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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.
I think honestly this isn’t a system we created and thus don’t “deserve”. The thing is that we’ve been taught to be cynical hyper-individualistic, hedonistic, lazy jerks. It comes from everywhere. You’ve been taught that your traditions are old and stodgy and nobody cares about them anymore. You’ve been taught that your ancestors were rotten, terrible people who genocide their way around the globe. You’ve been taught that striving is pointless and that the rich will keep you down. You’ve been taught to deconstruct everything, but never to construct.
There are lots of reasons for it. Some are hyper-consumption: if you lose access to a community in which someone can solve your problem for free, then you have to buy that service somewhere. You don’t know someone who can cook and you don’t know how to? Door Dash. Daycares are essentially replacements for extended family. It used to be that if both parents needed to work, grandparents were close by and retired and the kid could stay in a place where he’d be safe and with a loved one. Now you hire a company who pays strangers less than $20 an hour to do the same. Go down the list of home repairs, car repairs, lawn maintenance, and a lot of services replace community.
The other part is that traditional systems are terrible for governments who want to control their populations. A strong community doesn’t need or want much government interference. The Amish have their communities in pretty good order without too much need for the state to come in and control them. They don’t need welfare because they have their church to help those in need.
The final thing is the issue of legitimacy. Legitimacy comes from the people. But in order to get people to vote for whatever it is that you want, job one is to convince them to want it, or convince them that they’ve always wanted it, or that “good people” are like this. So people vote as they’ve been taught to do. You have to be taught to believe in an atomized society with no deep connections so that you’re more willing to accept the breakdowns, less willing to trust community.
I think you’re assuming the conclusion. The economic forces which make babysitters and dishwashers ubiquitous wouldn’t disappear if we’d never started critiquing imperialism.
I also think your view of the past is rose-tinted as hell. 1700s America wasn’t an endless quilt of Amish communities, waiting to be tempted out of Eden. It was a hungry, dirty, disease-ridden frontier just starting to climb the curve of industrialization. Communities weren’t solving each others’ problems “for free.” They were paying their dues on their own social contract.
We've seen a remarkable, unprecedented increase in GDP per capita in the last 200 years. However, the GDP gains may overstate the actual gain in wealth. In 1800, someone would take part in fulfilling but unpaid labor such as child rearing or food preparation. This is not measured in GDP because no goods or services were exchanged. Nowadays, the equivalent person might use daycare and Door Dash while they pursue their higher paying job as a laptop worker for a big nonprofit. More GDP is being created by the commoditization of previously unpaid work even if no more value to society is being created.
So maybe GDP per capita has increased 5,000% but real wealth has only increased like 2,000% or something. We're vastly better off now than before, but imagine how much better things could be with stronger communities.
It's not about GDP. Individuals don't choose their career to please the Federal Reserve. So why are women--because men, naturally, aren't expected to do anything so fulfilling--choosing instead to sell their labor on the market?
As far as revealed preferences go, this one isn't particularly shocking. Since the dawn of civilization, the rich and powerful have been paying other people to deal with their kids. Technology has made that dubious ambition much more attainable.
Bad equilibrium.
A lot of labor is people competing for zero sum positional goods. There are 10 houses with a view of the lake. If I have one, you CAN'T have one. So I work extra hours to get ahead in the rat race. So do you. We're all running as fast as we can to stay in the same place.
The career woman personally benefits from her big non-profit job, gaining high prestige and access to positional goods such as housing. But this is all zero sum.
Look to East Asia to see how negative this can be when taken to an extreme.
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