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> I swear, the richest businesses in America could be so much richer if they banded together to lobby Congress for legislation that benefits all of them. Example: Imagine if the US switched to a single-payer healthcare system; how much money that would save the big tech companies.

You're misunderstanding how the corruption works.

Single-payer isn't the thing that causes other countries to pay less for healthcare. For example, Medicare and Medicaid pay significantly more per-patient than healthcare systems do in other countries, even for patients in the same demographic groups. Other countries with hybrid or private healthcare systems also have lower costs than the US.

The US system is so expensive because it has been captured by healthcare companies. If you change the funding source without changing the other aspects of the system, it doesn't get any cheaper; if you change the other aspects of the system, it gets cheaper regardless of the funding source.

But the healthcare industry makes the tech industry look like chumps. US healthcare spending is $4.9 trillion. The people getting all that money don't want it to cost less and lobby Congress to make sure it doesn't.

And it's to their advantage to deflect blame to insurance companies so they can propose laws that make it even worse, like capping insurance company profits to a percent of claims to keep the insurer's incentives aligned with increasing rather than decreasing costs, because then the only way for the insurer to make more money themselves is to pay out more claims to the healthcare companies, depriving them of the opportunity to profit from reducing waste.

I broadly agree, with two caveats: 1) some of the extra cost is used to buy state of the art treatments and systems, that help drive down their cost in other countries, and 2) it's been just as captured by legislative tug of war over the decades, that cause strange loopholes and constraints.

https://marylandmatters.org/2024/01/19/report-finds-some-dru...

Not everything is drug discovery. Even stuff like "this digital system would save you going into a hospital in person" is done very well in the US, as it can afford it. Kaiser Permanente IT is particularly amazing, from what I hear.

It really doesn’t take billions of dollars for that type of system - coming from someone who worked at healthcare SaaS companies between 2014-2020. That’s not where the money is going

My question would be - which countries did your companies target if not the US for their SaaS solutions? What was the place that made you the money if not the US?

For the most part, because of laws, regulations and certifications, all healthcare IT systems are localized to the country. Investments in software in the US, only helps the US.

That's definitely not the case. I've worked in the UK on two health platform things, and the US market was by far the only one that could sustain normal prices. And the UK buys US software (EPIC/Cerner, for example) from the US. It's not localised at all. There aren't that many systems. Plenty of countries use the FDA's rules, and many standards are relatively global.

That one's kind of a math problem.

Suppose you're selling your new drug for a net margin of $100/unit and then you put all of that back into R&D.

If you don't buy advertising, you sell 10,000 units and put $1M back into R&D.

If you buy $7M in advertising, you sell 100,000 units, get $10M, $7M goes to pay for the advertising and you put $3M back into R&D. Then you're spending more on advertising than R&D.

But then you're spending three times as much on R&D. So which one of these is better?

There are only two countries where you are allowed to advertise prescription drugs.

https://www.health.harvard.edu/medications/do-not-get-sold-o...

You can’t buy them anyway without talking to your doctor who should be better informed than a consumer would be based on a 30 second commercial.

One thing that RFK is pushing for that I agree with is getting rid of commercials for prescription drugs. I doubt he can.

The purpose of the commercial is to make the patient aware of the drug so they ask a doctor about it, instead of e.g. having given up on finding any treatment for the condition because there hadn't been one when they asked a doctor about it five years ago. This can result in people getting treatment for something they wouldn't otherwise have been aware was available.

It could also result in people buying stuff they don't need, but then their doctor should be advising them that they don't need it, right?

I have mixed feelings about it. I would hope that the doctors keep up with the latest developments and would know the options available. But I also like the idea of patients having agency to advocate for themselves to do their research and talk to doctors and they can’t do that without knowing what they don’t know.

On the other hand, if it weren’t for marketing, could costs come down?

As you can tell, these are weak opinions weakly held instead of strong opinions weakly held

> I would hope that the doctors keep up with the latest developments and would know the options available.

One of the issues is that people often go to the doctor and find out the existing treatment doesn't require a prescription or doesn't exist, so they have no more reason to interact with the doctor and the doctor learning about it only matters if the patient knows to go back to the doctor.

> On the other hand, if it weren’t for marketing, could costs come down?

Probably not, since drugs under patent (which are nearly all of the ones advertised) are sold for the monopoly price until the patent expires.

The biggest problem there is that a drug company can produce something which is 2% better than a non-patented alternative but then patients will choose it over the existing thing even it it costs 100 times more, because it's 2% better and the insurance is paying for it, and the drug companies are great at getting the media to yell at insurance companies that refuse to cover things.

The thing that would really help here is to make copays a percentage of costs, so instead of the insurance paying $10,000 for something 2% better, the patient has a 10% copay and can say "wait, I'm not paying a $1000/year higher copay for this negligible improvement" whereas if it's really worth it then they do pay it and the insurance is still covering 90%.

