I suffered from pretty bad eczema which has some similar qualities to your condition. Glad you got yours under control. I was saved by Dupixent which I consider a miracle drug, thankfully I can self inject.
Yea I know a bunch of folks who have eczema. Biologics in general and monoclonal antibodies in specific are all really great. Dupixent just got approved for EOE, it seems like its just a really good generalizable 'stop bad immune problems without fucking up the rest of your life' kind of drug
I basically never interact with the health insurance industry if I can help it. I paid for coverage after college, then the one time I tried to use it they denied me and made me sit on the phone for like 4 hours before telling me to go fuck myself. Now I’m uninsured because I’d rather not deal with it.
I pay for a one medication out of pocket and it’s very cheap. When I got knocked off my bike on the west side highway a few months ago I cracked my femur, which was extremely painful. The doctor suggested I get a cast, but I didn’t want to have to deal with and pay for that so I just went home and sat in bed for two weeks. Now I feel fine so I guess all’s well that ends well.
That’s all anecdote to say that I think the healthcare system is incredibly stupid. I like to think of myself as not an idiot, but I can’t for the life of me understand what it is exactly I’m supposed to even do to get the right coverage, to use the coverage I have when I had it, or to even understand what I’m covered for or how to go to the doctor that will accept my insurance.
I also happen to have recently finished getting a new insurance policy filed with the state, which took years of banging my head against the walls of large corporations and the government. I understand pretty well on the regulatory side why this stuff is as expensive as it is. There’s basically a 10-20% bloat on any insurance product that is the result of regulation that hasn’t been relevant since like the early 1900s when people would set up insurance companies, spend all the premium, then collapse as soon as there was a major claim.
I like the idea of doing something in the healthcare space now that I understand the backend of insurance quite well. I like the idea of healthshare but don’t really understand it. I’ve considered trying to visit Luigi and proposing he licenses his name or partners to found a health tech startup (You can still own part of a business in prison), but I don’t have the bandwidth for it right now.
Not sure what the point of my comment is exactly other than I empathize with the frustration. I’d like to meet someone who actually understands the whole ins and outs of the system, but everyone I’ve spoken to in healthcare or health insurance can only really talk about their little bubble that they regularly interact with. Nobody seems to grasp the whole.
I think the system we have in Israel does a good job at injecting some degree of useful competition into a fundamentally universal healthcare system (which as you say, is the best method we have right now).
The Israeli health system has 4 health funds, that are non-proft insurers. By law, each resident has to be a member of one of them, and can switch between them at no cost and without the possibility for a refusal.
The funds have to offer a certain "general basket" of treatmenta by law, and are allowed to compete with each other on coverage for additional treatment as they see fit.
In practice, you get them competing at offering better administrative services, digital support, and "unusual" coverage, while everyone still gets good universal access to the general basket of health services.
I think my biggest concern with this is the impact of changes on innovation.
As you note, you are quite lucky to live in a world where Skyrizi exists. A counterfactual world where there is less crazy drug pricing and Skyrizi costs $20, but the actual likely counterfactual there is it straight up doesn't exist for a decade or two longer. That's a very big deal and a golden goose I am quite reluctant to kill.
Unfortunately as currently framed this is a universal argument. It is _possible_ that the cost of the drugs is necessary for their development. It's also possible that the cost of the drugs is massively prohibiting development. There's no way to adjudicate these claims beyond vibes.
Still, I think the vibes suggest that this take is much more likely to be incorrect than correct. I think you'd see way more drug development with better and more streamlined regulation. Most of the research that led to biogics was funded by US tax payer dollars funneled into universities, not private enterprises. That research is the hardest part. Once you know how to make monoclonals they are very cheap to make. The reason they cost so much anyway is entirely due to excess regulation, which is something I call out as primarily caused by the FDA having ridiculous standards for approvals. So at worst drug development and research are totally mutually exclusive; at best, decreasing barriers to entry would result in more players in the space, resulting in even more drug development. To use mabs as a specific example, the initial research was done in the 70s. In a hypothetical world where everything else is the same but we have universal healthcare, I have a very hard time believing that we would just sit on the knowledge of how to do this kind of treatment and _no one_ would productionize and distribute it.
