The Brand is the Point: Voting Against Your Interests to Stay in Your Tribe
Down here in Mississippi we are already being inundated by campaign paraphernalia – we have a Governor’s election this fall. Why you ask? Well the best I can answer is Mississippi doesn’t want to follow Yankee traditions and elect its governor in federal election years.
Like other governor’s races in prior years, we have the option to choose a Trumpian conservative incumbent, or the other white man, a conservative Democrat who currently serves as our northern state public service commissioner. It’s essentially a rerun of the last election, when the then-current lieutenant governor (anointed by the term-limited governor) beat the last Democrat in a state-wide office by taking down the retiring State Attorney General (also a conservative white democratic man).
And normally I’d sit back, decry the situation, vote and then go get a good stiff drink. I may have to do so again this year.
That said, polling on the race by Mississippi Today points up why Chip and I and others are always so quick to say that most people vote brand, not policies. From the article:
The latest poll, conducted Aug. 20-28 of 650 likely voters ahead of the Nov. 8 general election, shows Reeves leading Presley 52% to 41%.
Yet a whopping 92% are concerned with the financial condition of Mississippi hospitals that put them at risk of closure. While Reeves has barely spoken of the hospital crisis unless asked about it by the media, Presley has made the issue key to his campaign.And one of Presley’s primary solutions to the hospital crisis — expanding Medicaid to provide health care to primarily the working poor while at the same time providing another source of revenue for struggling hospitals — is supported by 72% of poll respondents and opposed by 23%.
To further amplify that voter disconnect, poll respondents are evenly split on which candidate “would do a better job addressing the Mississippi hospital crisis” at 44% each.
The only issue polled by Siena where Reeves appears to have an advantage is on the issue of transgender women competing in women’s sports. The issue was viewed as a concern by 70% of respondents, with 50% saying it was a very serious concern.
Now you’d think a well-funded Democrat – even a conservative one – could make hay out of that. And given that Reeves consistently polls in the 40’s for approval, normal political calculations would lead one to the conclusion that there might well be an opportunity here, especially since the Democrat is a conservative white man. Add in the fact that the governor has refused to accept a Medicaid expansion (done years ago in neighboring and no less conservative Louisiana), and you really have to wonder why Governor Reeves thinks he should win.
Not so fast:
The disconnect perhaps can be attributed to the fact that a vast majority of Mississippians want to vote for the Republican candidate over the Democrat more than they want to expand Medicaid or address the hospital crisis or cut the grocery tax. For many Mississippians, their default position is to vote for the Republican.
And when you drill down into the demographics, it becomes a lot clearer:
Mississippi by the numbers
– Voting-eligible population: 2,246,323
– Breakdown by sex: 47.5% male, 52.5% female
– Breakdown by age: 21.4% 18-29 years old, 24.2% 30-44 years old, 32.8% 45-64 years old, 21.6% 65+ years old
– Breakdown by race: 60.3% White, 37.1% Black or African American, 0.7% Asian, 1.9% Hispanic or Latino, 0.0% Native American or Alaska Native, 0.0% Native Hawaiian or Pacific Islander, 0.9% two or more races
– Breakdown by education: 3.9% less than high school education, 10.5% some high school (no diploma), 30.1% high school graduate or equivalency, 25.0% some college (no degree), 10.2% associate’s degree, 12.7% bachelor’s degree, 7.5% graduate or professional degree
What you quickly see in those statistics is that the modern Republican Party, which feeds off white cultural resentment and fear among the petit bourgeois and those with only a highschool degree, has a lot of fertile ground for voting. In fact, 62% of voting age adults claim Republican allegiance. Based on the numbers, it appears we will get another 4 years of a governor who doesn’t want to lead on issues that actually impact his supporters, and who (because he will be term limited) can effectively ignore almost anything except trying to seed the ground for Donald Trump’s reelection.
Still, you have to wonder how long rural hospitals can close and no one gets upset. You have to wonder how long people can look next door to Louisiana, where no Republican candidate is willing to commit to rolling back Medicaid expansion, and not see a path forward. You have to wonder how long we will remain a state where the population is leaving and not make changes. You have to wonder how long insurance cost increases as a result of climate change will be ignored.
And you have to wonder how long the white power structure is going to stick its head in the sand about the damage its inflicting on itself by fiddling while Rome burns.
Because people who vote against Democrat governance know that it is not in our interest to do so. All you have to do is walk through these cities that have been in the clutches of Democrats since 19someoddwhenever to see it. Hospital or not, we don’t want what we have, to turn into what you have. Real simple.
Medicine is screwed up not because government hasn’t intervened in it enough, but because it has intervened too much. Bureaucracy ruins everything it touches and the medical industry is a prime example. The reason why you are scratching your head over it all is because the system works just fine for people like you. Those of us for whom it isn’t working don’t want more of the same.
Honestly, it’s far grosser to me how people like you continue to vote so nakedly for your interests, even as you watch cities being taken over by drug zombies and see the great unwashed experiencing 12 hour waits in emergency rooms. I would say it was puzzling, but now that you explain that to you, voting is all just what is in YOUR best interest, rather than the good of the nation, it all makes sense.Report
How is allowing rural hospitals to close in anyone’s interest? How is purposely underfunding schools (against state statutes) in anyone’s interest? How is forcing women to carry infants to term they don’t want and society lacks infrastructure to support in anyone’s interest?
And how is demanding to be reelected by actively ignoring these issues – as our governor is doing – in anyone’s interest?Report
“How is allowing rural hospitals to close in anyone’s interest? ”
Well, you do not have a 12-hour emergency room wait if there is no ER because the hospital closed.Report
QED, baby!Report
Again, for every dysfunctional city led by a Democrat, we can find a dozen miserable blighted rural areas run by Republicans.
The differences between capitalist West Germany and communist East Germany were stark and obviouus- if you were riding a train from one to the other, it was obvious the moment you crossed the border. But blighted Detroit looks just like blighted West Virginia.
As I posted just the other day, there are vast swaths of Republican-led rural areas taken over by “drug zombies and the great unwashed experiencing 12 hor waits in hospitals” (if they have a hospital at all).
I’ve posted this challenge before, to document a successful test of conservative policies.