But then people don't like that, so instead of paying $2000 in premiums and $1000 in copays they end up paying $8000 in premiums because there is nobody saying "no" to things that are overpriced.

> Probably not, since drugs under patent (which are nearly all of the ones advertised) are sold for the monopoly price until the patent expires.

Doesn’t that get back to if you got rid of marketing and let both the government negotiate drug prices (which it legally can’t do now) you could reduce prices and not spend less on research?

Other countries seem fine with restructing advertising on prescription drugs

> Doesn’t that get back to if you got rid of marketing and let both the government negotiate drug prices (which it legally can’t do now) you could reduce prices and not spend less on research?

"Negotiate drug prices" is a monopsony buying from a monopoly. It's like divide by zero, there's no pricing mechanism there. This drug is already developed so if the government makes up a lowball price they have no real choice, but if the government offers them less then they cut research for new drugs because now it has a poor ROI. It's effectively price controls and government officials using a ouija board to make up drug prices when what you actually want is some kind of market to determine how much it's worth to people in order to supply that much incentive for developing drugs like that.

And a lot of countries do use price controls because then they still get the drug as long as the US market is picking up the tab to fund the R&D. But that doesn't work if everybody does it, so now the problem is the tragedy of the commons. The US is being cheated into shouldering the burden for the whole world, but if they stop without everyone else starting to pay their share then the research funding collapses, so what do you want to do?

> how much money that would save the big tech companies

It would directly save them money, but it would also remove a significant source of leverage in salary negotiations (if you don't get a job, you won't be able to get decent health insurance). In the end, it's probably better for companies that can afford to pay for health insurance that people are forced to rely on them for it. It gives them an anti-competitive edge.

I seriously doubt the overwhelming majority of candidates are asking for the detailed coverage information from the company's health insurance.

I did this twice as I have specific needs with coverage. Both times were with in-house recruiters, and both times I was met with a rather confused face.

So in an imaginary world, sure I can see this maybe playing out. In practice? Not a chance.

Since the ACA, all health insurance coverage from companies with at least 50 people has been good enough. At this point, what I did ask about was the cost of insurance when I talk to the first internal person, usually HR. That is going to determine comp conversations.

Depends what you need covered.

Not all medications are reasonably covered by all plans. Good luck if you’re unable to take the medication that your insurance pushes you to take. The appeals process isn’t necessarily easy, even with doctors involved.

> I seriously doubt the overwhelming majority of candidates are asking for the detailed coverage information from the company's health insurance.

No, but having an additional thing that makes you fear unemployment helps them, both in salary negotiations and in retention.

I doubt the average Meta employee has to worry about finding a job so is this scenario actually realistic?

Meta laid off 5% of it's employees just a few days ago

The market is a shit show right now even for those coming out of BigTech. There are thousands of them being laid off and working for one isn’t really that impressive anymore if it ever was.

Besides, they may have to sully themselves and become an “enterprise developer”.

Besides that, they probably have a lifestyle that requires them to make top of market.

Good point. I always assume others in tech also manage to live well below their means.

Because Zuckerberg runs his own app stores with a 30% cut and similar arbitraty and capricious rules. Virtual Desktop's PCVR streaming feature was blocked for a year until Meta released their own clone.

Company provided health care makes it harder for people to leave and start their own business that might compete with them

This is because the money is only one aspect of it—not that they don't care about money; of course they do. But they also care about the power.

They especially care about entrenching the new stratified class system they've been putting into place. Single-payer healthcare would make us plebes less dependent on them, our neofeudal overlords.

You can see this in things like proposals to improve working conditions. They would cost nominal amounts, and there's plenty of research that shows they would increase productivity, employee morale & retention, etc, but if they make it harder for the managers to treat the workers like unworthy peasants, they don't get done.

>"Socialism never took root in America because the poor see themselves not as an exploited proletariat, but as temporarily embarrassed millionaires."

That quote is from Ronald Wright. It appears to be a paraphrase from this Steinbeck quote. In the actual quote you can see Steinbeck is not trying to criticize the poor, but rather champagne socialists:

>...Except for the field organizers of strikes, who were pretty tough monkeys and devoted, most of the so-called Communists I met were middle-class, middle-aged people playing a game of dreams. I remember a woman in easy circumstances saying to another even more affluent: 'After the revolution even we will have more, won't we, dear?' Then there was another lover of proletarians who used to raise hell with Sunday picknickers on her property. I guess the trouble was that we didn't have any self-admitted proletarians. Everyone was a temporarily embarrassed capitalist. Maybe the Communists so closely questioned by the investigation committees were a danger to America, but the ones I knew — at least they claimed to be Communists — couldn't have disrupted a Sunday-school picnic. Besides they were too busy fighting among themselves.

https://en.wikiquote.org/wiki/John_Steinbeck

https://classic.esquire.com/issue/19600601/print