Yeah. The hardest number I've seen is that if we reduced the spend on health care in the US just to the OECD average, it would reduce overall revenue in the sector by $1 Trillion every year. That's a lot of peoples salaries and livelihoods wiped out and they will fight tooth and nail to protect it.
This is why we should not accept any health care reform proposal that any of the American Medical Association, the Pharmaceutical Research and Manufacturers of America, or the American Hospital Association are generally supportive of. Whatever we try, they should be vehemently against, just like they were with Medicare.
> we should not accept any health care reform proposal that any of the American Medical Association, the Pharmaceutical Research and Manufacturers of America, or the American Hospital Association are generally supportive of.
That seems like a lot of people to piss off to get any reform done.
Wouldn't an actual smart negotiator play off one against the other, and make the doctors support the initiative at the expense of the pharma industry, or vice versa?
Coal miners, car companies, and sears catalog were not consulted when their industry was disrupted. No one is entitled to a gravy train, especially when your entire industry is cartelized.
Middle men jobs, no matter how good, need to be on the chopping block if all they do is be extractive pests. They can't both be protected from the pressures of the free market, and not have any accountability from an improved service standpoint.
As for the actual workers, Doctors can charge what they like, but they shouldn't be able to limit the supply of doctors within the nation. That is NIMBY mentality.
Those companies weren't disrupted by a democratic government for which all of their employees have a vote.
The government acts at the behest of the governed so they need to get support from at least some of those groups because a lot of families rely on someone working in one of them.
That's absolutely true, but the direction in which public policy fails the will of the govern is predictable. Reforma that hurt a few people a lot, and help most people a little, tend to fail in politics. Things like tobacco legislation are minor miracles in a long line of lobbyists winning. So the way in which the US government will keep failing to match the will of the governed here is, if anything, towards the insiders that are ruined by anything resembling health care efficiency.
I suspect that the disruption will come outside of the regulatory realm: As prices go high enough it's cheaper to get the same treatment in Mexico, or have an AI be your primary care provider, the US system will fall. It will not be this year, and probably not this decade, but eventually such level of waste crashes big.
The US government is arranged to ensure that, the Senate and Electoral College both give significant electoral weight to rural areas in the Midwest. Reading the writing from the time that's intentional and by design.
Perhaps, but this is also a great example of tyranny of a (demonstrably corrupt) minority. It’s fundamentally anti-Democratic to say “everyone has to suffer worse health outcomes and pay more money because this small group of people has established a quite profitable scam and pays politicians to keep it that way.” This is why most developed democracies don’t allow this to happen. That being said screwing over the majority people to benefit a corrupt, self-serving minority, is about as close a definition of American “democracy” as I can think of, so I expect little of this to change.
The government has been directly interfering with this industry since the ACA (“Obamacare”) was enacted; forcing everyone to purchase health insurance.
The government has been interfering in the industry since at least the imposition of wage controls during World War 2 that drove employers to offer non-cash benefits to attract and retain employees.
Before as well, of course. But prior to the ACA there was no requirement for every individual filing taxes to show they had coverage, or most businesses (even relatively small ones) to offer benefits packages.
It also changed small medical practices because suddenly everyone wanted to use this insurance they were paying for. No longer could it just be a doctor and maybe a couple of medical staff; they needed medical coders, specialized software, and so forth. Some decided to join large hospital networks (for worse, from what I have generally heard).
And this cascaded into multiple sub-industries developing around this revenue stream and the medical system. Everyone trying to sell something and grab their piece of the pie.
It was not great before, but you could go see a doctor and literally pay a small amount of cash for an appointment. Many won’t even accept anyone without insurance now.
Edit: as mburns@ pointed out, the IRS no longer asks individuals about their health insurance status since 2019.
I feel like "piss off a lot of people" is a general prerequisite to any substantial reform on any topic. Almost anything that requires reform is going to be at the point where it is being abused and (inordinately) capitalized on.
There's always winners and losers with any type of change. Look at COVID. Some companies thrived and had their best years ever and others went bankrupt and closed down.
A lot of negotiators talk about win-win agreements which may be true with just two parties. I think once you get beyond that, no true win-win agreement is possible and some people are going to lose out. Trying to appease every single interest group is what leads to a lack of progress.