Where is the city where we can see them put into action, and where it works?Report
A quick look at Wikipedia reveals that the largest U.S. cities with Republican mayors are:
Fort Worth, TX (#15 nationally, population 956,709);
Oklahoma City, OK (#23 nationally, population 694,709);
Fresno, CA (#35 nationally, population 545,567);
Mesa, AZ (#37 nationally, population 512, 498);
Omaha, NE (#41 nationally, population 485,153);
Virginia Beach, VA (#43 nationally, population 455,618);
Miami, FL (#45 nationally, population 449,514);
Tulsa, OK (#48 nationally, population 411,865); and
Bakersfield, CA (#49 nationally, population 410,647).
I’m confident that if there was something different about these nine cities vis-a-vis dysfunctional or closing hospitals, drug zombies, homelessness, blight, crime, and/or violence, we’d have heard about it by now.
But maybe I’ve missed something and some of our more Republican-favorable commenters will point to interesting data suggesting Republican policies are somehow better than Democratic policies at solving these very difficult-to-solve problems, or at least some of them.Report
Interestingly, of those 9 cities, 7 are in states which have accepted the ACA’s Medicare/Medicaid expansion.Report
Only the two California ones are in the top 50 most dangerous, if what I found online is correct.Report
Care to share the link?Report
I did a quick google of “50 most dangerous cities in the US” and got PopulationU.com.
Never heard of it before but… there it is.
Fresno is #37.
Bakersfield is #43.
WARNING! The website appears to use FBI Crime Stats. So if you don’t think that FBI Crime Stats are reliable, this website is also not reliable.Report
I’m happy to accept the FBI’s stats as at least a single benchmark; the FBI does give us apples-to-apples reporting because they use the same definition of “violent crime” in all jurisdictions (since 2017).
A lot of these are smaller cities. I can’t tell if they are run by Republicans or Democrats easily; a lot of cities have nonpartisan elections so it’s hard for outsiders to tell if they’re Republican-run or Democratic-run. I’d agree that the bigger cities (whether on the “unsafe list” or not) tend to be Democratic-run. I don’t know if that holds true for smaller cities.
So many smaller cities on this list dovetails into Chip’s point — big cities aren’t the only places where you find violence, homelessness, mental illness, addiction, blight, and questionable medical care. Beaumont, Texas, but it’s evidently a much more violent place than, say, Chicago, Illinois, which didn’t even make the list.
The “Crime by state” table at the end is interesting too!Report
I can’t remember who pointed this out on the site earlier, but the large number of smaller cities on the list highlights the fact that there are a large number of smaller cities.Report
To be sure! And the inclusion of smaller and larger cities on the list of dangerous cities demonstrates that danger exists in similar proportions in both smaller and larger cities.
My point here is not that Democratic-led cities are free from serious problems. Rather, it’s that these serious problems are going to be hard for anyone to solve. They are also ubiquitous.Report
I admit to being surprised that Pueblo was #5.
The State Fair was so nice!
I suppose that this is the same thing as folks who go to Chicago and get their picture taken at the Bean. “I don’t know what Jussie Smollet was talking about!”
I mean, *I* wouldn’t argue that Chicago was safer because it was MAGA country.
I digress.
Maybe there’s some sort of crosstabs thing we could do to find out any correlations on there that might be overlooked.Report
So much of it is also where in a city you are. For Denver, do you frequent the seedy clubs on East Colfax? Hang around in LoDo at the bars’ closing time? Decide to eat out along N. Federal at midnight?Report
The fact that people need to niggle over statistics proves the point.
There isn’t any obvious and undeniable difference between say, San Francisco and Omaha in terms of dysfunction, crime, disorder and general quality of life.
Number of homeless people in Omaha up 200% in 5 years
http://www.wowt.com/video/2023/03/20/number-homeless-people-omaha-up-200-5-years
The ills of large cities are more visible for the same reason that small cities are invisible. There’s not much that can possibly happen in Omaha which would make national news or go viral, but one guy shoplifting in SF is an internet sensation.Report
What even are numbers, anyway? Has anyone even explained the concept?
Here are some numbers.
It’s weird how Utopia isn’t that different from Omaha, at the end of the day.Report
I dunno, Jay. Utopia looks like it has a pretty high crime rate to me.Report
Everything went downhill after we got rid of that kid.Report
We can also find a lot small and medium sized Democratically run cities where things are, in fact, relatively good.Report
I’ll have to keep saying this, that the century-long struggle over economic systems is over, with regulated markets within liberal democracy being the unambiguous winner over all other contenders.Report
Yes. As to regulated markets, it’s just a matter of degree of regulation over those markets.
Liberal democracy is getting something of a challenge right now, but to be fair the authoritarian forces are now wearing the masks of the democratic institutions rather than suggesting replacing them outright. (For now, as what we must assume is an intermediate step. Napoleon was First Consul before he was Emperor.)Report
Are there examples elsewhere in the world that you would point to, examples of a system that works better than what we have in the U.S.?Report
EpiPens.Report
As has been discussed before on this site, Scott Alexander is wrong about EpiPens. (He’s actually wrong about a lot of things.)
EpiPens had a cheaper competitor in the US called Adrenaclick since 2009 (Which is about the time prices for EpiPen started going up.), approved by the FDA and everything.
https://www.drugs.com/availability/generic-adrenaclick.html
And the largest problem, believe it or not, was doctors being some of the stupidest and most easily confused people on the planet.
See, doctor would write prescriptions for an ‘EpiPen’. Now, EpiPen is a specific medication, and can only be replaced by a pharmacist with an _identical_ product, which Adrenaclicks are not. The medication is the same, but it is mechanically different, a thing that is usually not relevant in medication, but it is here and a few other places. Now, it would have been possible for the FDA to say they _counted_ as identical, and in fact several states have gone ahead and done that, but, they are not, in fact, identical.
But also…pharmacists could just have called and gotten the prescriptions changed…but hardly ever bothered. Or doctors could just start writing the actual medicine and how it should be dispensed instead of a fricking brand name, but they didn’t because they are, somehow, the stupidest people on earth who are perfectly fine with their patients extremely overpaying for things. (This is not the only place doctor do that, they write brand names all the time and patients end up overpaying for literally not reason, but it was exceptionally insane here.)
This is also confused by the fact that, shortly after that article was written, there _was_ a identical generic version of EpiPen released by the original manufacturers for about half the cost that pharmacies could replace it with, without contacting the doctor. The fact that most people still end up with the identical, more expensive version of something produced by literally the same people should tell you something about how much doctors and pharmacies care about this.(1)
None of this has anything to do with the government, and in fact most other countries do not have more versions of those injectors than we do. Two or three is about the right number. What screwed us over is a for-profit medical system that is full of doctors and pharmacies that don’t even slightly possess a trivial amount of concern for how much patients are overpaying for medication.
