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PaperclipPerfector  2mo ago (text post)   33940 thread views

Culture War Roundup for the week of February 10, 2025

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@2rafa? Your response?

DOGE sets its sights on Medicare and Medicaid:

Elon Musk's Department of Government Efficiency is quickly expanding its reach through the federal government. It recently accessed systems at the Centers for Medicare and Medicaid Services. Musk and his team are now looking at key payment and contracting systems for Medicare and Medicaid - that was first reported by The Wall Street Journal. On X, Musk posted, he believes that, quote, "big money fraud is happening."

Mostly just talk and speculation at this point, but there are clear indications that medicare/medicaid have not escaped the notice of the DOGE.

In spite of the perceived celerity with which DOGE is eviscerating government programs, I'm still mostly in the "nothing ever happens" camp. "Cutting government spending" at this point is akin to rearranging deck chairs on the sinking Titanic that is Western civilization. The slow Brazilification of America is irreversible either way. Nonetheless, I am enjoying the apoplectic response that Musk's antics have occasioned.

EDIT: Oh, and social security was named as a potential target alongside medicare/medicaid as well.

He attacks Medicare at his peril. As they have found with Aid, cutting out 'waste' is basically impossible without also threatening core and useful functions. This may not be so politically destructive when it's foreigners who get the raw deal, but when it's Betty, 76, Iowa, the backlash will be much greater.

What I’d like to see (like significantly cutting medicare coverage for treatments that prolong the lives of the very elderly / sick for minimal benefit) happen still seems very unlikely to happen, so I’m not updating any beliefs now.

Here in the UK every government comes to power promising to cut “waste” in the welfare and/or healthcare bill. And sure, there is some waste here and there. But in the end, they all find that real savings require real cuts to coverage, quality and funding, and they lack the guts to do that.

Perhaps Trump will be different, but I think Trump’s instincts run against that. As with calling for a federal abortion ban, he knows that’s unpopular.

To my knowledge the UK already has a relatively efficient healthcare system (lower ratio of administrators to front-line staff than comparable systems, lower spend per capita than most EU countries) and uses a fairly robust system of QALYs to decide which treatments should be offered. I find it plausible that the US far out-consumes the UK in healthcare in the same way that it far out-consumes the UK in literally everything else, and that it might be relatively easier to find trimmable excesses in Medicare than it would be for the NHS.

It's not very efficient. We spend more than the OECD average, and we get fewer doctors, fewer nurses and fewer hospital beds for it. The waiting times are infamously long, and productivity is still worse than it was pre-COVID. Honestly, it might work better with more administrators if that means that GPs don't need to spend time writing actual paper letters to refer their patients to specialists, and similar kinds of bureaucratic nonsense.

Honestly, it might work better with more administrators if that means that GPs don't need to spend time writing actual paper letters to refer their patients to specialists, and similar kinds of bureaucratic nonsense.

The problem in quite a few western countries seems to be that there are too many mid and upper level administrators and an order of magnitude too few low level secretaries.

Partially but I'd say the much bigger issue is overregulation and then "cutting administrative bloat" by cutting administrators rather than the regulations necessitating them, leading to things just getting worse and more expensive.

Most everything seem to come down to the college degree bubble.

You can cause so much damage to a society by introducing as stupid a price signal as "we'll issue an infinite amount of risk free loans for this particular service".

Most everything seem to come down to the college degree bubble.

You can't blame this on college degree bubble or student loans. The phenomenon is strictly driven from above where secretaries have been cut years ago in the name of "efficiency" while ignoring the basic fact that having a doctor do all the admin work is much less cost efficient than when you have someone who's both good at it, at least somewhat likes doing it and has a salary that's half or less of a full doctor's salary.

The middle and upper management boom is typical bureacracy doing its natural thing and would otherwise be a fairly minor source of inefficiency except they need to pretend to do something useful and thus disrupt actual work as well as make it appear as if the useful administration (ie. low level secretaries) wasn't already cut deep into the bone.

