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BiggerBoat posted:
If you recently lost your job you should see about Medicaid and/or exchange plans. A lot of people assume they won't qualify for Medicaid because it isn't "for them", or because they remember rules from pre-2008, and while there is some variability from state to state one of the things that happened with the ACA is that a new minimum standard for who was covered was established, and not just in terms of income range. My sister, who is around your age and recently lost her job as a mid-level exec at a small local bank, assumed that she wouldn't be able to get it because it used to be that the standards for Medicaid were a lot like food stamps (couldn't qualify unless you had a kid, can't have any money in savings), but the ACA mandated that only income could be used as a baseline determining factor, and if you are completely unemployed then you should qualify. Edit: lol popping into the actual current conversation, which I hadn't read yet when I made this post- I think the fundamental thing to recognize here is that basically all of the existing roles of the pharma companies would need to continue to exist in any formulation of single-payer, and I think that advertising, while an obvious target for cuts, is maybe a little TOO easy to say. Basically, you have the Coke vs Pepsi marketing which is clearly a waste of money, as laid out above in the effort post about cancer treatments, but you still need to publicize your studies to get participants, propagate the differential outcomes to doctors/pharmacies/etc. It's probably true that given private companies maximize for profit and government orgs maximize for public good (generally) there is some set of changes you could make that would lead to greater public good in the US, but that doesn't necessarily mean that it leads to greater innovation, or greater global good (though if you include those factors in your optimization then maybe it could). The thing is, when people talk about M4A being cheaper on a per-person basis, they explicitly are talking about people in the US, and that's where the focus of the argument is (for valid reason, of course). However, if we kill off multinationals by subsuming their functions into our structure for US health care, there's an actual loss globally even as the US benefits locally, and I think that's what all the professionals in the thread are saying. Because there are so fewer strong international governing bodies, we have let multinationals fill the gap, and while this is obviously a terrible state of affairs and one we should work against it also means that if we take aim at multinationals without a suitable replacement in mind we are potentially creating a vacuum that nothing is able to fill in the short-term. That's where the loss of innovation is coming from, the fact that governments set standards for drug trials but don't run them themselves, typically. Basically, if we intend to take action which has the logical consequence of running some of these companies out of business, we should be concerned about how we handle that, because you can't just point at it and shout "nationalized!" when the functions and benefits come from it being international. We'd need to move some of these functions into the UN or some other organization established by treaty to really keep from having some sort of knock-on effect when we decide not to continue subsidizing these companies, which isn't to say that it shouldn't happen, just that you need to think of second-order effects and not just the immediate consequences in the immediate vicinity. I don't have sources, I'm not in the field and wouldn't know how to properly vet them, but this is just my thought process as a layman who supports M4A in the US. It probably isn't as simple as I would like it to be or even as simple as I could reasonably picture, and I'd rather someone else do the legwork of policy, but I don't think it's outrageous to say you need to acknowledge the existence of trade-offs on ANY policy, because then you can buttress it and find a way to fill those gaps. In this case, it just means that when we move to restructure our national policy we should also be making overtures internationally to avoid disruption of ongoing trials and make sure that research efforts DON'T take a hit, but it's not something I've seen discussed with any seriousness and the effort posters have been making the case for it pretty well IMO BougieBitch fucked around with this message at 21:27 on Oct 23, 2020 |
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Oct 23, 2020 20:23
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doverhog posted:Opposing health care as a human right because the drug companies need the money for research is like opposing abolition because the slavers need the money to produce cotton. I'm pretty sure all the people with the effort posts started and ended them with "so yeah we still obviously need single-payer, but let's be plain about possible drawbacks", everyone agrees that US health care is hosed and needs to change ASAP, it's just about making sure we don't collapse the Jenga tower by virtue of being the last rich country to get around to it. I've seen Nastidon make some pretty bad posts in other threads (generally by explaining why a bad thing happened mechanically when the discussion didn't really need that kind of nuance), but this is pretty much the ideal thread for the perspective being brought and it'd be nice if we could actually keep the long-form posts going because I think there's a lot to be gained from this being a srs business policy thread. If we can acknowledge that drug development (in the sense of efficacy and safety testing done almost exclusively by large companies) is important, then step 2 is to come up with a viable solution to keeping it alive in the absence of those large companies, because, again, it's an international problem that currently is being funded by the US through profit-motive. To address Jaxyon's point above, these companies conduct trials using an international pool of participants, but the money being made is in the US. Approval in other countries is happening because the marginal cost of getting it once it is already approved in the US is virtually nil, but most drugs wouldn't make it to that phase if the payoffs were