1) I really like how, while drugs are advertised on TV, the actual spending is on personally lobbying doctors to make sure they write patients prescriptions _using brand names_ instead of the medication name, so _someone else_ pays too much. You don’t advertise to the people buying the product, you advertise to the people who tell people what to buy and are supposedly experts but are often gullible doofuses.
“Should I write down ‘EpiPen’ and make them pay $600, or ‘epinephrine – autoinjector’ and have them pay $150? Well…I got some free samples from that hot sales rep, so EpiPen it is. Somehow I am an ethical and trusted person.”Report
My criticisms of the whole Epipen thing involved the FDA’s rigamarole (which were documented in the story). “But there was a generic alternative!” is a good thing (and I didn’t know that!) but the stories about Teva, Sandoz, and Adamis were documented and, excepting the FDA link, the news stories are still up. (And those stories don’t seem to know about Adrenaclick either.)
(And I’d *LOVE* to see where we discussed the Epipen thing and demonstrated how SA was wrong. Do you have a link to those comments?)Report
(we didn’t talk about Adrenaclick because at the time Scott Alexander wrote his essay it didn’t exist)
https://foxcitiesallergists.com/need-know-adrenaclick-generic-epipen-competitor-cvs/Report
Wait, wait. We discussed it here.
So it wasn’t a “we already did this!” when we had not, in fact, already done this (which is what I thought it was).Report
None of which answers or even responds to my question:
Where in the world is health care done better (or less badly, if you prefer) than the United States?
Although I originally addressed the question to Kristen, it is of course open to anyone who cares to offer up an example.Report
What tradeoffs are you looking for?
Would you rather have access to the most bleeding edge of the most bleeding edge treatments (even if it’s expensive)?
Would you rather not have to worry about getting a large hospital bill for something as routine as a broken leg?
If you want to purchase medication, do you want a dozen options that have been approved by the EMA or would you prefer two or three options that have been approved by the FDA?
Do you want to have the option of Medicinal Marijuana?
How long are you willing to wait to see a specialist?
What tradeoffs are you willing to make?
Because there are answers you might give that would make me say “You want to live 20 minutes away from the U of M.”
And others that would have me say “You probably would be happier in London.”Report
I’m not the one lodging the complaint, Kristen was, I and I responded to that by searching for some example we might use as an exemplar to test, and possibly prove, her argument. That argument, as I block-quoted in my question, is:
Medicine is screwed up not because government hasn’t intervened in it enough, but because it has intervened too much. Bureaucracy ruins everything it touches and the medical industry is a prime example.
So the thesis is that government involvement and bureaucracy do only bad things to health care, thus “better” must necessarily mean “less governmental, less bureaucratic.”
My question is aimed at testing the validity of this argument.
So. Where is there a medical system with less government involvement, less bureaucracy, than the U.S.? Once we identify such a system, then we can compare and contrast and possibly make judgment about whether the trade-offs between those systems favors the U.S. or [as-yet-unnamed nation]. (I suppose it might not be a nation but some other sort of health care delivery system, but I strongly suspect that in this context we’re mainly looking at the national level.) It’s at that point we can start wondering what qualitative or quantitative criteria matter more.
But without a comparator, it’s very difficult to do more than offer theory, ideology, and conjecture. Those things do not interest me. Galt’s Gulch could be as great as the novel depicted it, but when and where has such a thing ever really existed?
Your last sentence leaves me wondering: do you suggest that the UK’s NHS is a less bureaucratic system than what we have in the U.S., and therefore less bad than what we have? It’s hardly less governmental, but it could be that it’s a very efficient governmental system. I honestly don’t know. But if so, then perhaps the issue is more “bureaucracy” than “government,” and that would provide an important data point as we consider what to do about the issue raised by the OP, specifically rural hospitals closing and leaving communities without any significant health care providers at all.Report
Oh, for that? I’d say that the FDA is captured to a degree that the EMA is not.
It has a better risk profile and, if you ask me, is less corrupt.
Epipens provide a decent example of the EMA being less corrupt than the FDA.Report
So your contention is that he FDA’s regulatory capture problem is a root cause of healthcare in the US being in the sorry state it is?Report
Root cause? Nah.
I’d say that the root cause is The Iron Triangle and we cannot let go of “Done Fast”.
But I’ve given this rant before. (I can give it again, if you want.)Report
Ironic indeed to look to the European Union for a “less governmental, less bureaucratic” system of medicine! But the EMA is only one part of the system of medical care that a citizen of, say, Czechia would navigate.
As far as I can tell, the EMA has a 210-day limit on the amount of time it can evaluate a drug before it either blesses it for release to the public or sends it back to the lab. The FDA’s calendar is longer and more malleable (which, if you’re right about the relatively higher corruption level, is ripe for abuse). An FDA defender would say the EMA may not be giving itself enough time to really understand a drug’s risks before releasing it, but I think you’re on to something. Let’s award this point to our European friends.
So this part of the system one encounters in an EMA nation is better than the U.S. Does that mean you’d rather get sick in Florida, or would you rather get sick in Finland?Report
One last epipens point and then I’ll get to your question.
The example we got into at the bottom of the Epipens discussion involved Vikram mentioning that a friend of his had a European Connection that got him/her an EMA-approved piece of equipment that helped with a particular affliction but was not approved by the FDA.
The questions that I think are interesting are “Is your immediate response to hearing this to say ‘Good for Vikram’s friend!’? Is it, instead, to say ‘Oh, jeez. His friend is doing something foolish!’?”
Because I’m a “good for them!” guy, myself.
Okay: “So this part of the system one encounters in an EMA nation is better than the U.S. Does that mean you’d rather get sick in Florida, or would you rather get sick in Finland?”
Depends on what I come down with! A splitting headache and it turns out that I have a leech up my nose? I’d probably rather be in Finland. A broken leg? Probably Finland.
Something weird and obscure that showed up on an episode of House? I’d probably want to be somewhere near Princeton Plainsboro Teaching Hospital.Report
Yeah, I’m with you on Vikram’s friend. I certainly don’t have any LESS faith in the EMA than I do the FDA to screen out something unsafe and I’d need to see more than one failure story to be convinced to change my mind.