Why do we seem to need to create insane amounts of management jobs if not because there is a huge supply of college educated people?

I think there's a legitimate debate to be had here about the ultimate cause of this extraordinary bureaucratic growth that followed the managerial revolution.

My working theory is that after the world wars and New Deal era, people saw the ascendency of managers and sought this good fortune for themselves, a degree became a surefire ticket to power and status, and it was collectively decided to bestow this boon onto people. The GI bill was the start of this movement that saw education as a magical wealth totem, and thus the start of a cycle that would aliment bureaucracy with fresh legions of young professionals that then advocate for the growth of the bureaucracy, rince and repeat until everyone is festooned with useless credentials. There is a reason every middle class person always agrees that the one thing we need more of is education.

Now, without direct intervention to both grow the bureaucracy and fund higher education at any cost, this would have fizzled out because you would not be able to justify the expense of a degree. But with their newfound power the managerial class maintained the mechanism that grows itself and its power and didn't let price signals tell would be graduates that these degrees would be useless once the bubble pops.

I don't think our theories of this phenomenon are that different, we're just pointing at different components of it.

It is probably possible to make an at least noticeable difference in the medicare/medicaid bill by cracking down on fraud, without reducing coverage, just because outright billing fraud is so common. Remember, these are single payer healthcare, not single provider, and the payer is well known for always paying. For for profit healthcare providers, that's tempting.

A bunch of the somalis convicted of that $250,000,000 COVID child food aid fraud had also been conning Medicaid for "adult daycare services." Some of them were still being paid for running non-existent daycares even after their fraud convictions!
It hasn't made the news much, but there's billions of dollars of theft out there.

Were these the same ones that brought jurors grocery bags full of cash? I think I remember the story if so.

That's the one. Of course it dropped out of the news quickly

Medicare fraud is extremely common. There are entire companies that just ship wildly expensive, random "medical equipment" (which is usually some kind of actual equipment, like a back brace or something) to old people and charge it to Medicare on their behalf, and then just see if the octogenarians can figure out how to file a return through their Byzantine phone trees or website.

What’s Musk’s plan to stop that, though? Seems like that would require (as the IRS did when it seriously stepped up pursuit of tax evasion) many more staff, more audits, more money.

Given some of the stories about Medicare fraud I’ve heard, there are likely ‘save a billion here, save a billion there’ process changes which won’t cost any money.

I'd be absolutely fine with an agency dedicated to "fucking shit up" and personally wrecking these fraudulent people's whole industry. Maybe there should be staffers from DOGE personally assigned to each of these medical companies, with their sole job being scrutinizing their financials, practice, hell maybe DOGE should be in the e-mail/phone loop with each doctor that's being billed shit.

Use modern tech, hell involve publicly auditable blockchains if you must. A god damned public read only SQL database would even be a start.

The problem with making things publicly auditable is that it exposes the loopholes and therefore makes it easier for any chancer to try to get on the fraud train. It would be like exposing the inner details of the IRS’ investigation process, it wouldn’t lead to less tax evasion, just more efficient and more effective forms of it.

It's almost impossible to escape fair and simple taxation. Not worth the money even.

Loopholes exist because there's an entire industry of lawyers paid to exploit them and politicians create new ones to reward their allies all the time.

In a properly setup taxation scheme, there would be no need for the IRS. At best you'd only need a small legion of accountants to enforce a simple formula.

And that's just with 2000s technology. Nowadays if you actually wanted to implement a modern and efficient taxation scheme from scratch, you probably only need as many bureaucrats as DOGE has to operate it. Everything can be done on chain in a way that is both private and traceable.

And this is all the more absurd now that the point of taxation isn't even to fund USG but to take money out of circulation.

I suspect you aren’t a tax lawyer. To be fair, neither am I, but my guess is they’d laugh at your comment.

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Let’s say you own business asset A. You want to incorporate it for legal protection. Should you be taxed?

What if you transfer that asset (say it’s worth 10m) to Apple for shares?

