventative surgery she should have because insurance wouldn’t approve it without the positive lab results confirming she was at high risk for cancer.

It’s dystopian.

And beyond the most obvious stuff too. I worked for a company that ran claims benefits management systems. We had regular inquiries from our customers (insurers) saying that they had genealogy databases and wanted to be able to mine not just their own systems for "increased familial risk" based on claims history, but wanted to be able to get this information from "partner" (not actual partners, just "our other customers") databases similarly.

We would not, thankfully. But many of them asked. Some, repeatedly.

A rather naive take. That information will be taken and used against you in some way. But, hey, you do you...

Lots of downvotes for this comment. Yet it represents the prevailing public opinion on privacy (even if the polarizing point about a particular US president is removed).* How will the privacy landscape change if the vast majority of people don't care?

*Apologies for the excessive alliteration. Didn't see until I submitted.

>costs of business have been raised so far that both doctors and pharmacists can't operate independently. From mountains of school debt, to requirements for IT services and compliances, to the insane cost of real estate everywhere.

It's worth noting that the costs you listed, only "requirements for IT services and compliances" seems to favor large corporations. Everything else you listed don't offer economies of scale (eg. 100 pharmacists = 100 "mountains of school debt"), so unclear how they're contributing towards consolidation.

>This country is heading towards one of those cyberpunk endings where corporations own people.

I don't get it. Does a future where you have to work for corporations mean "corporations own people"?

> I don't get it. Does a future where you have to work for corporations mean "corporations own people"?

These kinds of responses are always so frustrating to see. The average person clearly is not paying attention to how much of a stranglehold corporations now have over the populous and how often they just buy themselves power - or even worse, the average populous just doesn’t care or is willfully ignorant. In the US especially - folks always screaming about gov power but not caring about corporations and billionaires owning governments.

It’s not a problem unless they do something I don’t like like Apple /s

>The average person clearly is not paying attention to how much of a stranglehold corporations now have over the populous and how often they just buy themselves power

Sounds like the actual issue is "corporation control over government". Why not say that directly instead of making a tenuous point about how "corporations own people"?

>the average populous just doesn’t care or is willfully ignorant

Have you been living under a rock? "big corporations bad" is a bipartisan issue. The only difference between the parties is the reasoning for why they're bad. eg. "big tech is bad because they're hoarding wealth" vs "big tech is bad because they're pushing woke agenda".

Comments full of doomsaying with no examples are always so frustrating to see.

For example, 99.9% of the smartphone market belongs to two huge corporations, which are not very different from one another (except marketing of course): https://news.ycombinator.com/item?id=34299433

"screaming about government power but not caring about corporations and billionaires" - that's by design. Anyone falls for this (worries about government power over corporations) is simply not intelligent enough to see past the corporate media's shaping of the narrative. The US needs a massive shift of power towards the government as well as a decrease in the democratic deficit. While there are plenty of problems with unions and the government, overall the state of the US needs a change, and smashing unions was one of the worst contributors towards increasing the democratic deficit, and it would greatly help to increase the functioning of local democratic organizations to improve the national democratic deficit.

"so unclear how they're contributing towards consolidation."

Easier to work for another entity than start up your own if you are already on debt, especially if overhead costs related to regulation require more capital.

> only "requirements for IT services and compliances" seems to favor large corporations.

Of course other two matter. Large corp will have its own property management department and can get better deals for good locations to open new pharmacy or other medical location. Further large corp can offer more reliable income and better insurance to Doctors and pharmacists than small single store pharmacy or doctors with individual practice.

See cost of group medical insurance for employees in big corp vs insurance for self-employed individuals. Simply it favors big corp.

>This country is heading towards one of those cyberpunk endings where corporations own people.

That was settled in 1971, when money itself ceased to exist as humans have generally known it for thousands of years, and was instead replaced with fuduciary credit. So long as this stands, anything, you can only buy something if you or someone else has gone into debt to aquire the money for it, and those dollars will eventually be removed from circulation when they make their way back to a private banking cartel, the federal reserve.

For all intents and purposes, working for federal reserve notes and working for yellow lumps of metal (via federal reserve notes) is the same. Yellow lumps of metal can't provide you with food or shelter, so you'd have to exchange it with someone else that has those things. There's no difference between the two aside from the fact that federal reserve notes can be printed at will in response to economic conditions, and yellow lumps of metal are extracted from the ground at haphazard rates.

> aside from the fact that federal reserve notes can be printed at will in response to economic conditions, and yellow lumps of metal are extracted from the ground at haphazard rates.

That's a pretty key difference.

The value is based on scarcity.

When there's no scarcity constraint, we can all just collectively vote ourselves to be billionaires.

What could go wrong?

And yet, after all this time, we haven't voted ourselves to be billionaires.

>What could go wrong?

I could say the same for basing your money supply on the production of a yellow metal. What happens when there's a massive discovery of gold? Or there's a (trade) war between the top producers (eg. china, australia, and russia)? Or when there's a worldwide pandemic and you need to provide stimulus so the economy doesn't collapse?

>What happens when there's a massive discovery of gold? Or there's a (trade) war between the top producers (eg. china, australia, and russia)?

Never in history has this situation caused a collapse like the hyperinflation seen in Weimar Germany or recently Zimbabwe. Because even a huge change in supply is only going to affect price by a double digit percent (check a chart of historical gold price volatility), while hyperinflation can reduce the value of currency by orders of magnitude.

>Or when there's a worldwide pandemic and you need to provide stimulus so the economy doesn't collapse?