So if you’re trying to persuade me that the FDA is in need of reform, you succeeded.
This wasn’t really what I was thinking of when I first engaged on the subject though. The Finland-or-Florida question is, because the rub of it is we don’t know when or how we’re going to need medical care. You don’t get to pick something exotic or obscure like Incredible Rare Blood Condition Only Dr. House Can Identify and you don’t get to pick “Leech up your nose how did THAT get there?” or any of those things. What you get to pick is “I’ll live HERE,” knowing that eventually your number is going to be up somehow. (A fact that, as we age, becomes all to ominously real.)
I didn’t choose to dislocate my finger out on the river, but that’s what happened to me a few weeks ago. I got to deal with a U.S. healthcare system for the entirely unanticipated and unchosen orthopedic injury. I might have preferred the NHS or the Canadian system as it turned out; the speed with which I actually got service from the appropriate physician after first doing the telemedicine visit then doing the primary care physician screen then getting referred to the orthopedic specialist when I knew good and damn well all along what I needed was an X-ray and an orthopedist to verify that my field repair had put the knuckle back where it belonged and get me into the right kind of splint. That was a lot of co-payments and time consumed. What would my experience have been in Canada? Probably a faster route to the orthopedist, but not MUCH faster — so if it isn’t going to be much faster, then it might as well be CHEAPER. Because I pay for the equivalent of a silver-level plan for myself, and at my age and with my health profile, it’s the second-largest check I write every month after my mortgage payment.
(By the way, my finger hurts like a big dog. Still. If you get the chance to dislocate a finger or a toe, I suggest you pass on the opportunity.)
So there’s inefficiency and bureaucracy (as Kristen complained of) anywhere I go. I don’t know if I had to jump through all those hoops because the government made my health insurer put them in place for some reason that may or may not have a rational basis intelligible to a user of the system, or if the insurer did that on its own because the trolls in underwriting insist that there be screening mechanisms to protect their expensive orthopedist from people who don’t really need them.
I’m not sure if the reason my health insurance is the second biggest bill I pay every month is because of the government. I know that there are other ways of doing healthcare that would result in me paying zero for health insurance every month, getting what amounts to the same speed and quality of care I just experienced, at the trade-off of me and you and everyone else paying higher taxes. And that there are steps intermediate between what we experience now in the U.S. and those other systems. But I’m not aware of any country that has a care-gatekeeping system and payment-for-services system that is LESS governmentally involved than ours, except if you’re super rich and can pay for concierge medical services, which you can do anywhere in the western world if you have enough money. Most of us don’t have that kind of money.
Which is part of the source of my skepticism that government involvement in healthcare is going to be any worse than privatized healthcare. And that’s the case if “worse” or “better” are measured in 1) economic efficiency, 2) temporal efficiency, 3) quality of medical outcomes, 4) user friendliness, 5) long-term sustainability of systemic viability, or any other index one might care to propose.Report
We’re stuck with the Iron Triangle.
Done Right
Done Fast
Done Cheap
Pick two. AT MOST.
I’d say that we can cheat a little and say that something that gets done a million times a month and is downright routine can be shuffled under “done fast” because most of the efficiencies have been wrung out of the system. So when it comes to a broken leg or a colonoscopy, it’s relatively cheap and relatively done right and relatively fast. Relatively.
It’s the weird stuff that makes you pick between Done Fast and Done Cheap.
And the worst part is that the worst of the weird stuff doesn’t really give you as long a timeline as you might like.
How many corners of “Done Right” are you willing to cut?Report
Which two is the EMA doing?Report
Done Right and Done Cheap (but with a *LOT* less corruption).Report
“I’m not the one lodging the complaint, Kristen was…”
so I’m confused, because when I look back at the posts, you’re the one asking for examples of Where Non-Americans Do A Better Job, and when we gave you one, you said “that’s not an answer”, and then we asked you what you think is an answer and you’re replying that you’re not the one who asked the question?Report
That is incorrect, and that article is incredibly misleading This sentence, in particular, is utter gibberish: Branding their product as Adrenaclick, CVS put their product on the shelves in late 2016 for around $225 pre-insurance.
What they mean is that sentence is that Adrenaclick, a product that had been produced since 2009, in 2016 _started being solve at CVS_ for $225 for people without insurance.
I promise, the drug was approved when my link says it was. And it was sold at that time. Here:
https://www.nytimes.com/2016/11/02/business/also-ran-to-epipen-reaches-for-a-closing-window-of-opportunity.htmlReport
so would you say that EpiPens are or are not an example of how a medical system elsewhere in the world works better than what we have in the US?
Like…as you yourself point out, The System wouldn’t let customers buy Adrenaclick even if they did know it existed (which they mostly didn’t) unless the doctor specifically wrote “Adrenaclick” in the prescription instead of “EpiPen”. And that’s The System, that’s not pharmacists being jerks or customers being idiots. Like, you and all of us know that the two are equivalent, but it’s the FDA that says differently, and that’s The System.
(although it’s worth pointing out that what you’re saying regarding “trained to write the brand name so patients are forced to buy it” isn’t actually true. Every prescription plan I’ve ever had has stated that the pharmacy is required to substitute generic for brand-name when a generic is available, unless the doctor specifically marks that you get the brand-name stuff, in which case the insurance won’t pay for it; and most states make it a matter of law that this be done.)Report
What do you mean by ‘The System’? Because Scott Alexander meant the FDA and he was wrong.
Here’s the thing: EpiPen basically won because no one else even bothered to really compete, cause it was too much work. As the article I just linked in another thing said, the reason Adrenaclick, despite being available since 2009, was not widely know is that the company didn’t really do it well, and the Mylan advertised the hell out of EpiPen, so almost everyone, including doctors, defaulted to it, and even when doctors knew about alternatives they were not widely available because the company that made Adrenaclick was bad at it and didn’t make much, and sometime it wasn’t even available, not because of any law, but simply because there wasn’t enough.
If we want to blame The System, the actual part of The System that failed was the Free Market part. Because the way for Adrenaclick to succeed would have been advertising and having production capability, or, failing that, another company to step in. (In fact, several did during the product’s life, as it move between a few different companies.) But…no one truly wanted to fight the EpiPen juggernaut until price hikes and the consumers started revolting, at which point it took years to get into the market…except for one company that had a workable product but hadn’t really bothered until then.