At the end of the day, the golden goose argument is essentially a status quo bias argument, that is, "because things are, they must be". I'm totally unconvinced that things are good because of this monumentally fucked system. A good thing -- mabs -- happened. It may very well have happened in spite of the current status quo
I'm very familiar with Scott. You may be surprised to find that I entirely agree with him, and I don't think the article you linked says anything about my position (namely: we should reduce the cost of creating drugs by reducing regulatory hoops around drug development instead of price controls)
You need to first think, in theory, of a system without insurance and come up with basic regulation to make that work. Essentially, first make generic healthcare extremely competitive and extremely cheap.
Then, you need to think about IP and make innovation work out. Of course, you can free ride on USA (as an Indian, I have no qualms admitting we do but since misery likes company, I will point out that Europe and China and every single country other than USA does exactly the same)
Once you have very cheap basic healthcare and good progress (and India embodies this - you get most generic medicine at a few cents a dose or less; doctors see you for a few minutes and give you an injection for a couple of dollars) then you think about insurance WITHOUT messing up the above two.
You think of insurance as a luxury for the upper mid segment - the poor get most of healthcare paid out of the pocket; the rich don’t care about insurance. The people who need insurance are the ones who worry about the slightly experimental / novel procedures and are fine paying 3x-4x more for the certainty (yes, insurance will increase costs by that much).
NOW, if you have a working insurance sector as well, they you let it expand, keeping a lot of regulations in place to ensure that the insurers don’t become too big - because if they do, they will mess everything up.
And restrict the government to giving a UBI.
And btw, a libertarian imho the author definitely is not.
I find it interesting that you have hit on the fundamental flaw in the ACA yet do not want to be rid of it as a result. The inherent conflict of interest in the private insurance industry is clearly the fatal flaw in the ACA imo. I can understand not wanting to be rid of it without a viable alternative but I don’t think it deserves anything other than tremendous scorn for its performance thus far.
I tend to agree that Medicare works ok, though it needs financial streamlining as the reimbursements are in many cases nonsensical (high reimbursement for new/simple/straightforward problems, low reimbursement for complex/difficult/time-consuming problems). That is something that I believe could be accomplished within 6-9mos if so desired at the governmental level.
The disaster that is the VA system is proof positive that you do not want the government running healthcare/ hospitals. Let the government be the primary payor and it can audit providers/systems to detect/prevent fraud, but let private sector run hospitals and clinics. Same issues I know personally about the VA are common in the British NHS as I understand it as well.
Your personal experience with Skyrizi injections is a prime example of the nonsense that is prevalent throughout the healthcare system. There are too many such scenarios to count. I believe streamlining those would increase efficiency and decrease costs significantly. It would certainly make it easier to get an actual appointment with your provider to address an actual problem.
Anyway, we can and should do better. But the influence of politics money from the insurance and pharmaceutical industries will prevent actual change in the near term. We also probably need to consider a federalist approach since program execution and healthcare delivery solutions that work in Wisconsin probably aren’t ideal for California or Florida.
You didn’t address the explosion of health care administrators as a driver of cost, but it might be fodder for another foray into the healthcare debate for you at some point. Minimal value added by these layers of bureaucracy most of which can and should be eliminated.
Nice work on the article, it was long, I skimmed the bit about Luigi but the first portion was compelling. I encountered it due to the restack by @dennisonwrites so thanks to you both
Sorry, maybe this wasn't intended but your comment comes across as extremely snarky. I think if you want to make an argument you should approach it with evidence of what you're saying and a tone that suggests you actually are interested in an answer instead of scoring Internet points on strangers
It was not a statement. It was a question. You wrote a long article. The idea seems like something you might have covered. Are you saying you do not believe that government programs are largely driven by ruling class self-interest? Do you really feel like I need to prove it?
You asked a very leading question, and you're following it up with more leading questions. If you have an argument you want to make, please make it clearly and with some amount of evidence. If you are going to ask another leading question, I'm just going to ban you for 30 days
To answer your questions:
- for the most part I believe our government is pretty good, though this iteration is very bad precisely because it thumbs its nose at the things that make this country good. I think it was better before citizens united
Best thing I’ve read in ages. Thank you, and really well done on this.
I suffered from pretty bad eczema which has some similar qualities to your condition. Glad you got yours under control. I was saved by Dupixent which I consider a miracle drug, thankfully I can self inject.