The stimulus was only necessary because of the lockdowns, which in hindsight proved completely counter-productive, empirically producing no overall reduction in deaths (https://onlinelibrary.wiley.com/doi/full/10.1002/hec.4737 ). Without the ability to print money governments wouldn't have been able to get away with locking down their citizens so long, and the damage they inflicted on mental health and children's educational outcomes could have been reduced.

>The stimulus was only necessary because of the lockdowns

The question of whether lockdowns were justified aside, pandemics aren't the only form of economic calamity that might occur. Financial crisis occur. Other supply shocks (eg. war in ukranie) exist as well.

And printing money isn't the only way to deal with supply shocks; a government could also use its reserves, as e.g. Singapore did during covid.

1. Singapore is a city state that has a GDP around twice of other developed economies. What works for it does not necessarily work for every other country.

2. There's opportunity costs with keeping such high reserves around, rather than doing something productive like investing in infrastructure.

3. It's unclear how introducing massive amounts of gold (previously held in reserve) into the economy won't cause inflationary effects. Like I said earlier, you can't eat gold. Dumping a bunch of gold into the economy doesn't magically increase the amount of goods in existence, which would also lead to inflation that money printing would cause.

> 1. Singapore is a city state that has a GDP around twice of other developed economies. What works for it does not necessarily work for every other country.

China as a country with relatively low GDP per capita also manages to maintain high foreign exchange reserves.

>2. There's opportunity costs with keeping such high reserves around, rather than doing something productive like investing in infrastructure.

Infrastructure spending is only a small fraction of the US budget compared to warfare; if the US hadn't gone to war in Iraq and Afghanistan it could have a few trillion dollars of reserves with no drop in productive spending.

> It's unclear how introducing massive amounts of gold (previously held in reserve) into the economy won't cause inflationary effects. Like I said earlier, you can't eat gold. Dumping a bunch of gold into the economy doesn't magically increase the amount of goods in existence, which would also lead to inflation that money printing would cause.

It would cause inflationary effects initially, but this would be a one-off thing, as the mining rate of gold is relatively steady.

>China as a country with relatively low GDP per capita also manages to maintain high foreign exchange reserves.

And they're only able to pull it off by having a high trade surplus. Needless to say, not everyone can have a high trade surplus, so it's unclear how this is a policy that can generalize.

>if the US hadn't gone to war in Iraq and Afghanistan it could have a few trillion dollars of reserves with no drop in productive spending.

If the pandemic is anything to go by, if there's a surplus the money would get plowed into tax cuts, not reserves.

https://www.economist.com/united-states/2022/08/25/states-ha...

>And they're only able to pull it off by having a high trade surplus. Needless to say, not everyone can have a high trade surplus, so it's unclear how this is a policy that can generalize.

Governments with a gold-backed currency could maintain high (government) reserves even with a high trade deficit. Imagine a king with literal gold currency, a huge pile of gold in his throne-room. No matter how large the private economy's trade deficit, he's still going to have the same amount of gold in his pile.

>If the pandemic is anything to go by, if there's a surplus the money would get plowed into tax cuts, not reserves.

If governments couldn't print money they'd be forced to be more economically cautious, because they couldn't just print themselves out of trouble, instead they'd need a tax, which would face more resistance.

>Imagine a king with literal gold currency, a huge pile of gold in his throne-room. No matter how large the private economy's trade deficit, he's still going to have the same amount of gold in his pile.

Isn't that just quantitative easing/tightening by another name? During good times you're taking gold out of circulation to build reserves, and during bad times you're releasing gold out of reserves to stimulate the economy.

>because they couldn't just print themselves out of trouble, instead they'd need a tax, which would face more resistance.

The above example involves US states, which can't print their own money.

>Isn't that just quantitative easing/tightening by another name? During good times you're taking gold out of circulation to build reserves, and during bad times you're releasing gold out of reserves to stimulate the economy.

Yes, exactly. But in this scenario the gold's being taken out of circulation by taxation rather than by inflation, which makes it more visible and constrained. Similarly the release is constrained by the amount of physical gold reserves, so you couldn't realistically have e.g. a few years of 100%+ inflation rates. And the process of transferring the wealth is less lossy; 100% goes to the government, none to intermediaries in the financial system.

>The above example involves US states, which can't print their own money.

They can't, but they can try to get the federal government, which can, to bail them out.

>which makes it more visible and constrained

It comes at a heavy cost though: you need to keep tons of the yellow stuff around, rely on the past administrations being prudent to actually keep a sufficient reserve. In the end you're still relying on people to act prudently.

>They can't, but they can try to get the federal government, which can, to bail them out.

I mean if you're going to invoke extraordinary measures like this, then I can also invoke up extraordinary measures like the government debasing the currency, which was still done even when countries were on the gold standard.

>It comes at a heavy cost though: you need to keep tons of the yellow stuff around

A cost to the government, but much less of a cost to the lower classes, who pay low taxes thanks to progressive taxation so inflation represents the biggest drain on their wealth (especially since most don't have access to financial instruments or the education to use them).

>I mean if you're going to invoke extraordinary measures like this

It's not necessarily extraordinary; we haven't seen the Federal government bail out a state yet but we also haven't yet seen a state undergo a complete financial collapse, so it's quite possible there'd be a bailout if things got bad enough. The WSJ predicts a bailout of the states is upcoming: https://www.wsj.com/articles/the-coming-biden-bailout-of-blu...