I.e., the thing that is broken here is in fact capitalism, and the fact that market correction are not instant. Because that means when a product is required for people to not die of anaphylactic shock, and most of it made by one company, if that company jacks the price up most of them will pay outrageous prices and the rest will die of anaphylactic shock for a couple of years until things fix themselves.
The FDA might have made the barrier to entry slightly higher, but a) there were people already past that barrier, and b) mechanical devices that inject medication are incredibly complicated and a huge chunk of those have have actually had manufacturers that had to repeatedly redesigned products that did not actually work well. (Adrenaclick itself is a redesign of an earlier product). The FDA isn’t the barrier to entry, it’s the fact that the design is legitimately very difficult and FDA requires you to have a good one…so not many people bothered.
Now that I think about it, the only actual barrier to entry was the _patents_ on EpiPen. Because they clearly had a workable design. So…if we want to stop having patents, we could easily have fixed the situation with people using the already invented design.
I like how you say what I said about doctors doing that isn’t true, and then you talk about how insurance companies made rules and laws were passed requiring pharmacists to fix the problem because DOCTORS DO THAT.Report
“What do you mean by ‘The System’? ”
I mean the system that made it illegal for pharmacists to say “there’s an alternative to EpiPen and it’s a lot cheaper and I’ll give you that instead if you ask”, or even to say “there’s an alternative to EpiPen and it’s a lot cheaper and if you ask your doctor he’ll write you a prescription for that instead”.
Like, you rolled in with “they TRAINED doctors to WRITE BRAND NAMES and then the pharmacists CAN’T SUBSTITUTE” and you’re…aware of why the pharmacists can’t substitute AdrenaClick for EpiPen, right? Like, that’s a matter of regulatory action by a government bureaucracy, that’s not Evul Beeg Farmuh doing a Capitalism.
“The FDA isn’t the barrier to entry, it’s the fact that the design is legitimately very difficult and FDA requires you to have a good one”
See this is interesting, because you started out telling me how the government is totally captured by industry and that’s why they’re training doctors to write brand names because capitalist big pharma made substitution impossible.
But if the government were truly captured by industry then why is the FDA making such a big deal about reviewing epinephrine-injector products? Why doesn’t Pfizer have their own “EpiPfi” injector? Why did Sanofi recall Auvi-Q instead of telling the FDA to eat it?
“I like how you say what I said about doctors doing that isn’t true, and then you talk about how insurance companies made rules and laws were passed requiring pharmacists to fix the problem because DOCTORS DO THAT.”
okay so the thing you described doesn’t actually happen because government (and, for that matter, the Evil Capitalist Bastard Insurance Company) specifically says that it can’t, but you’re very angry about it anyway because in a world that you made up it where those laws and regulations didn’t exist it would happen?
(PS thank you for posting the same link that I already posted, nice to have actual proof that you just rage-blind bash the keyboard instead of reading my posts.)Report
Mostly because it was a generic drug that made no profit and auto-injector are weirdly complicated to get the dose right and Pfizer didn’t want to design one. There was no profit in auto-injectors whatsoever, until Mylan decided to skyrocket the price. But, of course, Pfizer wouldn’t have been able to do that with a competitor already existing.
This isn’t really rocket science: Why did someone who had managed to find a functional monopoly of required cheap and not-very-profitable product not have any competitors to stop them from skyrocketing the cost? Um, because why would anyone else be in that market?
People tried to scramble into it afterwards, and the one competitor who was already in it but not great at it tried almost immediately started to get their act together, but that sort of things takes time.
That is legal if we add ‘after I call the doctor to get them to modify this prescription’ or ‘state law allows me to substitute this specifically’.
The alternative is that pharmacist can distribute prescription drugs that were not prescribed. Which sounds bad.
…what the hell are you talking about, captured by industry? When have I said anything about that at all?
The only person here arguing that the government is captured by industry is Jaybird, and…he’s wrong. Or at least, wrong here.
The people ‘training doctors’ to do that are the pharmaceutical reps who wander around plying doctors with attention.
I not only didn’t say that was true, it is not true. Pharmacists can always(1) substitute a generic drug if a generic exists. My complaint was doctors writing a brand name _at all_, because pharmacists don’t always do that unless required by either law or insurance.
But Adrenaclick is NOT A GENERIC. Just, straight up, it’s not a generic, it’s actually a brand name. In fact, both EpiPen _and_ Andrenaclick have generic versions at this point in time!
Generics have to be identical. And Adrenaclick should not be regarded as such. If it was identical, it wouldn’t actually need FDA approval, for one thing, and we have plenty of evidence that these injectors are not always particularly well made, as several have been withdrawn from the market or revamped because of that.
If you want companies to be able to produce _identical_ products to the EpiPen, your complaint is actually with patent law, and not even drug patent law, the drug is not patented. It’s just…device patent law. That’s what’s stopping people from just using Mylan’s already-FDA-approved design.
If you want to argue that the government should seize that parent and void it so everyone can make those devices…I mean, okay, I won’t argue. Let’s do that! But don’t pretend ‘patents existing’ is ‘government regulation’ unless you actually are anti-patent law.
No, I’m saying it is such a big problem that insurance stopped putting up with it, and some states passed laws about it. (Also not sure why you think I’ve been railing about insurance companies here?)
1) In fact, state laws about this are incredibly varied, and in fact often cause doctors _not_ to use generics:
https://www.healio.com/news/primary-care/20200831/generic-drug-substitution-laws-vary-greatly-across-us
Because what drugs can be substituted for other drugs is almost entirely a state issue. The FDA merely approves the _use_ of a specific formulation of a drug. It’s the states that say ‘You can substitute, or cannot, or must notify, or whatever, generics for name brands’.
And again, just because this does not seem clear to you, Adrenaclick is not a generic. Although various states have _also_ said it can be substituted for EpiPen.Report
As a point of order there has been a well documented revolving door between senior pharma execs and senior FDA execs for decades. You call as to whether that constitutes regulatory capture.Report
I’m not saying there is not regulatory capture, I’m saying that none of this situation is due to it.Report
Completely agree.Report
did you forget about the article that you just posted describing AdrenaClick as an alternative to EpiPen
…did you post that article because you thought it was wrong?
