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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.
I got thinking about this when Richard Hanania pointed out that the political systems practised by Vietnam, Japan, Korea and China could hardly be more different from each other: China is nominally-communist-but-really-state-capitalist-and-authoritarian, Vietnam is actual no bullshit communist, Japan and Korea are modern capitalist societies. And yet, the day-to-day experiences of living in any of those countries are remarkably similar: low crime, low rates of children born out of wedlock (coupled with low fertility in general), high rates of educational attainment, high life expectancy. It suggests that, to the extent that your country following a particular political system makes a difference to the lived experience of its citizens at all, the difference is mainly felt on the margin. A particular political system can help to safeguard and maintain stability and economic productivity in a country, but you'll never establish a stable, functional and economically productive country without a critical mass of human capital, regardless of which political system it nominally follows. A corollary of this is that debating what political system your country should follow when it doesn't have the prerequisite human capital is like debating what colour to paint your car when it doesn't have an engine.
I agree you need human capital. But compare say Hong Kong with Beijing over the last hundred years.
Or compare the Ming Treasure Voyages cancellation with the European Age of Exploration. China was on top of the world, but their institutional infighting manifested as stasis while Europe's often-more-literal infighting manifested as a mad scramble for power, and the difference in incentives set China back centuries.
Compare East Germany with West Germany, or South Korea with North Korea. The economic effects of better vs worse governance on nearly-the-same-genes can literally be big enough to see from space.
I think a more interesting wrench in the gears is the question of better vs worse culture, though. South Korea has a lot more lights than North Korea in all the satellite photos, but at 0.72 and still falling TFR they might as well start turning lights off now before the last person "leaves". Their genes haven't significantly changed, and their government changes over the past 60 years (since the TFR started falling from 6) seem unrelated, but the cultural changes have been massive and baffling. Nerds started getting a mathematical handle on voting system foibles and game theory back around the time of Condorcet (though we've now got much better alternatives to FPTP than IRV-misnamed-as-Ranked-Voting, so the lesser-nerds' focus on the latter at this point in history is weird...), and likewise for economics and at least the most obvious Communism-level economic mistakes. But does anybody have any sort of mathematical analysis of WTF happened in South Korean culture, to cause the gender war to get so bad and the fertility rate to plummet eight-fold in 2 or 3 generations? It's like the stereotype of the pushed-into-overachievement kid burning out and becoming suicidal, but on a 50-million-person scale!
Two crazy statistics to think about:
So there is social pressure to not have kids out of wedlock, and more than half the population is deferring marriage until after the fertility cliff. I blame the marriage deficit on high financial expectations on young couples and a culture which teaches that marriage at 35 or later is okay. The birthrate crisis is downstream of the marriage crisis.
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