>like the government debasing the currency, which was still done even when countries were on the gold standard

They did that by essentially turning their currency into a fiat currency: saying it was worth X, when the actual precious metal it consisted of was only worth e.g. half of X. But yes you're right that in theory nothing prevents a government with 100% gold standard from debasing it like that, however doing so would be more visible to citizens than inflation since it'd require centralising how the currency was priced.

I dont know whether being able to call it quantitative easing matters at that point. If the government has a pile of gold it deploys during an economic downturn, say they get it right and actually help, people will be less dissatisfied with the subsequent taxation. If they get it wrong though, and cause problems or fail to help the situation, people will be more resistant to that taxation; in the next cycle the government will be more careful about their allocations, pressured both by resource constraints and political pressure.

Wouldnt that be a healthier cycle than one where we just paper over everything?

Right, its just how the power was used in real life, rather than the utopia that you were promised.

>For all intents and purposes, working for federal reserve notes and working for yellow lumps of metal (via federal reserve notes) is the same

It's absolutely not because with federal reserve notes 2-3% of your purchasing power (more recently) is transferred every year to the elites in the financial system. Because the Federal Reserve doesn't just deposit money evenly into everybody's bank accounts, it loans it out to banks, and banks as the first recipients of the newly created money benefit from a wealth transfer from the last recipients of the newly created money (termed the Cantillon effect).

It's a leap to go from "Cantillon effect" to "2-3% of your purchasing power (more recently) is transferred every year to the elites in the financial system". I agree there's some benefit from getting the money sooner, but it's nowhere close to 100% of inflation.

Yes you are right, a lot of that 2-3% goes to the government, and only the remaining part goes to elites in the financial system. It's still higher though than the 0% it'd be with gold-based money (or a Fed that helicopter-dropped money directly into people's bank accounts).

>Yes you are right, a lot of that 2-3% goes to the government

I'm not really sure how that's the case when inflation expectations are baked into any sort of fixed income products.

>I'm not really sure how that's the case when inflation expectations are baked into any sort of fixed income products.

The poorest people in the US, lower and lower-middle class, aren't holding many fixed-income products, and they're the ones hit hardest by inflation. But that aside, even if your fixed-income product covers inflation, you're still taxed on the capital gains as if it was real profit, because capital gains taxes (at least in the US) don't account for inflation. I.e. they tax the nominal gain, not the real gain.

This presumes that inflation wouldn't happen with gold, which isn't straightforwardly true. Technological advances could make gold easier to extract which would increase their supply, which in effect is printing money. Also, going back to your point about how benefit accrues to "elites in the financial system" because of the Cantillon effect, it's unclear why that wouldn't occur with gold backed currency. After all, gold would still be mined. The only difference is that it would go to miners rather than "elites in the financial system".

>This presumes that inflation wouldn't happen with gold, which isn't straightforwardly true. Technological advances could make gold easier to extract which would increase their supply, which in effect is printing money.

Yes, but it's unlikely there'd be such advances made consistently year after year, given that's not what we've seen historically. The US had a gold-backed currency for the entire 1800s and there wasn't any significant inflation: https://www.minneapolisfed.org/about-us/monetary-policy/infl... .

>The only difference is that it would go to miners rather than "elites in the financial system".

Yes you're right. Based on historical data though I'd expect them to receive overall much less than the financial industry currently does, given how much less inflation there was in the period prior to Bretton Woods ending. As per that link I shared earlier, the CPI was 51 in 1800, 25 in 1900, 116.7 in 1970, and 900 in 2023.

>The US had a gold-backed currency for the entire 1800s and there wasn't any significant inflation: https://www.minneapolisfed.org/about-us/monetary-policy/infl... .

The same source also shows that between 1800 and 1850 prices halved. I guess that's technically not inflation, but 50% deflation isn't great either and causes other economic problems.

>I guess that's technically not inflation, but 50% deflation isn't great either and causes other economic problems

Yes, there was a lot of deflation in the 1800s, and although it caused hardship, GDP per capita continued to grow at around 4% throughout the century, without huge dips like we saw in the Great Depression or the GFC.

Historically the profit from gold mining was the least common denominator of society. The cost of gold mining closely tracks the revenue, meaning almost any other profitable investment would be preferable.

Gold mining is effectively a black box that takes diesel in and produces gold out

The bailouts of 2008 led to a k shaped recovery just like the bailouts and stimulus of covid.

People save money when times are hard, interest rates rise and unproductive ventures collapse, that is the homeostatic response of the economy and it is a healthy one; when productive ventures prove themselves, they are able to attract the investment of savers and use it to aquire capital goods etc.

When you print money in an attempt to stimulate the economy, you are sending mixed signals to investors who now have to worry about inflation eating their savings, ecouraging them to spend or invest in often unproductive ventures. This response drives up the cost of consumer goods and allows those unproductive ventures to suck up the capital goods that would be better used elsewhere.

The alternative of "economy goes bad -> people try to save money -> supply dries up -> economy goes even worse", as we saw in the great depression isn't great either.

The great depression wasn't caused by just people saving money. The US imposed massive trade tariffs prior to it, which as predicted by basic macroeconomics had a big negative impact. It also added price controls, even on labour, which again as predicted by basic econ prevented the market from clearing and led to mass unemployment (as deflation was happening, price floors prevented wages from following it, so in real terms wages were too high for employers to afford, causing mass unemployment). Those price controls BTW are why health insurance is tied to employers in the US: because companies at the time couldn't offer higher wages above the price ceiling, so instead compensated by offering benefits like insurance instead.

The federal reserve admitted that their policies prolonged the great depression.

