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PaperclipPerfector  2mo ago (text post)   33942 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.

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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