half the current size, because the risk and benefit projections of the initial drugs would go from net positive across all outcomes to net negative, i.e.: Odds of failing at phase 1: 25% Cost of failing at phase 1: -1 Odds of failing at phase 2: 25% Cost of failing at phase 2: -2 Odds of failing at phase 3: 25% Cost of failing at phase 3: -3 Odds of making it to market: 25% Value of making it to market: +8 Where at present the weighted benefit of proceeding with a drug is +1/2, but if the value of making it to market was only +4 it would be -1/2 and the drug would not proceed to the first phase. Obviously this is an over simplistic example, and I realize people mock economics and game theory in particular, but it seems to me that the only premises you need to accept here are: 1. The US is currently the most profitable single market for drug sales 2. If the US got single-payer health care and began doing national negotiation on drug prices the level of profitability for drug companies would decrease 3. Given tighter margins, fewer drugs have the potential to be profitable and therefore fewer drugs will be taken through the steps needed for approval. If you disagree with one of those premises, then specify which one and lay out why, but all else being equal it seems that the argument that single-payer plans as-proposed would decrease the number of new drugs brought to market. To head off the obvious arguments (which you have already made and people have already agreed with): -Yes, profitability of a drug has no relation to how much good it does, as in the case of the copycat cancer drugs or Viagra. This is actually a key part of this point, as we should acknowledge that many of the drugs that are on the cusp of profitability might actually do a huge amount of good if we were able to confirm their safety and efficacy, such as new antimicrobials that were mentioned upthread. -Yes, a public entity that was able to do the same job as the existing private entity would be massively better, but I am not aware of any proposals of the sort, and especially not any that are included in any current healthcare plans. Due to the necessary scope, it may not be possible to create such an entity within the bounds of the US, because testing requires MASSIVE number of participants, and for many conditions there simply aren't enough candidates in JUST the US to fill a trial and have any real level of statistical power. Thus, it would need to be an international undertaking if the goal is to totally replace the existing pharma companies. -No, these concerns do not outweigh the net positive from improving US health care, especially not to US citizens. The reason they are worth mentioning is because they are a meaningful externality to the REST of the world, not because they would have some massive impact on US citizens. Essentially, the US has been paying a wealth tax to these private companies, and after they vacuum up some percent of it to pay their employees they spread the remainder around to the entire world as new approved drugs. The goal is to find a way to give the US better health care while also making sure that we are still funding those new drugs, and there ARE legislative ways to do that even if we don't want to totally supplant the drug companies. For instance, one idea I've heard floated is bounties for needed drugs or classes of drugs. I have no idea about the merits of this idea versus any other, but that's the point of bringing up the shortfall created by the US fixing health care, to make those ideas part of the policy discussion as well! Edit: It's also kind of funny to me that this discussion is happening with an ongoing health crisis taking center stage, like there's literally no way that the US could single-handedly develop a coronavirus vaccine even if we threw all of our national budget at it because we straight up do not have the combination of study participants, researchers, and manufacturing capacity on-hand. Given that, how can we expect to replicate that in the next 5-10 years if we move to a single-payer model? It's absolutely something that we would rather be handled by companies with broad public accountability or directly by the government, but if you aren't taking the steps to get there then it isn't going to happen by accident. BougieBitch fucked around with this message at 20:00 on Oct 24, 2020 |
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Oct 24, 2020 19:48
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Complications posted:If drug companies actually require more money for R&D instead of shareholder dividends or executive bonuses or for marketing or bribes or whatever we can just give them money. Well it's a debate because that's not actually a functional policy. If you say "here have $2 billion for R&D" then they just shift any internal money that was going to R&D over to marketing or CEO salaries and you've effectively just given them free money. You could give them a tax deduction proportional to the amount of R&D they perform, but that could be seen as a protectionist play, since it benefits US pharma corps over ones in other countries. Basically, the best play if you want to fix it by just throwing a wad of cash is to just straight-up buy the companies, change the stated goals of drug development so that decisions are made based on the number of total years of extended lifespan a drug gives across all patients instead of the amount of money it makes, and continue operations as normal otherwise, but that has its own risks because the next time Republicans get control they can shift the priorities back around to loving the poors or sell the parts to whatever private companies still exist like state and local republicans have done for years with public infrastructure, so ideally we'd come up with a more durable solution if one exists. That's also not getting into what it would mean in terms of international borders and whatnot, like can the US just buy a company that has real property in China or Russia or whatever without starting a whole debacle? Do we give the international employees US citizenship and move them over here? IDK, so far as I know nationalization hasn't been successful outside of situations where the primary value of the company was physical property like railroads, telecomms, or oil production, but I'm not all that well-read overall so maybe someone else could link a primer Edit: Let me be clear, in response to the above post- I don't think pharma companies are "good, actually", basically this is an exercise in hostage-taking but it's pretty hard to completely decouple a company from one of its core functions the way you are proposing, which is why you actually need some fiddly policy proposal to handle it instead of just a mission statement. We can't even get a national bill passed to regulate the price of insulin (or just buy whatever operation is responsible for manufacture and do it ourselves), so it's a reasonable thing to be concerned about us doing on a larger scale BougieBitch fucked around with this message at 20:29 on Oct 24, 2020 |