People will buy the things that they need, resources will follow those needs because thats what people are actually buying. Some things might die, that is a reflection of society not actually caring very much about it, otherwise they would be buying it. This is in fact an attempt to re-organize the economy around specific things that wouldnt otherwise be supported by the market, with some crumbs left to curate votes.

When people save, interest rates go up, freeing the capital goods needed for ventures that the market actually has a revealed preference for.

> The federal reserve admitted that their policies prolonged the great depression.

their policies of what? Not engaging in stimulus?

>People will buy the things that they need

People buying the bare minimum also means there's little investment going on, which needless to say is bad for economic growth.

>When people save, interest rates go up

Why would that be the case? Interest rates are a reflection of the cost of money. When there's more money floating around, the cost of borrowing becomes cheaper, not more expensive. Or to put it another way: for every saver, there has to be a borrower. If there's more savers than borrowers, then the savers will have to compete with each other on price (ie. the interest rate they charge), driving them down.

>People buying the bare minimum also means there's little investment going on, which needless to say is bad for economic growth.

Not spending money indirectly contributes to investment. If you imagine 50% of the population suddenly decided to not spend any money for 10 years, and they hold 50% of all the money in circulation, in the short term this is essentially equivalent to burning 50% of the money supply, in that the reduction of the supply of money in the market leads to an increase in the value of money, which allows the people spending money at that time (including people making investments) to obtain more goods and services for their money.

But if the economy is going to shit, who are the people that are sticking their necks out by borrowing money to invest, rather than accumulating savings to weather the downturn?

>who are the people that are sticking their necks out by borrowing money to invest, rather than accumulating savings to weather the downturn

Normal people aren't, but rich people (who don't face any real risk to their standard of living from a crash) are incentivised to "buy the low" while everything is cheap. And they can buy more thanks to the purchasing power that other currency holders temporarily forfeited by pulling their money out of circulation.

You claimed a few comments up that printing money would cause people "to spend or invest in often unproductive ventures", but based on what you're saying now, it would have the same effect? ie. more savings = more investments are needed to balance them out = more questionable ventures being funded as savers chase ever more questionable ventures for yields.

>more questionable ventures being funded as savers chase ever more questionable ventures for yields

The difference is that for private investment there's a process of natural selection: bad investors lose money to good investors, and over time the people with a record of better investment end up with more money, and overall better investments are made. Whereas the US government can keep spending money on economically unproductive things like the war in Afghanistan indefinitely without any feedback loop to stop it.

I agree that if government was somehow involved in the lending (ie. choosing which companies to bail out), there would be a risk of picking winners/losers and creating zombie firms, but it's unclear how it's an issue exclusive to fiat currency. After all, governments can still take on debt even while on the gold standard, and can still engage in bailouts.

Yes, the lending during bailouts could still pick winners/losers, but overall during normal times the government would be spending relatively less compared to the private market (as it'd be constrained to what level of taxation voters were willing to tolerate), and there'd also be potentially more oversight over its spending (as it'd have to justify spending increases in order to receive public support for increasing taxes to pay for it).

People wkll invest in the ventures that have a profit, because those can weather the storm. Eventually the growth of those companies creates the economic surplus that allows greater specialization to return, only built on a foundation of profitable companies.

When you bail companies out, you create zombies that dont need to compete for the business, they will weather the storm and come out the other side monopolizing the market. The specialization that flows from that is the spread of a cancer, doubling down on a failed foundation.

>their policies of what?

This was answered by the other poster

>People buying the bare minimum also means there's little investment going on, which needless to say is bad for economic growth.

Growth for who? There is little investment going on, that is the point, ventures that cant profit die, freeing their resources up for more productive ventures.

>Why would that be the case?

In this paragraph you moreso identify the market forces that eventually cause rates to come down. Eventually there is enough savings, and when companies come forward demonstrating their ability to create value, competition between savers pushes rates back down. This comes after the period of everyone stuffing their money under the mattresses.

You are confusing saving and lending, there is a creditor (buyer) for every lender, not every saver.

--------------

Lets summarize. I hope you find the following to at least engage you and make you question your prior understanding of the issue at hand.

You are concerned that companies will own everything, but are not concerned with the 7% YOY (its not 2-3%) growth in the money supply, and how all interest on money that was printed into existence. The principle of that money will eventually be taken back out of circulation, leaving interest that remains to be paid. If you bought a house, but only paid back the principle, the bank is still going to repo your house, they own it afterall; there isnt enough money in the economy to repay the principle, meaning either mega-default across basically all industries, or we have to take on more debt to repay the interest on the last debt; since we are dealing with precentages and compounding interest, a greater and greater sum of resources go explicity to repaying debt.

If you wanted your repo-men world where everyone is enslaved to debt and private companies, thats all you need, just let it play itself out. If you really wanted to take it up a notch though, theres more we could do to confuse and repress the poor. Print lots of money, it doesnt matter how you justify it, forever wars, bank bailouts, socialized healthcare and welfare, it doesnt matter! When this money is printed, it will accelerate the process by rapidly growing the total amount of interest owed, and you will of course have your pockets open to receiving these streams of cash.

Why do you think politicians have been getting so rich off the stock market? Do you think its because these people are world class investors? All of them? They are invested in the same companies that they regulate, and by that I mean they protect those companys against competition, and provide stimulus when possible.

For the average person? The time-price of everything this money touches goes up, thats how many hours the median american has to work to aquire a good. Housing, healthcare, education, defense, everything that is paid for with money being printed into existence, is going up in price dramatically. Things like, tvs, computers, they become more accessible every year.