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There was an interesting article about that in Foreign Affairs. The relevant excerpt here:

The undoing of modernization through its principal process—the coming apart of formal employment and of the rise of precaritization—is the root of the whole phenomenon of “Brazilianization”: growing inequality, oligarchy, the privatization of wealth and social space, and a declining middle class. Its spatial, urban dimension is its most visible manifestation, with the development of gentrified city centers and the excluded pushed to the periphery.

In political terms, Brazilianization means patrimonialism, clientelism, and corruption. Rather than see these as aberrations, we should understand them as the normal state of politics when widely shared economic progress is not available, and the socialist Left can­not act as a countervailing force. It was the industrial proletariat and socialist politics that kept liberalism honest, and prevented elites from instrumentalizing the state for their own interests.

The “revolt of the elites”—their escape from society, physically into heavily guarded private spaces, economically into the realm of global finance, politically into anti-democratic arrangements that out­source responsibility and inhibit accountability—has created hol­lowed-out neoliberal states. These are polities closed to popular pres­sures but open to those with the resources and networks to directly influence politics. The practical consequence is not just corruption, but also states lacking the capacity to undertake any long-range developmental policies—even basic ones that might advance economic growth, such as the easing of regional inequalities. State failure in the pandemic is only the most flagrant recent example.

To add my two cents, this idea is about turning Western world into cycle of elitist/populist cycles which entrench corruption and oligarchy in place. Imagine a world where every single person in your country is corrupt - from lowly nurse or police officers to supreme judges and presidents. Everybody accepts this as a new normal, the way to move forward is to accept this and move in cutthroat environment toward wealth and power. If you don't have it, you cheat and corrupt and do whatever is necessary to attain it. If you have it, you defend with all your might - ranging from creating gated communities, crushing lowlifes under your boot to propagandizing and using social status to make yourself look good. Imagine that the whole country is full of Vito Corleones from Godfather: ruthless power hungry thug who is "respected" in local community for his strenght and directed "charity" which helps his power.

And the point is that it is even hard to see Vito Corleone as a "bad guy". He is just product of his Brazilian surroundings, he may see himself as a hero of Kolmogorov complicity type of a problem.

To expand on what @Primaprimaprima wrote, it means you will have walled communities with armed guards that will provide first world living standards, but will have little to no political power, because huge numbers of black and brown bodies voters will live in the slums outside and demand more and more handouts with each election. At most, left-wing populists will be replaced with right-wing populists for a term.

It means becoming like a Latin American country in terms of racial demographics, standard of living, general texture of the social fabric, etc.

The actions of Trump on immigration and Doge on the budget will set the Brazilification project back by at least a decade, or indefinitely as long as the Republicans can keep winning elections.

Consider that immigration under Biden 2 would have been something like +15 million and under Trump it will probably be negative.

Similarly, there is hope on the budget. A return to 2019 spending would mean a $500 billion budget surplus. While that's not possible due to inflation, the era of mega deficits only started in 2020. We can and will go back to a more reasonable 3% deficit/GDP. When we do, interest rates will fall, reducing our borrowing costs and further reducing the deficit.

Similarly, there is hope on the budget. A return to 2019 spending would mean a $500 billion budget surplus. While that's not possible due to inflation, the era of mega deficits only started in 2020. We can and will go back to a more reasonable 3% deficit/GDP. When we do, interest rates will fall, reducing our borrowing costs and further reducing the deficit.

Actual question- where's the extra spending? Totally understandable that the deficit exploded in 2020 and 2021 due to stimulus packages but those aren't going on anymore. Is it just social security increases due to population aging?

A decent chunk is also interest expense

Yes. And this is what makes the problem more tractable than it may seem at first. If we can get the budget under control, interest rates will come down, which creates a virtuous cycle.

Check out the IRA budget. I haven't even started to wrap my head around the scale of it. It's literally all the crazy "green new deal" stuff they ever asked for. I see articles from WA green groups about how they can't spend all the money.