Yea I know a bunch of folks who have eczema. Biologics in general and monoclonal antibodies in specific are all really great. Dupixent just got approved for EOE, it seems like its just a really good generalizable 'stop bad immune problems without fucking up the rest of your life' kind of drug
I basically never interact with the health insurance industry if I can help it. I paid for coverage after college, then the one time I tried to use it they denied me and made me sit on the phone for like 4 hours before telling me to go fuck myself. Now I’m uninsured because I’d rather not deal with it.
I pay for a one medication out of pocket and it’s very cheap. When I got knocked off my bike on the west side highway a few months ago I cracked my femur, which was extremely painful. The doctor suggested I get a cast, but I didn’t want to have to deal with and pay for that so I just went home and sat in bed for two weeks. Now I feel fine so I guess all’s well that ends well.
That’s all anecdote to say that I think the healthcare system is incredibly stupid. I like to think of myself as not an idiot, but I can’t for the life of me understand what it is exactly I’m supposed to even do to get the right coverage, to use the coverage I have when I had it, or to even understand what I’m covered for or how to go to the doctor that will accept my insurance.
I also happen to have recently finished getting a new insurance policy filed with the state, which took years of banging my head against the walls of large corporations and the government. I understand pretty well on the regulatory side why this stuff is as expensive as it is. There’s basically a 10-20% bloat on any insurance product that is the result of regulation that hasn’t been relevant since like the early 1900s when people would set up insurance companies, spend all the premium, then collapse as soon as there was a major claim.
I like the idea of doing something in the healthcare space now that I understand the backend of insurance quite well. I like the idea of healthshare but don’t really understand it. I’ve considered trying to visit Luigi and proposing he licenses his name or partners to found a health tech startup (You can still own part of a business in prison), but I don’t have the bandwidth for it right now.
Not sure what the point of my comment is exactly other than I empathize with the frustration. I’d like to meet someone who actually understands the whole ins and outs of the system, but everyone I’ve spoken to in healthcare or health insurance can only really talk about their little bubble that they regularly interact with. Nobody seems to grasp the whole.
Regarding competition in the healthcare sector:
I think the system we have in Israel does a good job at injecting some degree of useful competition into a fundamentally universal healthcare system (which as you say, is the best method we have right now).
The Israeli health system has 4 health funds, that are non-proft insurers. By law, each resident has to be a member of one of them, and can switch between them at no cost and without the possibility for a refusal.
The funds have to offer a certain "general basket" of treatmenta by law, and are allowed to compete with each other on coverage for additional treatment as they see fit.
In practice, you get them competing at offering better administrative services, digital support, and "unusual" coverage, while everyone still gets good universal access to the general basket of health services.
A few other countries have similar models, like Germany and Korea
I think my biggest concern with this is the impact of changes on innovation.
As you note, you are quite lucky to live in a world where Skyrizi exists. A counterfactual world where there is less crazy drug pricing and Skyrizi costs $20, but the actual likely counterfactual there is it straight up doesn't exist for a decade or two longer. That's a very big deal and a golden goose I am quite reluctant to kill.
Unfortunately as currently framed this is a universal argument. It is _possible_ that the cost of the drugs is necessary for their development. It's also possible that the cost of the drugs is massively prohibiting development. There's no way to adjudicate these claims beyond vibes.
Still, I think the vibes suggest that this take is much more likely to be incorrect than correct. I think you'd see way more drug development with better and more streamlined regulation. Most of the research that led to biogics was funded by US tax payer dollars funneled into universities, not private enterprises. That research is the hardest part. Once you know how to make monoclonals they are very cheap to make. The reason they cost so much anyway is entirely due to excess regulation, which is something I call out as primarily caused by the FDA having ridiculous standards for approvals. So at worst drug development and research are totally mutually exclusive; at best, decreasing barriers to entry would result in more players in the space, resulting in even more drug development. To use mabs as a specific example, the initial research was done in the 70s. In a hypothetical world where everything else is the same but we have universal healthcare, I have a very hard time believing that we would just sit on the knowledge of how to do this kind of treatment and _no one_ would productionize and distribute it.
At the end of the day, the golden goose argument is essentially a status quo bias argument, that is, "because things are, they must be". I'm totally unconvinced that things are good because of this monumentally fucked system. A good thing -- mabs -- happened. It may very well have happened in spite of the current status quo
https://slatestarcodex.com/2016/09/07/reverse-voxsplaining-brand-name-drugs/
That's a good starting point - I'll have a more substantial reply after the weekend
I'm very familiar with Scott. You may be surprised to find that I entirely agree with him, and I don't think the article you linked says anything about my position (namely: we should reduce the cost of creating drugs by reducing regulatory hoops around drug development instead of price controls)
My thoughts -
You need to first think, in theory, of a system without insurance and come up with basic regulation to make that work. Essentially, first make generic healthcare extremely competitive and extremely cheap.