These "costs" you speak of are purely fabricated through a complex system of insurance, pharmacy consolidation, medical practice consolidation, and intermediaries who structure the pricing.

Consolidation drives consolidation. It’s a closed loop.

We’ve gotten to the point where ‘communist’ China has more competition than most of the west does.

> mountains of school debt

Is this, plus the liability insurance aspect, the root of the problem? I wonder if prospective doctors could “enlist” where the government pays for all this training and shields them on the condition that they follow orders for some period of time like “be a primary care doctor in this underserved community and treat everyone.” You can’t go be a Malibu plastic surgeon until after your mandatory service period.

Isn’t this just the military? Canadian military is perpetually short of medical staff even with this.

Not exactly my thoughts, but similar. The military trains doctors for troops and veterans. This would be for the benefit of civilians. One provides for the common defense, this would promote the general welfare.

"Is this, plus the liability insurance aspect, the root of the problem?"

Maybe for some, but not all. I know of more than a few older doctors that decided to retire because they didn't want to deal with increased regulation. So it's not always a money issue.

"I wonder if prospective doctors could “enlist” where the government pays for all this training and shields them"

They have these programs for military doctors. Doctors working for the VA (and maybe other federal things like prisons) can usually avoid a lot of state related costs, which I believe includes malpractice insurance (or maybe the federal version of malpractice is cheaper).

Medical school is so expensive because it's a cartel; the government limits new entrants, so the schools can charge whatever they want because they know they're not going to get any competition. And it doesn't allow people to practice medicine unless they attended one of those privileged schools.

> the government limits new entrants

... based on lobbying from the AMA, which is only in the last couple of years reluctantly acknowledging that maybe, perhaps, possibly, it shot itself in the foot with the increasing amount of physician burnout.

Source? I don’t think the federal US government has any say about how many medical school students there can be.

The federal government does provide funding for residency positions, and all doctors are required to complete residency. This residency funding has been effectively flat for many, many years, effectively capping the number of residency positions, which then caps the number of new doctors per year.

But I am not sure what exactly limits anyone other than the government from funding residency positions.

Teach for America (a non-profit) works with some colleges to offset some of the tuition. There are states in the US that will cover the difference of out of state tuition at an out of state veterinary medical school in exchange for years of work in state.

Unsurprisingly, those programs still exist because there are still shortages despite the help they're bringing. But there's precedent.

Perhaps we'll get single-payer... but the single payer will have a profit motive.

A move towards "Value Based Pricing" for medical services, where pricing corresponds to the value of our lives.

Now consider states make it illegal to get birth control pills and retroactively go after anyone who has them prescribed. It's according to the law, ain't it?

The states should keep their noses out of this and in effect all drugs should be made legal. If you do have a problem (ie an addiction) we should make it trivially easy to get help instead of burning resources to investigate these. As far as abuse goes: it should be trivially easy for a pharmacy to check if a doctor did indeed prescribe something without raping the privacy of everyone involved. As a matter of fact, why the hell does it take 30 minutes to fill a prescription in 2023?

I don't agree with your proposed solution (make all drugs legal), but I do think that the pharma industry in the US basically gets to socialise their losses while privatising the gains.

The Sackler family's opioids, for example, have caused untold damage, and they made billions from it. They were able to offset the cost of all of that onto the society.

The "make all drugs legal" was meant as a way of saying that we should not punish people that have an addiction. I was not advocating giving highly addictive hard drugs out without prescription.

Aren’t these two stances mutually exclusive?

How do you propose not punishing people with addictions while somehow never giving out hard drugs without a prescription - since addictions are by their definition destructive and Dr’s shouldn’t be giving prescriptions for things that are known to cause problems for someone?

Are they? You don't prosecute anyone. You get them help.

I think the term you’re looking for is “decriminalisation”, which is different than “legalisation”.

So then it’s not actually illegal to do any of these things?

Prescriptions exist to allow a non-doctor access to drug classified by the FDA/FHA as being “dangerous”. I agree that we should make all drugs legal in the sense that it’s a mental health problem but I’m not for allowing everyone access to fentanyl.

Ex post facto laws are not possible in the United States

Nominally. But if you’re relying on a drug for medical care and it becomes illegal, the distinction seems superficial to me, no?

Lol. There are a lot of things that should not be possible in the majority of the civilized works.

If this is your defense you're in trouble. Take for example the mythical "checks and balances" that are supposed to keep elected representatives under control. How is that working out?

US == freedom and democracy! Until you see the fucking army mobilized to protect the capitol like we are some banana republic where the dictator in charge decided they would like to remain in power. This also is not possible in the US, right?

By convention, but in practice rules get ‘reinterpreted’ to punish previously at least nominally legal behavior all the time - especially when it comes to finance, business, guns, sex/porn, etc.

In theory, however California eliminated their statute of limitation's for rape (was previously 10 years) and now people are being charged (and convicted) for 20+ year old crimes with only verbal evidence.

You might argue it’s not the same thing, but the effect is definitely the same: the law changed and people went from unchargeable to chargeable

This is bad reasoning. Ex post facto laws are intended to prohibit making otherwise legal prior actions retroactively against the law, as no law was broken at the time the events occurred, so it would make a mockery of the rule of law to find someone guilty of a crime when no law was broken at that time.

What you’re arguing against is absurd. Regardless of the existence or lack thereof of a relevant statute of limitations, ex post facto laws have nothing to do with prosecution of acts that were already illegal at the time they were committed. It may not engender respect for the law or respect for lawmakers to remove the statute of limitations after the time has already passed, but I side with those who the law has already failed: victims of those who break the law to the detriment of victims.