(even though you’re the one who brought up AdrenaClick in the first place?)
like…you’re just all over the place at this point. Doctors are idiots who write EpiPen because they don’t know any better, but that’s not their fault because the AdrenaClick makers don’t advertise, and pharmacists aren’t allowed to substitute which means they HAVE to dispense the super-expensive EpiPen, but that’s actually good because AdrenaClick isn’t the same even though it is, and epinephrine auto-injectors are a generic product which is why it’s obvious that nobody would bother making a competitor product but also Mylan is exploiting their sole-supplier monopoly to gouge consumers with inflated prices.
“…what the hell are you talking about, captured by industry? When have I said anything about that at all?”
well bro I brought it up because otherwise I have no idea why you’re so upset about doctors writing “EpiPen” in the prescription and pharmacies being unable to provide a substitute item, although you seem to have recognized the idiocy of that position and retreated to “well if the FDA says they can’t substitute then I guess that’s just a real thing because it’s the government”.Report
Mostly, I’m all over the place because you keep saying random nonsense and refuse to even slightly education yourself about anything. For example, you started this off with a sentence about how AdrenaClick as an ‘alternative’ to EpiPen, which _you_ seem to think is meaningful somehow. But is not how prescription drugs work in any manner at all.
Pharmacists cannot dispense ‘alternatives’ to prescribed medication. If the prescription to treat youth acne says ‘spironolactone’, they cannot dispense ‘isotretinoin ‘ instead, despite that being a commonly prescribed alternative for acne treatment. That is not within the power of pharmacists.
The relevant word there would be ‘identical’, which they can, and do swap out, (Mostly by subbing in a generic, but there are identical name brand medications also.) but you do not seem to understand that specific word is important, so you sometimes use it and sometimes don’t, and seem to think I’m changing what I’m saying.
Likewise, you seem to think AdrenaClick is a generic, which, again, it is factually not. It is a name-brand product.
And your inexactness with language, and your lack of knowledge how it matters, is making this discussion _incredibly_ difficult.
Correct.
Why would that make it not their fault? Knowing this stuff is literally their job. If I hire a professional to make recommendations to me, I expect them to know things and not randomly pick things that make things way more expensive for me. If I hired an engineer to design a building for me, I’d be pretty pissed if they randomly included wires made of gold instead of copper for no reason, especially if I had to _legally_ follow their plan.
Unless they live in a state that says they can substitute AdrenaClick for EpiPen.
Or now they can dispense the generic version of EpiPen, which is made by the same company.
‘the same’ is not defined by any sort of law.
I said the _drug_ was generic, not the auto-injector. There is no profit in the drug epinephrine, it is trivial to make, and as it is just human adrenaline, it was not and could never be patented. If you get it in some other manner, such as an inhaler, it is incredibly cheap.
The epinephrine auto-injector is not generic, and it is extremely complicated to make in a way it gives consistent dosages. (Again, as evidenced by the fact various companies have repeatedly had problems, both in quality and quantity.) Drug companies, being companies that mostly make _chemicals_, do not generally like making mechanical objects. And certainly not a really complicated one.
And no one bothered making it because _until the price skyrocketed_, there was no obvious profit there.
You do remember the premise of this entire problem, right? A two pack of EpiPens used to cost about $110 in 2009. Which meant that other drug companies had no incentive to get into a market selling complicated mechnical devices. That price almost quadrupled by 2016, during which a lot of drug companies _did_ get interested in it. And also AdrenaClick got off its ass and was able to produce enough product.
You literally don’t seem to understand that the EpiPen cost is a crisis that happened at a particular point in time, and before it happened, it wasn’t happening.Report
The most important word in political identity is not political but identity. Or brand as you call it. Sometimes things get bad enough for people to vote against brand.* However, this seems to happen more at the national level than the local or state level.** As I have noted before, there are just a lot of people out there who are very invested in a government that addresses their cultural grievances and resentments. Or they think (whether they admit it or not) that white supremacy and/or Christian nationalism is in their economic interest. A lot of left-leaning people especially those with a more socialist bent have a hard time viewing physic wages as being part of economic self-interest so they don’t. Or they find it too depressing to contemplate.
*Inset famous quote on “I’m voting for the n…..” here.
**Local and state government often has more of an effect on the daily lives of people so there might be more of an imperative here to vote for the tribe.Report
I am very aware that in the South, being white and conservative means trying to perpetuate a power system that really on serves a few white conservatives. And that is is preferable for many white people to vote for other white conservatives even when it damages them economically. At some point however, either the supported politicians have to address these issues, or someone else will.Report
I think you will be surprised how long issues can go unaddressed.Report
More importantly, identity politics means that the conventional rules of politics don’t apply.
Conventional politics holds that people want objective improvements- in the economy, in infrastructure, in governance. A chicken in every pot and the potholes filled.
But identity politics casts that aside. In identity politics, people are willing to trade away objective improvements for status and position.Report
Important context here is that Philip H is an employee of the Federal Government.Report
And?Report
As far as I can tell, you want Democratic or Republican leadership to be hanging by a thread.
Sure, they have power… but if they start letting stuff slip, whammo. The other party gets in charge.
So you don’t have to put up with San Francisco craziness. And you don’t have to put up with Sterling Heights craziness.Report
Republican leadership in Mississippi is not hanging by a thread. Or even a rope. Maybe a steel beam. But not a thread.Report
I mean it’s already a well known fact that a very large portion of active voters simply vote party line and pay little more attention to politics than that. That is, in fact, one of the selling points of parties. Dislodging those voters takes a lot. More, I suspect, than it takes to activate non-voters into voting against/for a party. I don’t see much point in decrying it.Report
I suppose people dislike it because it means that the Democratic Party will always end up being a weird adhoc group of various minorities, a good chunk of suburbanites who would be Rockefeller Republicans in saner times, upper-middle class liberals, and AOC-Sanders types. A certain kind of leftie would love to ditch the bougie wineparents for a true working-class alliance. This is despite the fact that study after study shows bougie-boho wine parents (often white and Asian) are the most consistently socially and economically liberal voters out there.Report
Down here its a whole lot simpler then that. Republican = white. Democratic = black (or white communists). so if you are white and don’t want to be called a race traitor you vote for the GOP no matter how badly they screw up.Report
According to Pew data for the most recent years I could find lazily without searching too hard,
Mississippi:
White voters 65% R or lean R / 22% D or lean D
Black voters 12% R or lean R / 76% D or lean D
US:
White voters 51% R or lean R / 43% D or lean D
Black voters 8% R or lean R / 84% D or lean DReport
Like I said . . .Report
You said that in Mississippi, “Republican = white. Democratic = black (or white communists).” In truth, Mississippi is close to average, except for being weaker Democratic identification among both blacks and whites.Report
I understand the regional thing intellectually, but not emotionally. In the 13-state US western region (as defined by the CB), there are no states where Blacks are the largest minority group. There are several where they are not the second largest group. Like Italians and Greeks before them, Hispanics in those states are becoming “white”.