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Oct 24, 2020 20:19
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Complications posted:Look, the premise is that it's pharma company profit that's funding drug R&D for the world (PS lol), and that doing anything to fix the US's broken loving healthcare will be a loss for everybody everywhere because of christ no one is saying this, the point is that you need to explain how you are doing it, you aren't just loading up a T-shirt gun with wads of cash. There's not any US department or agency that currently does anything like this, the closest we have the the FDA and we would need to multiply their budget by like 16 and establish a bunch of new departments and poo poo, it's not just a handwave. The current FDA budget across all departments is $5.7 billion and half of that is paid for by the industries they regulate, annual pharma R&D is like $150 billion across the industry, with individual companies contributing up to $12b a piece. That STILL doesn't address the other point, which is that phase 3 trials require like 1000-3000 participants, meaning 3000 people with the disease in question who aren't disqualified for various reasons. How are we going to do all of the necessary testing for any given drug, assuming the trial is for something reasonably specific like "stage 3 leukemia in adolescents" or whatever? Again, RIGHT NOW there are a bunch of companies doing trials for COVID vaccines and for a bunch of practical reasons they have concurrent trials in the U.K., Japan, South Africa, Brazil, etc. https://www.statnews.com/2020/10/23/covid-19-vaccine-trials-from-astrazeneca-johnson-johnson-to-restart/ There are a lot of practical reasons to do that, it's not just a cost-saving measure! If some gene would cause you to have a severe reaction to a drug, you could easily miss it if you are pulling your trial sample from a localized population. There are a lot of genes like this, where the frequency is extremely variable based on geographic location, so trials done only on US participants BY NECESSITY would be potentially deficient. BougieBitch posted:
doverhog posted:It has been pretty clear that the private market will research boner pills opposed to new antibiotics. The private market has failed, and ought to be dismantled. Are you planning to contribute? Yes, the private market should be dismantled, what is the actual PLAN though? BougieBitch fucked around with this message at 23:06 on Oct 24, 2020 |
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Oct 24, 2020 22:53
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HootTheOwl posted:How does this jive with the NHS producing all the innovation? If they're already providing all the underlying research why can't we also pay them to turn that research into treatments. NHS is the british one, I'm assuming you were going for the NIH. The extent of that research is usually "synthesize a novel compound", "test in non-human subjects", and possibly "determine if this compound targets the appropriate cells or receptor sites in human tissue", not "determine the clinical efficacy and human safety for a variety of dosages and determine the list of side effects and interactions with other drugs". People fall into the trap of thinking that the first translates to the second, and it SUPER does not. Mice are cheap, and there are minimal ethical considerations, plus you can order them with whatever specific genetic abnormalities you need to test against. Humans want to be paid for their time and participation, your sample needs to be drawn in a way that ensures sufficient variance across all relevant factors to be suitably random, and there are tons of regulations and procedures that need to be followed. It's not the same sort of work, it is very technical and requires a lot of education and training to get to the point where you can do it effectively. There might be a lot of people in the sciences stuck at dead-end post-docs and the like right now, but I don't think it's a sure bet that we could find enough people to even SPEND another $150b without working our way up to it over at least a decade, maybe longer. I personally got an undergrad degree in biology, failed to make it into grad school, went back to school for CS and now can't find a job in the corona-wastes, so if we wanted to suddenly open up like 10,000 new positions at this theoretical new office I'd be all for it, but it is NOT just a matter of scaling up the things that exist in the NIH or FDA right now. doverhog posted:Plan is build up grassroots leftists organizations to primary corporate democrats, before that is done any talk about details is irrelevant. It cannot be fixed without that being done first. This is literally in the OP: "But it might stifle innovation". If you just want to talk about how politicians are bad there's like 5 threads for that, this is the US Healthcare thread and if you don't want to talk about the details of US Healthcare and all the ephemera attached to it then just don't, but don't poo poo up a thread that has a lot of effortposts just because you don't have any concrete opinions on the "how" part of the equation. Again, no one in this thread has posted anything close to "I like Joe Biden's plan" or "actually I think we can just keep things the way they are", so stop trying to frame it like requesting nuance is the same thing as opposing progress. Complications posted:The numbers do not impress me. $150 billion annually? Chicken feed to a government budget. We already know how to administrate budgets to organizations that are literally an order of magnitude larger than that, I assume