If justice delayed is justice denied, then the statute of limitations is a double-edged sword that makes a mockery of the law and of those victims of the law’s failure to be enforced; the original victim is victimized again by denying them their just reward: justice itself.

Similarly, we collectively also suffer as a society when lawbreakers aren’t held responsible for their actions, which further foments contempt for the law, by allowing a state of affairs that is demonstrably unjust.

Decrim has been an unmitigated disaster in Portland and Seattle. I once agreed with you, but seeing what's happened on the ground changed my position

Nobody talks about part 2 of the decriminalization which cannot happen in the US - which should be providing support for the addicts to recover.

There's two massive hurdles to clear in public perception: 1) that addiction is a personal vice that people _shouldn't_ get help from others for, if they die on the street, it's their own fault, and 2) that helping people who are homeless is somehow offensive and unfair to people who are "productive" and don't get help for free.

It baffles me, if someone homeless in my community gets housing, that doesn't make me feel aggrieved for having to pay for mine. Yet we spend more money per person on homeless services that fail to get them housing than we would spend just... paying for apartments for them, because it would be unfair to do so.

The problem is that the welfare system failed to get implemented during the new deal and was introduced by the “Great Society” amendments to the Social Security Act in the 1960s.

The core compromises essential to getting it done were the usual “states rights” revenue split and later limiting state liability by abusing social security disability. There’s alot of overhead dollars that fund state operations so it is difficult to effectuate change - by design.

Things like addiction support are aligned with mental hygiene and Medicaid, so you really need to destroy your life until the safety net kicks in. If you live in a place like Mississippi, they’ll try to ship you north or push you towards SSDI (ie the Federal budget). In states that are less bleak, the community standard for disability is lower, and usually rehab is covered in some way by Medicaid.

The other thing that’s different about addiction vs regular healthcare is that the person needs to be ready. I worked for years with a gentleman who beat alcoholism and became a counselor. He was only able to get by it after harming one of his children accidentally.

Indeed. It's a multistep process, like changing the oil in your car.

Step 1. drain the old oil

Step 2. pour in the new oil

If you skip step 2 and damage your car, it doesn't mean oil changes are an unmitigated disaster. It means you didn't fucking do it right!

Just because the powers that be in Portland and Seattle failed to it properly does not mean that the opposite is better.

There are dozens on things that should of been done better - but they disenfranchised those who could of helped the most.

I don't have the data that I would like to have on funding for treatment and education there, but I'd like to see real case studies that could inform other places to get ahead of the issues rather than give up.

> Now consider states make it illegal to get birth control pills and retroactively go after anyone who has them prescribed. It's according to the law, ain't it?

Your example is ex post facto, but it doesn't even have to be that egregious. State A makes it illegal to leave the state with the intention of having or facilitating an abortion. Because CVS operates nationally, cops in State A can go to a CVS locally and pull records of a CVS in State B filling a prescription for a medication that is sometimes, but not always, used for abortion. They can then use that to build a case for prosecuting the person in State A.

> State A makes it illegal to leave the state with the intention of having or facilitating an abortion.

States do not have the authority to regulate travel across borders. The supreme court would strike this down 9-0, as the implications would be enormous.

You might be meaning to refer to interstate commerce? Which appears to be the more applicable situation?

Medical procedures are commerce.

There are already numerous "leave the state with the intention of" laws, which I assume to be just some extra charge to throw at someone, like wearing body armor while committing a felony.

Can you show a ‘leave state with the intent’ law that has been successfully prosecuted?

Texas counties are taking the “bounty hunter” model, similar to the states abortion ban law. So, not sure what “prosecution” means in that type of case. https://www.vox.com/23868962/texas-abortion-travel-ban-uncon...

Regardless, the law only needs to be on the books to lead to needless pain and suffering of women, as we’ve already seen in Texas and elsewhere.

Tell that to Idaho

https://www.nbcnews.com/health/womens-health/idaho-most-extr...

That statute applies to people facilitating the travel of minors without parental consent.

This bill establishes parents as having full legal authority over their minor children and no one else.

As such, it does not really apply in the same way as a blanket travel ban. Parents have always been given preferential dominion over their children.

> Now consider states make it illegal to get birth control pills and retroactively go after anyone who has them prescribed. It's according to the law, ain't it?

Are we discussing legality, morality, what should be legal, or what should be moral? I agree that would be bad morally, and shouldn't be legal, and currently isn't. My original comment was regarding how the process currently works, and why. It was also to explain that any concern of privacy regarding prescriptions comes more from the department of health/board of pharmacies than it does from 3rd partys providing documents, as the documents arent invading privacy anymore than what already happens.

> The states should keep their noses out of this and in effect all drugs should be made legal.

The whole "your right to swing your fist ends where someones face begins" thing applies here. The problem with some heavier drugs, and their addictive nature, comes in how it effects others. When something is so addictive that a person would sell their own child to acquire more of it, maybe we should limit access to that thing. Ive known a lot of addicts professionally and personally. They come in various degrees of wanting help. Some are in denial, some would do anything to kick the addiction. Some don't care at all and would fight to refuse any help under any circumstance. Its a super complicated issue, "Just legalize all of it", and "Just criminalize and punish all of it" are both equally shortsighted solutions.