Anecdotally, somewhat farther east… my niece married into a Hispanic family in Omaha. (Hispanic acquaintances there say, “Oh, that Martinez family.”) Her mother-in-law and sisters-in-law thought her husband had married beneath his status. The mother-in-law came around as soon as black-haired* grandchildren started to appear. The sisters-in-law are, as I understand it, still not sure.
* My mother had jet-black hair despite “Hawkins”. My sister had, before it got gray now, jet-black hair despite “Cain”. My niece has jet-black hair despite “Moeller”.Report
Today’s white Southern Republicans are yesterday’s “Segregation, now, segregation tomorrow, segregation forever” Dixiecrats.Report
Yesterday’s pro-segregation Dixiecrats are largely dead. You may not believe this, but people of every race and generation are capable of independent thought.Report
Their children and grandchildren run the GOP in the modern South.Report
And if you weren’t a racist, you’d think that descendants aren’t identical to their ancestors.Report
Clear multi-generational voting patterns, copious media interviews, even books on this subject make it quite clear that today’s Southern GOP is the Dixiecrats next act. Those children and grandchildren didn’t form their political, social or economic views in a vacuum.Report
When you say “the Dixiecrats’ next act”, you mean that they’re racist, right? Well, prove it.Report
Well that’s heresy Saul! It is left identarian cannon that hyper liberal identity politics is favored by minority groups more than anyone else. The idea that identarian nostrums are principally the domain of white liberals would send Robin Diangelo straight to her fainting couch.
But, yeah, I suspect most interest groups across the electorate wish they could just ditch their squish fellow travellers and win an overwhelming electoral victory based on adhering strenuously to their first principles. They never could, probably never will, be able to.Report
The GOP has done much better job of it than the Democrats and I suspect that makes a lot of people jealous. Yes, they have written off California and many other blue states but because most people do not pay attention, they can just rely on “throw the bums out” for Congressional majorities or pluralities enough of the timeReport
Their coalition is somewhat less fractured and very geographically well positioned. If the left aped the GOP’s tactics the GOP would have a permanent super majority.Report
I generally think there are a bunch of issues that constantly confound the Democrats. One of the main ones is that the long history of anti-black racism in this Country really continues to screw things up and flattens a lot of issues that should otherwise deserve more nuance.
Defund the police/abolish prisons is an obvious one. No one can deny that the police and the criminal justice system spend a lot of time and energy in ways that disproportionally hurt and target black people and I don’t think it is far-fetched to say that we use prisons as a way of keeping the mentally ill out of sight and out of mind. Spending more on social services, decriminalizing sex work and drugs, will go along way to helping. However, there is also the prison might be the worst punishment devised by humans except all the others and there is what do you do with people like Madoff/SB/Holmes or that dude who allegedly killed the college students in Idaho or Murdaugh. I’m also under no illusion that decriminalizing sex work will be a majority opinion any time soon.
Education is another one that is tough. There are a lot of arguments about the way we fund education and set up school districts in this country is pretty screwed up and racist. However for Democrats to win a majority, we are going to need to win suburban Congressional districts filled with largely liberal squishes who still moved to their suburbs because of the public schools.Report
Yes, and it bears noting that no one hates the idea of defunding the police more than the minority residents of crime impacted communities. When we well meaning liberals talk about ending prison and law enforcement as we know it, resident of those communities don’t think for even an instant that comfortable liberals will be accepting their neighborhoods overflowing with crime and homeless encampments.Report
Private Security in the US is growing by leaps and bounds.
Pierre Omidyar (the Ebay guy) invested heavily in private security companies and donated heavily to “Defund the Police” orgs.
Pretty sweet gig.Report
l think this characterization is a bit reductive. There does seem to be a generational component but a lot of white liberals seem constantly in awe of the handful of black radical students they remembered from collegeReport
Maybe reductive but probably true too.Report
“Yes, and it bears noting that no one hates the idea of defunding the police more than the minority residents of crime impacted communities. ”
If this is so to a person, why did Brandon Johnson, the more anti-tough on crime candidate overwhelmingly win black areas in the Chicago mayoral race.
Maybe it’s more complicated than the “silly white leftists are speaking for minorities, who are all moderates like I am” talking point, just like my lefties who think all minorities want to defund the police are incorrect as well.
As Saul pointed out, Bernie overwhelmingly won under-30 Asians & Latino’s and went 50/50 with under-30 black voters in 2020.
More than a racial thing, in urban areas, this is a generational thing.Report
I think the buried lede here is the transgender sports poll. How such a vanishingly small population is seen as a threat to anyone is completely baffling to me. It’s as if every other problem has been solved and we’re inventing crises just to keep legislators busy.Report
It’s not a threat. But it’s a useful distraction that finds cachet with an influenceable voter pool and that the left has not yet embraced an answer to it that disarms it with said voter pool.Report
Nor will they down here. The fundamentalist Christian strain of nationalism that the white power structure clings to requires “traditional” gender and race roles to sustain itself. And when you have zero plans to address the issues voters care about, and good moral panic seems to be in order.Report
In red strongholds like yours it’s not really relevant or important. The strategy is aimed more at swing states.Report
How many men lop off their genitals for the meager rewards of becoming, at best, state champions in non-remunerative women’s sports? (I once had as a goal becoming as strong as an elite women’s weightlifter, but was too lazy to get there.) We have sporting authorities with the experience and expertise to deal with this sort of thing, and, given the lack of urgency or scale, in a sane world we would let them mull it over and set rules in the first instance, before getting into a moral panic and legislating in the dark. I suspect that when all is said and done we’ll end up with something like the traditional rules anyway, perhaps allowing former men to compete in women’s events without being eligible for medals. Or maybe something else. There are likely multiple acceptable ways to skin this particular cat and in the ordinary course we would be able to get there.Report
I think that if the standard was that a man actually had to have the uh.. primary weapon removed to be granted access to womens’ spaces the way this is discussed would change a lot. Not that there would no longer be a discussion, but I think it would neuter, as it were, a number of the safey concerns about predatory men abusing the system.Report
Yes well since all that panic is based on odious lies about transwomen as men who are sexual deviants . . . . .Report
Not all of it. There are several issues, and it doesn’t help anyone if we mix them together.