Consider that immigration under Biden 2 would have been something like +15 million and under Trump it will probably be negative.

It's unclear that Trump can even deport all of the people Biden let in.

I don't think the solution is to deport them all. The solution is what Germany used to do, which made immigration from their poor neighbors (e.g. Poland) roughly zero: make sure illegal aliens can't get a job, public education, welfare, or a place to live. They'll deport.

On the other hand, as long as life is better for illegal residents of the US than for legal citizens of Mexico, and I and my family live in Mexico or South of there, nothing is going to stop me from getting into the US. Wall? pshh. Under the wall, over the wall, through the wall, around the wall, bribe, fly, or swim, one way or another, I'm getting my family to higher ground.

There are declining numbers of illegal migrants from Mexico IIRC, because of more $4/hr(the breakeven wage for the same standard of living as the lower working class in USA, given lower Mexican prices) jobs in the north due to offshoring. Guatemala, Honduras(much, much poorer), Venezuela(lack of macroeconomic sanity causing… issues) and Haiti(sub Saharan Africa in the western hemisphere) are the big sources of migrants.

The problem here is that deportation is what Trump controls. He can't change state policies towards migrants or things like them having a "right" to schooling in the US. He can catch them at the border or send them back when he gets them but most anything else will be partly determined by lower governments.

To make sweeping changes would require Congress and, well, they've had years to do anything. If they could, Trump wouldn't exist.

Beyond that, nations like Germany don't have birthright citizenship. Plenty of people would eat shit indefinitely until their kids are born and have citizenship. That's just the incentive of all incentives (even if you stopped the sponsorship loophole). And there's no conceivable way Congress amends the Constitution any time soon. Let alone for that.

Oh, he can't. There's no question about that. The Biden Wave was unprecedented and terrible.

But I think net immigration will be negative for the next 4 years. If Biden had got a second term, that would have resulted in a second Biden Wave and put us firmly on the path towards a Third World future.

I think it’s possible net immigration can be ‘engineered’ to be negative by including stuff like returning students (if Trump doesn’t follow through with his / Elon’s plan of stapling green cards to diplomas) and border pushbacks, but

  1. There have been no announced plans to cut H1B numbers and Elon, H1Ber-in-chief appears even more powerful than most people expected, such that we’re more likely to see the number of those visas rise (mirroring the ongoing rise in O1 visas) along with those for dependants than we are to see them fall.

  2. Restricting family / chain migration, which is the other major source of legal immigration, would have to go through congress and there seems to be no big effort to do that at all, nobody even seems to be speaking about it.

  3. Refugee intake will likely go down, or the composition will change (there are not ‘that’ many white South Africans, but it would conceivably be possible to eg. hand out a full allocation of refugee visas to them and Ukrainians or whatever such that the composition would be altered), but that makes up a small percentage of legal migrants.

  4. Trump has criticized the Diversity Visa / lottery but hasn’t done anything about it yet. 2025 visas are being granted, 2026 applications are open and the program is going full steam ahead. Congress is doing nothing.

H1B, O1

H1B depresses wages -> political power for Blue voters, so that's working as intended; and the O1s you want no matter what anyway (it's a vital part of the brain drain pipeline, and I'd expect exit controls from countries that generate a lot of these before any limit from the US, perhaps as part of a response to economic sanctions).

Refugee intake will likely go down

Deleting the paragovernmental organizations that bring them across will help with this.

Criticized the diversity visa

It's been what, 3 weeks?

I was hoping you were referring to the dystopian movie Brazil, written by written by Terry Gilliam, Charles McKeown, and Tom Stoppard.

I assume this is exaggerating for effect? The US has way too much going for it in comparison to Brazil, from geography to demographics to the structure of their economy, for something like this to happen in the forseeable future.

geography

Sure, the continental US is a valuable piece of land. But as the saying goes, there’s no magic dirt.

demographics

For now. But you have to look at the trend line.

the structure of their economy

Ultimately dependent on and a product of demographics. A high quality population produces high quality conditions, and vice versa.

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