> make the doctors support the initiative at the expense of the pharma industry
(Full disclosure: family member works for Big Pharma)
You might not get them to admit it out loud, but Big Pharma sees the USA as the cash cow that funds R&D for everyone on the planet. If a potential product can't or won't ever make it to market in the USA, or if there aren't enough potential patients in the USA to be prescribed said product, then it might never get off the drawing board.
Yes, a lot of people don't understand the sheer amount of labor and time that is required to bring a new drug to market. (Edit: Or the number of things that are tried but don't pan out for one reason or another. The success rate is very low.) I myself have only the vaguest understanding. Someone has to pay for it all.
We need India to get rich ASAP, so Indians can start paying for it. :-)
Surprise, surprise but a huge chunk (maybe even the majority of?) of drug research is conducted by academic institutions using government funded grants. Then the drug companies come swoop up the research, refine it, mass produce, and market. They shouldn't be able to get such a free ride from all this government funded research imo. The taxpayers already funded the research so why are they getting the short end of the stick?
Research is the least labour- and time-intensive part of the system.
Trials are punishingly expensive.
Edit: protocol development. Drug interactions. Poisonings, Doctor education -- er, marketing. Incorporation into manuals. There's a lot that happens after the research talent has strutted its stuff.
Edit edit: oh, yeah developing manufacturing and logistics as well. The 'D' part of "R & D" is usually over 95% of the total for a reason.
The challenge is that Pharma companies still spend huge sums on marketing, both to patients and to doctors. While I could probably be convinced that there's some role for spend on physician education about new drugs or spreading awareness, it should be a small fraction of the spend on R&D and manufacturing.
Frankly this system is already deep into market failure in the US and should be reformed anyway. We are not getting important drugs approved here because they can’t make it through approval despite track records of safe and efficacious use in hundreds of millions of people. That’s an intense life-wasting market failure.
I think most of the issues in the US are due to a sizeable amount of people are systematically ripping the rest off.
Healthcare? Doctors, hospitals, insurance, etc all are taking a bigger cut than they should. You'll get a ton of pissed people if you want to solve it.
Housing? Nimbys are just regular homeowners that block housing to implicitly (or explicitly) protect their property value. Solving that gets a ton of homeowners pissed.
Universities? Tons of university admins and loan programs that benefit from restricting tertiary education supply. Fixing is pissing lots of people.
So much of our economy is captured by large cohorts of people that are not explicitly conspiring to do so, but their incentives moves them to behave like that.
Hm. That’s a good point. Provide government care and it pays more than private insurance (which it should if economies of scale are employed). That would basically gut the private industry entirely.
> That's a lot of peoples salaries and livelihoods wiped out and they will fight tooth and nail to protect it.
Why? We're currently undergoing a major shift in labor wrt to automation, AI which will absolutely destroy entire sectors. Not a lot of people give a shit, it's considered good for the bottom line and for profitability. But when it comes to healthcare, the narrative is that we suddenly care about labor? People applauded the tech layoffs but the parasitic private insurance overhead is just too important? Disgusting
> AI which will absolutely destroy entire sectors. Not a lot of people give a shit,
A lot of people __do__ give a shit and this is a very common conversation among blue collar workers. I've heard about it every Christmas for the past 5 years from people who don't know how to google. Mass shifting in jobs has always been a big conversation but there's just a big divide between the working class where people aren't talking together as much.
We have coal miners complaining about "big solar" taking their jobs. We have the whole "just teach to code" fiasco. We have a lot of discussions about Amazon. And I can keep going. If you think this is a "suddenly care" type of thing then you're likely in a bubble or not paying attention (a different bubble).
What is the "the whole "just teach to code" fiasco"? I'm familiar with the idea of widespread coding education, but the fiasco part is news to me. Is it something interesting, or just another face on the same story of struggling/failing public schools?
Basically a bunch of journalists told laid off coal miners that they should just learn to code, which some people saw as callous. Then in 2019 Buzzfeed and Huffpo and a few other places laid off a bunch of journalists. People started tweeting "learn to code" at them and they weren't happy about it.
It is a bit callous to be fair. Job retraining is costly and the way it was said more comes off as blaming the person for not knowing any better (people who've been working in that field for decades and started before the 90's). Predictions that people could not have reasonably made given the information they had at the time even if obvious in hindsight. There's also plenty of historical examples where rapid industry shifts result in a lot of people being out of jobs and entering poverty even if the total economy turns out better or smooths out in the long run. Temporally local events still matter and you can't just point to long historical trends to say the people suffering now aren't a problem.
