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Notes -
A Window Into How Health Insurance Companies Harm Consumers by Threatening to Deny Coverage
From the New York Times, we learn about how health insurance companies hire PBMs (Pharmacy Benefit Managers) to help them restrict access to doctor-prescribed drugs. For all the talk of insurance companies directly denying coverage, when it comes to pharmaceutical drugs, specifically, they're able to offload a significant amount of Delay, Deny, Defend onto third parties, in this case PBMs. By restricting coverage, insurance companies are able to reduce costs and increase profits. A bonus is that they don't even have to be The Bad Guy; they can pawn that off on a third party, who is ostensibly making the choices for them. They don't have to personally defend the decisions to deny; they can just obfuscate, wave in the direction of the third party, and let the complexity of The American Healthcare System stymie consumers.
The Times does a deep dive into a Good Guy Pharmaceutical Company and the lengths they have to go through to navigate this minefield to get their high-quality, purity-assured drugs into the hands of the market. Primarily, they've gotta give the PBMs a cut of the money, who in turn share it with the insurance companies and employers they represent. For a while, they were rebating 23% on average, allowing patients to access the drugs their doctors prescribed at prices that were reasonable to them, their employer, and their insurance company. One PBM reportedly wanted (and got) more - 60% rebate to keep prices low and avoid inflaming popular anger with denials. Of course, that still doesn't quite reach how good some Medicare plans were at 'negotiating'; they got about 70%!
The Good Guy Pharmaceutical Company knew how much people wanted its product; they knew that doctors were prescribing it; they knew how dangerous the alternatives could be for many in the market. They were offering a well-known, well-tested product, clean from any adulteration, and outrage would surely rule the populous if folks had to turn to alternative products or sketchier outlets, possibly with less-stringent quality control. So, they selflessly paid the toll to do the right thing, to get their product into the market, to save lives. NYT rightly applauds their admirable efforts to do what they could, at cost to their own bottom line, to protect consumers from the restrictive, denial-focused tactics of health insurance companies and their lackeys.
Oh wait. NVM. It's Purdue. It's Oxy. Flip everything 180 degrees. Apparently, nobody (other than Purdue and their supporters) thinks it's good to flood the market with high-quality, pharmaceutical grade opioids with well-known potency properties. They somehow don't think that this is preferable to folks getting funneled toward lower-quality, potentially dangerous alternatives. They're back to liking the gatekeeping of insurance companies and their lackeys, ya know, so long as they're doing so in keeping with their own political proclivities. Gatekeeping is Good and Right, so long as the folks who buy digital ink by the barrel can browbeat the gatekeepers into doing things the way they want it to be done. ...and they sure ain't even thinking about including libertarian politics on drugs in the list of their demands. Woke politics, tho? Sure, why not?
I think the bottom line, is this is just what a low trust society looks like. Everyone smashes the defect button as often and as quickly as possible, in every situation. There is literally no solving this problem, only clearing the way for a different species of defector who will ruin things, do material damage, and end lives with their greedy, corruption and indifference.
I was sitting in the car one day, pondering how low trust our society has become. I was at a gas station while my wife was using the bathroom. And I couldn't help but notice that the emergency gas shutoff switch is just out there, in the open, totally exposed. It got me thinking about the damage that will be caused when our low trust society devours that. I mean, it's there, unguarded, for a reason. Gasoline is dangerous, you can't just have it spilling all over the place. In case of emergency, you might not have time to grab the manager, have them get their keys, etc, etc. So it's just out there, for anybody to hit, whether there is an emergency or not. Which makes me wonder how long until some asshole tiktok prank becomes smashing that button as many times a day as possible until gas stations across the country have to start locking them up. Which then leads to more avoidable accidents at gas stations.
It's just going to be this way with everything. Nothing is going to be too trivial, or too important for some asshole to pillage, either metaphorically or literally.
I often feel like people get the system they deserve. That the system is a product of the people, and trying to change a system’s rules on its own can only have marginal effect. We have a low trust, somewhat dysfunctional society and so any form of healthcare is going to be similarly dysfunctional.
Nerdy discussions of voting systems like ranked choice vs FPTP always trigger this feeling in me, like the voting system doesn’t matter at all. Maine implemented ranked choice and it’s not really going to improve Maine, Maine was only able to do it because it’s the whitest state in the country and as a result extremely non-polarized.
The interesting question is: how do you change the people, or at least stop them from changing for the worse?
I spend a lot of time in Switzerland, and on paper it should be pretty similar to many US states. Population size and density, GDP per capita, Gini index, cost of living, ect. are all pretty comparable to one of the "nice" US states. Even healthcare is kind of similar (certainly closer to the US than to the EU). Also, they have insane immigration, and have had for decades: 40% of permanent residents over 15 have an immigration background, 35% don't hold citizenship. Walk through a major city, and you'll hear a dozen different languages spoken within minutes. Walk onto a construction site, and none of them will be one of the national languages (OK, you'll probably hear Italian).
And yet, Swiss society is insanely high trust. Bikes unlocked, phones left on empty cafe tables, unaccompanied children move all over town on bikes or public transit. Farm stands have cash sitting in an open box, stores don't have locks on any product, self checkout is 100% unsupervised (and isn't using a digital scale to check what you bought).
The question is: why? How do they run a 1%-2% immigration rate, and instill the honor principle/high trust into everybody that arrives? How do they keep their citizens from defecting, practically ever? Of course, rate of incarceration is extremely low, too.
Or maybe we have to turn the question around: why are Americans choosing to defect so frequently now? Is the gini index not covering real differences in inequality?
You don't change the people. Switzerland has very few immigrants from Africa or the Middle East so they don't have too many problems yet.
https://en.wikipedia.org/wiki/Demographics_of_Switzerland
Of course, immigrants from those countries commit crimes at a rate of several times the native population.
Switzerland isn't doing anything "right" except for restricting immigration from unsavory countries. Neverthless, numbers are increasing, so unless they start deporting people soon, they can say goodbye to that high trust society within a few decades. None of this should be surprising to anyone.
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