> we should make it trivially easy to get help I agree 100%

> it should be trivially easy for a pharmacy to check if a doctor did indeed prescribe something without raping the privacy of everyone involved

It is, and they do. They call the doctor, he says "I didnt write this". Then he gives me a list of people who filled prescriptions he didnt write. The biggest invasion of privacy of unaffected people is when we have a confirmed suspect, we see what other doctors he filled a prescription for, and then go through that list with the new doctor to see what is and isnt legit.

So yeah, at some point in a table of a few hundred people I probably saw some names of people who were a doctors patient, and that they have a prescription from him. I've been inside their privacy just as much as the receptionist at the doctor's office and the pharmacy tech at the CVS

> as the documents arent invading privacy anymore than what already happens.

Nope. Invading privacy is invading privacy. Just because something is happening today does not make it okay and acceptable

> call the doctor

Is this the 70s? Call the doctor? Do you call the doctor for every prescription?

Here is a wild idea: we have tjis thing called the internet and this other wild thing called PKI. Give the doctor a certificate pair and they digitally sign every prescription. You don't ever need to talk to the doctor, you just need to pull their public certs.

Since we're doing privacy, give the chumps that need the prescription a cert pair and encrypt their shit + make it a crime to store any of their PII at pharmacy level.

Ho man. Do you think the Dr’s illegible scribble on the prescription pad as it is, is because Dr’s are so great at attention to detail and learning new things that they’ll be able to do that effectively?

Without it being an even worse situation where they get a Trojan from opening random emails or surfing for porn, and then all the sudden 100k valid appearing prescriptions for controlled medications all the sudden show up in pharmacies across the country?

This stuff is mostly fixed with EMRs. For most applications, paper scripts are rare.

> Nope. Invading privacy is invading privacy. Just because something is happening today does not make it okay and acceptable

Thats not what I was trying to say. My point was that the state already has this data, and I've already seen it before I get a copy of the data from the pharmacy. If you're concerned about the privacy of the data, you should consider the root issue of warrantless access to the PMP by investigators. Anything I get from the pharmacy is just a piece of paper that says the same thing that I already had from that

> Here is a wild idea: we have tjis thing called the internet and this other wild thing called PKI. Give the doctor a certificate pair and they digitally sign every prescription. You don't ever need to talk to the doctor, you just need to pull their public certs.

This is a great idea in theory, but currently has some problems. Some of them probably could and should be addressed, some not.

- Old people who dont want to learn. The PMP lets doctors get a list of every prescription filled in their name in a spreadsheet. You can sort and filter by where it was filled, patient name, type of medication, etc. Of the doctors Ive dealt with, maybe 10% knew about this and used it. A few learned about it from me, got excited, figured it out, and used it to its fullest extent. Most just went "yeah okay" and ignored it because spreadsheets are too complicated.

- Where are we storing this? Can only the doctor do it? From only one computer? Can his receptionist call in the prescription? Can anyone else access that computer? Basically is there any way at all for fraud to happen? What if its the doctor whos the one doing it? Ive seen pharmacists say "Were getting a lot of suspicious prescriptons from this one doctor" who was just flat out selling them to people who had no problems. E-scripts are a thing, and ive seen cases where nurses and receptionists hop onto the system to write illegal scripts.

> Since we're doing privacy, give the chumps that need the prescription a cert pair and encrypt their shit

My mom thinks opening chrome dev tools is going to get her arrested for hacking a website. Please dont put the onus of key pair encryption on her in any way

> + make it a crime to store any of their PII at pharmacy level Im not sure if its a legal/regulatory requirement, or just a moral thing, but Pharmacists are highly trained, with a Doctorate in what they do, and they catch things. Whether its a Doctor wrote the wrong script, or a potentially lethal contraindication between meds. Them having records of what else a person is on is a legitimate medical use case. There may be ways to keep this sort of data without PII, but it would be another concern to address.

Bake the cert pair into the id you are giving out to people. Look at the system in Estonia

"Eschew flamebait. Avoid generic tangents."

"Please don't fulminate."

https://news.ycombinator.com/newsguidelines.html

We detached this subthread from https://news.ycombinator.com/item?id=38807378.

Does anyone know of an actual case of a person who was impacted by this? The OP does not describe such a one. Is the only impact on people suspected of using prescription drugs to kill, rape or otherwise harm? I am having trouble imagining other kinds of impacts.

If the police have a reasonable suspicion then they should have no problem getting a warrant. If they cant clear that bar then maybe they shouldn’t get that information.

Rules aren’t just for people you like or approve of.

So you're not curious at all about how this "information leak" you probably did not know about before today could bite you personally? For you, this conversation is only about public policy and how you and I might change it -- and not at all about how you personally (or someone you care about) could modify your purchasing behavior to reduce your vulnerability to adverse governmental action?

I agree with the legal principle you describe, but to me that is the less interesting angle because public policy is hard to change whereas my own behavior is much easier to change. It is amusing that I cannot have a conversation here about any other angle without getting downvoted by people opposed to any writings that could possibly be useful to the opposing side in the public debate over the one angle they want to talk (write) about.

The standard for a warrant is probable cause, not reasonable suspicion.

I think OP’s point is that, without privacy, there is no standard at all.

Does anyone know of an actual case of a person who was impacted by this?

What difference does that make? It's wrong, regardless of whether or not one can cite a specific case where it affected someone. This is no different than the b.s. "you don't need privacy if you don't have anything to hide" crap that people spout sometimes.

If the govt. needs this information, the can get a warrant. If they can't get a warrant, they don't need the information. This isn't that hard to figure out.

Oh boy...