Plus, we all know code bootcamps don't make great programmers. And if we're being extra honest, LLMs have a good chance of replacing low quality coders, so now in hindsight the advice comes off as even more pejorative and low quality. Hindsight is always 20/20.
AI will hit medicine pretty hard, it seems to me. Everything about medicine that isn't research is mostly identifying symptoms and applying the correct "standard of care" which an AI should be very very good at.
We haven’t gotten rid of pharmacies and that’s the easiest part of medicine to We haven’t gotten rid of pharmacies and that’s the easiest part of medicine to automate.
I don’t think AI diagnosis is going to change costs noticeably because tests and treatment is so much more expensive and you need people to provide that.
I interpreted that comment as an observation “about the weather”: not defending it, just pointing it out.
There’s a parallel to that observation: these parasites are a major part of the S&P (not as much as the article claims, per another comment) which means if they decline it will look like a secular decline in the market (=> peoples’ retirement savings) which will cause vocal anguish.
That latter phenomenon is why bills like the IRA splash out so much money on the fossil fuel companies.
In the course of my work as an ambulance chaser, I spend a considerable amount of time reviewing medical records and bills - including all sorts of unrelated treatment.
I agree with your concerns with the AMA et al. It’s clear that we are way overpaying SOME doctors and hospitals.
It’s also clear that our demand for medical treatment is almost insatiable and about as inelastic as it gets.
Ie we need to tell some drs and hospitals, fu the gravy train is over; but we also need to tell Joe Public, no you don’t have an existential right to wegovy.
Depends on how much of that trillion goes to actual salaries or how much goes to dividends?
Worst part of the privatization of the Swedish school system is that we know that the tax-money we pay to educate our kids is being diverted to Neo-Nazi funders and Saudi oil funds.
Outside of Pharmaceuticals, most of the US health-care system is non-profit, so no dividends are allowed. High salaries are allowed, but there aren't business owners that get the surplus the business generates.
"Most" might be technically correct on some grounds. But more than 1/3 of American hospitals are for profit several of the largest health insurance providers are for profit. and basically every specialist, independent doctor practice out there is private.
> there aren't business owners that get the surplus the business generates
You don't have to be a sole proprietor for those at the top to take a ridiculous level of compensation.
> Nonprofit hospitals are under increasing scrutiny for skimping on charity care, relentlessly pursuing payments from low-income patients, and paying executives massive multi-million-dollar salaries—all while earning tax breaks totaling billions.
The OP article provides clear evidence that for-profit companies is not limited to Pharma:
> ...insurers, chemists, drug distributors and pharmacy-benefit managers (PBMs)—sitting between patients and their treatments. In 2022 the combined revenue of the nine biggest middlemen—call them big health—equated to nearly 45% of America’s health-care bill, up from 25% in 2013. Big health accounts for eight of the top 25 companies by revenue in the S&P 500 index of America’s leading stocks, compared with four for big tech and none for big pharma.
It goes on to detail their profit relative to the S&P as well.
Same for politicians. If they aren't getting shut down by the established powers they probably aren't the person you want. That doesn't necessarily work the other way, though. Trump getting opposed by many doesn't make him the right guy for the job. But Biden making his way through politics with financial and political support means he's just another one of them.
Just to put it more succinctly: you’re in favor of angering all healthcare providers (doctors, nurses, etc) to make healthcare better.
I don’t know if the outcome you want is the outcome you’re gonna get with that strategy. Might want to consider the humans actually affected and how they might react instead of treating everyone as some faceless cabal of evildoers bent on pulling money out of your pocket.
And also consider that most doctors and nurses probably don't like the way the healthcare system currently works. Certainly none of the dozen or so that I know personally do. Using "makes doctors angry" a proxy for whether a proposed reform is a good idea probably isn't one.
I just think angering the people who are supposed to be caring for me is a great way to receive subpar care, I don't care how moral and "above it all" healthcare workers are supposed to be, at the end of the day they're human and if you tell them you don't value their hard work, they may just put in a little less effort than you'd like. (just like you might do the same for a boss who belittles you and refuses to give the raise you feel deserve).
As an example, in many countries where they have socialized healthcare, nurses and doctors do often go on strike, which has always resulted in worse care during those times...
This is why we should not accept any health care reform proposal that any of the American Medical Association, the Pharmaceutical Research and Manufacturers of America, or the American Hospital Association are generally supportive of. Whatever we try, they should be vehemently against, just like they were with Medicare.