And I still think you’re confusing “sexual deviant” with “sexual predator”. As long as there are any norms, those outside the norms will be deviating from them.Report
The assumption governing the moral panic over trans women is that they are sexually deviant men who will choose to masquerade as women in order to increase their access to women for sexual purposes. Some of that access would indeed be predatory, but I have explored extensively in comment threads elsewhere, those men don’t need trans women to gain access to cis-women’s spaces. And trans women are far less likely to be predators. Its a myth, resting in nothing other then odious fallacies.Report
That’s only one of the concerns. I mean, clearly that’s not the reason people are angry at Disney for gay kisses in animated movies, right? Or the explicit books in school libraries. I don’t think the female swimmers forced to undress in front of a biological male would be fully comforted if he could only watch them from behind a glass wall.
Also, you’ve never addressed my point that, even if the biological males who sincerely call themselves women are perfectly harmless, there’s no reason that creepy guys can’t go into the private areas as well.Report
The creepy guys who want to go into those areas will do so no matter whether we try to exclude transwomen or not. They already do at a measurable rate. We don’t need pernicious discriminatory laws to create that situation. It already exists.Report
That’s obviously not true. If you automatically question any apparent man walking into a women’s facility you’re going to be able to stop more men than if you increase acceptability.Report
We’ve been over this – but again you are creating MORE harm by preventing transpersons from using the bathroom they identify with not less. Because you end up forcing people presenting as women to use the men’s room and you force people presenting as men to use the women’s room, until you decide they can’t then I guess they have piss in the parking lot.Report
You’ve argued that point, but it’s still not persuasive.Report
Oh I know, because you feign concern for cis-gendered women but have none for trans persons of either gender.Report
What is not persuasive about this? There must be some transwomen who totally look the part, to the point where you’d never know until, Crying Game style, the undies come off. The fact that women’s bathrooms are all stalls precludes any sort of accidental voyeurism.Report
To say nothing of transmen with facial hair.
Its all a crock.Report
Elliot Page or Chaz Bono, if they visited a conservative state, would be forced by law to walk into the ladies dressing room where YOUR LITTLE DAUGHER IS NAKED!
*shrieking violins*
This isn’t an argument, it’s a simple fact.
But that of course is NOT the intended result. The intended result is that trans people are left with no legal space in which to live.Report
There are approximately 14-16 million Jews in the world. The number was around 6-8 million higher on September 1, 1939 and yet…..Report
The current moral panic is as if Hitler had only targeted Jewish haberdashers name Heinrich who lived in Dresden. The numbers are that small.Report
I know but I suspect being that small of a group also makes it an easy target. I think part of it is internet amplification making trans people seem like a bigger group than they are. I suspect a lot of people quite do not know how to react or feel by the people who do not do full transitions like seeing the guy with a beard who still wears clothing mainly coded for female.Report
The tiny size of the Trans population is part of its appeal. The right discovered, to their horror, that gays were too numerous and too advantageously scattered through the population to make good scapegoats once they came out of the closet en masse. Trans is an easier target and is demographically much less likely to be related to the angry old men and frightened old ladies who fund their campaigns.Report
Bingo, except for the part you left out where most fascists start small with easily defined opposition groups and then move up and out as their power grows.Report
Then this confirms the right isn’t widely fascist since they’ve been moving down and in rather than up and out over the decades.Report
Up and out is exactly what’s happening.
They started with “just asking questions” about trans athletes, and now any store with a rainbow flag gets harassed by belligerent jerks.Report
I’m old enough to remember the kind of harassment and threats that the right used to be able to throw around en masse against every flavor of the LGBT+ skittles jar with either the tacit approval or indifference of the majority of the population. What the right can muster up now is a quivering feeble shadow of that former power. But, on the plus side, they have social media to amplify every outrage.Report
This is exactly right. We’ve come down to machine gunning cases of beer because of a 30 second throw away internet video.
I think the most amazing thing to come out of this is seeing how much fear is in the brain of the MAGA right. What a horrible way to live!Report
The GOP has spent close to five decades marinating, nurturing and directing that fear.Report
Given that loving parents in Texas are at very real risk of state agents forcibly taking their tran children away, I wouldn’t call it a “feeble shadow”.Report
I would. I know every culture war present moment is constitutionally required by the laws of the interweb to be described as the worst in history but compared to the sheer numbers and intensity of the past oppression what is happening now is indeed a “feeble shadow” of what it was. They’re scooting around chasing after a handful of kids, a passel of athletes and a tiny tiny handful of people with a tiny tiny handful of marginal issues, That’s what the right has been reduced to. It’s pathetic.Report
There were only 17 million Jews on September 1, 1939.Report
Let’s go look at Idaho where OB/GYN specialists are fleeing the state because of its restrictive abortion laws: https://www.nytimes.com/2023/09/06/us/politics/abortion-obstetricians-maternity-care.html
When caring for patients with pregnancy complications, Dr. Gustafson seeks counsel from maternal-fetal medicine specialists in Boise, the state capital two hours away. But two of the experts she relied on as backup have packed up their young families and moved away, one to Minnesota and the other to Colorado.
All told, more than a dozen labor and delivery doctors — including five of Idaho’s nine longtime maternal-fetal experts — will have either left or retired by the end of this year. Dr. Gustafson says the departures have made a bad situation worse, depriving both patients and doctors of moral support and medical advice.
“I wanted to work in a small family town and deliver babies,” she said. “I was living my dream — until all of this.”Report
I wish there was a separate news article about each person who moved from California and New York. But at least we have the aggregated data proving that there would be hundreds of thousands more of them than these stories we’re getting.Report
You may find the linked articles relevant. They suggest that economics and in particular destination state tax schemes, and not politics (at least as a primary factor), are the dominant reasons California is experiencing net outmigration. It’s a fair point to say that a more liberal state government is more likely to adopt a taxation scheme that looks like California’s, although perception of the tax burden of living in California may be greater than the reality, which is very similar to that of Iowa, Nebraska or Ohio.Report
I thank you in advance for the links.Report