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?
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.
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.
Freedom of association shouldn't end just because I want to hire an assistant.
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.
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.
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.
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...
> 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.
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.
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.
Healthcare info being public invites all sorts of abuse by people going for political or "culture war" gains.
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.
We would not, thankfully. But many of them asked. Some, repeatedly.
*Apologies for the excessive alliteration. Didn't see until I submitted.
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"?
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.
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".
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.
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.
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.
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?
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?
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 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.
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.
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.
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...
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.
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.
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.
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.
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.
Wouldnt that be a healthier cycle than one where we just paper over everything?
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).
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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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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.
We’ve gotten to the point where ‘communist’ China has more competition than most of the west does.
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.
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).
... 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.
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.
Unsurprisingly, those programs still exist because there are still shortages despite the help they're bringing. But there's precedent.