Then, you need to think about IP and make innovation work out. Of course, you can free ride on USA (as an Indian, I have no qualms admitting we do but since misery likes company, I will point out that Europe and China and every single country other than USA does exactly the same)
Once you have very cheap basic healthcare and good progress (and India embodies this - you get most generic medicine at a few cents a dose or less; doctors see you for a few minutes and give you an injection for a couple of dollars) then you think about insurance WITHOUT messing up the above two.
You think of insurance as a luxury for the upper mid segment - the poor get most of healthcare paid out of the pocket; the rich don’t care about insurance. The people who need insurance are the ones who worry about the slightly experimental / novel procedures and are fine paying 3x-4x more for the certainty (yes, insurance will increase costs by that much).
NOW, if you have a working insurance sector as well, they you let it expand, keeping a lot of regulations in place to ensure that the insurers don’t become too big - because if they do, they will mess everything up.
And restrict the government to giving a UBI.
And btw, a libertarian imho the author definitely is not.
I was more libertarian when I wrote this. I've since become less libertarian
I find it interesting that you have hit on the fundamental flaw in the ACA yet do not want to be rid of it as a result. The inherent conflict of interest in the private insurance industry is clearly the fatal flaw in the ACA imo. I can understand not wanting to be rid of it without a viable alternative but I don’t think it deserves anything other than tremendous scorn for its performance thus far.
I tend to agree that Medicare works ok, though it needs financial streamlining as the reimbursements are in many cases nonsensical (high reimbursement for new/simple/straightforward problems, low reimbursement for complex/difficult/time-consuming problems). That is something that I believe could be accomplished within 6-9mos if so desired at the governmental level.
The disaster that is the VA system is proof positive that you do not want the government running healthcare/ hospitals. Let the government be the primary payor and it can audit providers/systems to detect/prevent fraud, but let private sector run hospitals and clinics. Same issues I know personally about the VA are common in the British NHS as I understand it as well.
Your personal experience with Skyrizi injections is a prime example of the nonsense that is prevalent throughout the healthcare system. There are too many such scenarios to count. I believe streamlining those would increase efficiency and decrease costs significantly. It would certainly make it easier to get an actual appointment with your provider to address an actual problem.
Anyway, we can and should do better. But the influence of politics money from the insurance and pharmaceutical industries will prevent actual change in the near term. We also probably need to consider a federalist approach since program execution and healthcare delivery solutions that work in Wisconsin probably aren’t ideal for California or Florida.
You didn’t address the explosion of health care administrators as a driver of cost, but it might be fodder for another foray into the healthcare debate for you at some point. Minimal value added by these layers of bureaucracy most of which can and should be eliminated.
Nice work on the article, it was long, I skimmed the bit about Luigi but the first portion was compelling. I encountered it due to the restack by @dennisonwrites so thanks to you both
I feel like this is framed as disagreement, but I think you actually just fully agree with me
I did not intend to frame it as a disagreement but rather some observations (tangentially) related to your points.
I can see that I have touched a nerve. I will not bother you again.
Did you mention how government involvement in any program is almost entirely motivated by the potential for kickbacks to lawmakers?
At best, taxpayers receive pennies on the dollar for the investment.
Sorry, maybe this wasn't intended but your comment comes across as extremely snarky. I think if you want to make an argument you should approach it with evidence of what you're saying and a tone that suggests you actually are interested in an answer instead of scoring Internet points on strangers
It was not a statement. It was a question. You wrote a long article. The idea seems like something you might have covered. Are you saying you do not believe that government programs are largely driven by ruling class self-interest? Do you really feel like I need to prove it?
You asked a very leading question, and you're following it up with more leading questions. If you have an argument you want to make, please make it clearly and with some amount of evidence. If you are going to ask another leading question, I'm just going to ban you for 30 days
To answer your questions:
- for the most part I believe our government is pretty good, though this iteration is very bad precisely because it thumbs its nose at the things that make this country good. I think it was better before citizens united
- you absolutely need to prove it