Here's a good one: the FAA categorically prevents any pilots from taking any psychiatric medication (minor caveats but the point holds in practice), in particular for depression, anxiety, and ADHD, all of which are extremely common in the airlines. As such, everyone just hides their diagnosis and waits until they snap because the alternative is permanently losing a job they took out hundreds of thousands in loans to get. Others pay out of pocket for treatment under false names so the FAA is currently trying to hunt them down.

Before anyone says the usual stuff about not wanting their pilots on meds, the medications are safe to fly on and much safer than the alternative, the FAA just hasn't updated their psych guidelines since Freud was the standard because any change would open whichever bureaucrat up to being hauled in front of Congress for the next accident regardless of culpability. Additionally the medication standards are also inherited from ICAO so even if we wanted to change, we'd need to convince the likes of China and the Saudis (both major stakeholders) that they can come out from the rock they live under and accept modern psychological science.

Thank you!

Ugh, this is absurd

And I agree, it is safer to just get the drugs. Maybe some very specific drugs should be excluded, but that's it

Same with leaded fuel and some very old mechanical gizmos in planes.

>we'd need to convince the likes of China and the Saudis (both major stakeholders) that they can come out from the rock they live under and accept modern psychological science.

Giving how overwhelmingly worse the mental health is of people, especially young people, in America, I can see why the Chinese and Saudis are so reluctant to accept western psychological "science".

What's it like to do a young woman in Saudi Arabia or a young Muslim in China?

That's completely irrelevant to what OP was saying.

No, it isn’t. Mental health is a lot easier if you don’t care about large portions of the population.

I would hope that the Chinese and Saudi's realize the youth in America's mental health is largely due to America's unique flavor of corporatacracy and the climate crisis. If you think this is wrong you either don't know or understand American youth or you're being willfully ignorant.

What does the climate crisis have to do with the drastic mental health crisis that is present in the US/Canada? Genuine question.

https://magazine.hms.harvard.edu/articles/climate-anxiety

We're talking about two different things: the cause of mental health issues and the treatment of mental health issues. The US is pretty modern at treating them and pretty outstanding at causing them.

Yes but it seems like the treatment is addressing the symptoms and not the outstanding source of them as you say. We are slapping band-aids on an open wound

As a person who experienced both the symptoms and the treatment in the US I can assure you that it’s better to receive band-aid treatment than nothing at all.

Treatments could be—and should be—better, but comparing US to countries where psychological issues are being ignored and stigmatized is not to the benefit of the latter.

Ha, it's like saying there are no gay people in Saudi Arabia. If having psychological issues is extremely stigmatized by the society don't expect the stats to reflect reality in any trustworthy sense.

> the medications are safe to fly on

Citation?

> FAA categorically prevents any pilots from taking any psychiatric medication

Some of those medications can alter you in a big way... at least many of those medications should be on the list...

Seems like the solution is to change the regulations (if warranted), not say "oh it's bad when data is used to flag pilots who are violating regulations".

> I am having trouble imagining other kinds of impacts.

You don't even have to imagine; there are plenty of concrete examples.

https://www.nbcnews.com/nbc-out/out-politics-and-policy/seat...

"Texas Attorney General Ken Paxton asked a Seattle hospital to hand over records regarding gender-affirming treatment potentially given to children from Texas, according to court filings that appear to show the Republican going beyond state borders to investigate transgender health care."

https://montanafreepress.org/2023/07/19/knudsen-other-republ...

"Montana’s attorney general and Republican officials from 18 other states are opposing a federal effort to strengthen medical privacy regulations, arguing that states with abortion bans should be able to obtain reproductive health care records for criminal investigations, including when a patient travels to another state."

Thank you!

> Republican officials from 18 other states are opposing a federal effort to strengthen medical privacy regulations

Against big government when it suits, I see. Hypocrisy is the worst disease in politics.

Succumbing to the temptation of expediency to achieve one's ideology is indeed a plague that affects all of politics.

Dismissing critical thought, first order reasoning, and "the ends justify the means" short-term focus has brought our country once again to the brink of civil unrest.

Unfortunately, it's a phenomenon that's not limited to any particular political party.

Yup, and Texas, who also tried to sue Pennsylvania (and Georgia, Michigan and Wisconsin) over how they ran their elections in 2020.

> Within one day of Texas's filing, Trump, over 100 Republican Representatives, and 18 Republican state attorneys general filed motions to support the case.

I expect that the 18 states opposing strengthening medical privacy are the same 18 states whose AGs filed these motions.

they could use it selectively to take away someone's guns. let's say someone gets on the wrong side of a politician who wants to wreck them. politician starts an "investigation" of the enemy, finds some very loose diagnosis of, say, depression, then has armed thugs raid the house and "remove all weapons", right after notifying the media. then the media leaks "our sources confirm $badguy was treated for an unknown psyciatric condition 2 years ago and tonight was found in possession of a high-powered rifle and out of concern for the safety of his family, his weapons have been confiscated". His reputation (whoever he is) is now shat on.

Thanks, I was wondering the same.

For those downvoting this question, I think askers are trying to weigh the benefits of better data-based decision making versus privacy. Amidst an opioid crisis we're wondering if more patient-level data may have helped form an earlier picture of abuse. Having done some data science, I immediately see the benefits of clearer pictures to inform policy; and having lucked out of being targeted for medical violence I'm honestly looking for examples.

>Is the only impact on people suspected of using prescription drugs to kill, rape or otherwise harm?

The point of a warrant is that you need to have this suspicion to pull the info. If it doesn't take a warrant, they can go on fishing expeditions.

Capsule doesn't do this, fwiw

Do you have an official statement from them on this?

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