that it's entirely possible to build another goddamn administrative wing onto an office building somewhere and build some labs for scientists to work out of. The WHO's annual budget for 2020-2021 is $5.84b, which, again, is for all programs. There have been concerns lately about certain countries having undue influence on WHO, imagine how much worse that problem would be if the US suddenly started paying them several times their annual budget to do stuff for us. It's really hard to come up with a single international entity that has both a meaningful impact and no ethical issues, because basically all of them have primarily been tools for exercising soft power since WW1. This obviously applies to businesses as much as to non-profits and treaty organizations, given the US's position during the Cold War, so it's not like the status quo is preferable or "safer" somehow, but it definitely means you can't beat capitalism by spending government money when it comes to problems with this kind of scope BougieBitch fucked around with this message at 00:26 on Oct 25, 2020 |
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Oct 24, 2020 23:56
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My main pushback is just on any sort of cut-and-dry solution, not because its wrong per se, but because there's not really any meat there, and if all you are talking about are the very broad strokes then you will inherently get more agreement than for any specific policy proposal, as in the national polling for these issues vs whether people vote for candidates whose plans match the descriptions. A necessary step of getting what we want passed is identifying what it is that people object to in a given plan, and while obviously the population of SA isn't representative, we can still anticipate the arguments that might be made by detractors or debate the relative merit of different methods of achieving the same goal. Again, the issue is that while we already do fund a lot of things through national policy, A. it is typically in the form of grants rather than direct employment and B. the amount we mean by "a lot" is not "the majority", "the plurality" or even "a large percentage", as I pointed out in terms of the current budget of relevant public orgs (~$6b each for WHO and the FDA). The NIH administers a total of $41.7b annually, but that's still only 1/3 of the R&D budgets of the pharma companies and only 10% of that is going directly towards national-level research, with another 80% going to public and private universities, medical schools, etc through the aforementioned grants, according to their own website: https://www.nih.gov/about-nih/what-...h%20activities. Even if we accept that a large portion of the R&D budget of the major pharma companies is wasted in terms of whatever metric we want to use, we still need to at least match whatever portion we consider "productive" - I can't speak to that, since I'm not in the industry and far from an expert, but at least for the sake of discussion we should consider what that number might be, because even if we are discounting it to 50% it is hugely eclipsing our current public spending if we were to wipe it out, so we'd need to make the argument that either much more of it is unproductive or that the changes we'd make would have a much smaller impact on direct profits and spending than the current US share of the market would indicate. Again, this is not to say that it's not a worthwhile goal, but spinning up a whole new department with a budget on that scale is not the work of a couple of years, but probably at least a decade. It's possible that grants could be allocated to a greater extent as well, but the marginal utility of doing that beyond a certain point is possibly rather poor, since the current system (at least in theory) is going to dole out grants according to the significance of the research in question, or at least how well-argued it is by whoever is writing the application. In terms of money saved by having the government doing both the research and the review, I'm not certain to what extent we could count on that to be a huge savings. The approval part of the process is relatively cheap (again, the FDA is doing it with only part of its budget, which is 30 times smaller than the amount spent on the R&D by drug companies if the numbers I've been citing are correct). If the argument is that the amount that needs to be recorded and reported is less, I'm not sure that's ideal - the consequences of a botched study are potentially catastrophic, so reducing the number of people that do the double-checking isn't optimal unless you think there's a cheaper way to implement a failsafe. I don't think it's fair to assume that public employees are more likely to be high-quality or more likely to operate in good faith in a vacuum either - at least where the path runs through academia, there's a lot of pressure to produce results, especially if you don't have tenure yet, and that can lead to mistakes and misrepresentation in data just as much as corporate profit-seeking does. Edit: Oh, and as a specific reply to "why can't we just do what the private companies do for hiring", it's not just the standards and such that are a roadblock (though they absolutely are), but also the fact we would be drawing from only the US talent pool, with maybe some few international applicants willing to uproot themselves to work for the government. Some of our grants already go to people in other countries or organizations that straddle the lines across multiple countries, so we can't absorb them into this theoretical government department. It's also not that we couldn't get to that level of funding eventually, but it isn't as though the huge companies did all their hiring in a single year - most of them have been around for close a century in one form or another, some of them longer than that, and that means you have a lot of people with huge familiarity with the systems they work with as well as a pre-defined tiered structure that is a lot more resilient to pieces being pulled out and replaced, not to mention a separate budget for HR that hasn't been included in this discussion. BougieBitch fucked around with this message at 19:49 on Oct 26, 2020 |
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Oct 26, 2020 19:41
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