I’m confused about how this relates to DOGE. Is there any credible evidence of widespread corruption in the US civil service? It seems like most of our government costs are above-the-board payments to old people and doctors, and the biggest problems with the agencies are taking their mandates too seriously. I’m all for shaking things up at the FDA, but they don’t seem to be accepting bribes or working with the mob.
I wrote this after reading the Cowen/Pahlka interview. Cowen says: Maybe the agencies should be just shut down and rebuilt by the next administration? Pahlka: That would be too much chaos. Cowen: So maybe do it in gradual way? Pahlka: We’ve tried, it does not work. And my reaction was: “Oh my, I know these discussions from the 90′s.”
It was a cool natural experiment: A bunch of countries tried reforming at the same time, used different approaches, got different outcomes. So maybe there’s something to learn there.
Or to take the FDA example: You want to do a shake-up. How exactly would you go about that? Organizations are already in equilibrium. If you shake them, they just return to the previous state. Is the only way to shut them down and rebuild them from scratch? Or is there a less destructive, gradual approach? Again, we may get some insights from previous reform attempts, even if the problems don’t match in 1:1 way.
Congress should repeal Kefauver-Harris so that “treatment X has not been proven efficacious by a wildly expensive high church effort at proof” stops being a valid reason for the FDA to ban something (the way it is (and has been since 1962) in the status quo).
The FDA’s ban on “treatments of unproven efficacy” has never been coherent, never helped people, and slowed medical innovation way way way down.
The FDA’s ban on “treatments of unproven safety” should be much much cheaper, and slowly scale up based on the size of the N who have tried a treatment, and it should only involve an attempt to measure the lack of safety, so that informed consent can be brought to bare in specific cases, by a trusted clinician, about how much danger is “worth it” in a specific case.
Chemotherapy, for example, is often brutal, and the side effects can be fatal… its just that this is a clinical cost worth clinically paying in some cases, for some cancers, with some prognoses. It isn’t “safe” it is just “probably safer than letting the cancer run to completion, and hopefully better than alternative treatments that the doctors even know about, contingent on the specific personalized diagnosis, by one or more doctors, regarding a specific tragic situation”.
For some diseases, nothing can save you from “doctor has low skill”. Medicine is intrinsically dangerous.
The FDA is a fig leaf on this… and it is a very very heavy fig leaf, that mostly only mitigates anxiety in exchange for OCD rituals, even while the form and cost of the rituals harm science and medicine and technology and “the production of more consumer surplus for patients (by getting them highly effective treatments at competitive prices based on an economic race to the marginal cost of providing the treatment)”.
The rent on health is too damn high. The FDA needs more judges, and tort lawyers of high integrity, and economists, and data scientists running statistical clearinghouses… not more molecular biologists.
This would be a huge change, and it would also probably work.
According to ChatGPT total salaries to doctors in the US are 385 billion per year. On the other total healthcare spending is 5 trillion. That suggests less than 10% of US healthcare spending is payments to doctors.
The US healthcare system has an amazing amount of middle men that take their cut. The money flows are sometimes pretty intransparent. While most of it is technically legal, it’s not above the board in every sense.
Let’s say you are insured with your employer. The deal between the employer and the insurance company is facilitated by an insurance broker. That insurance broker gets paid a fee that’s sort of transparent to your employer but probably not to you.
That insurance broker however also gets paid some bonuses that are not disclosed to the employer. The insurance broker also gets threatened with losing access to some insurance companies if they don’t recommend the insurance company when the insurance company wants it.
The insurance broker is subject to a bunch of incentives that the employer does not know about as they are hidden from the employer.
Apart from the things that are hidden from the employer, the fact that the insurance broker takes their cut of the transaction is also intransparent to most people, which makes them think about healthcare money going to doctors and not insurance brokers.
Functionally, the payments from the insurance company to the brokers that are in addition to the fee that the broker gets for the transaction (which is disclosed to the employer) are essentially bribes.
I would guess that this specific example is less and less a problem each year, as people and companies buy more directly their insurance (and other things).
For brokers serving small employers (e.g. firms with under 50 employees) a commission rate of around 4% to 6% of premiums (so likely not including extra incentive payments) is typical (numbers again from ChatGPT). It’s less for bigger employers, but it’s real money in the system.
People and companies buying insurance directly is helpful.
You have pharmacy benefit managers that got recently quite unpopular with politicians, so there’s also progress, but the system is really big and complex and at every point someone has an interested to take their cut.
Generally you have a system where a lot of money is flowing. Both patients and doctors often don’t even now how much money is flowing for a simple healthcare service.
One interesting aspect: The government does not set the prices for individual services in medicare. They are instead set by the AMA which is an advocacy organization. So inter-AMA politics determine which services get reimbursed how much and I would expect that there’s also plenty of non-above the board actions going on there.
Healthcare spending being somewhat opaque is a completely different problem than government agencies taking bribes and using violence though. The breakdowns for where this money goes exist if you care to look for it, and you can try to solve the problem but it turns out that “obvious waste” isn’t one of the line items. Healthcare would be cheaper if we had fewer doctors, nurses and support staff, or paid them less, but we don’t do that because the average person doesn’t think that’s a good idea (for better or for worse), not because nurses will murder us if we cut their salaries.
Compared to doctors in Germany, doctors in the US spend a lot more of their time dealing with billing issues. If you ask the average person about whether it’s a problem that US doctors spend so much time on billing issues instead of patient care, if they are a bit informed about how the system works, they will likely tell you that the would prefer that the system works in a way where doctors have to spend less time on billing issues.
After the first Trump administration passed a law allowing drugs without FDA approval being given out under compassionate care, the FDA didn’t like it. They communicated that in a way that got the drug companies not to give out drugs under compassionate care. I think you can call that fear of government violence.
I think there’s probably plenty of things that go on in healthcare setting because someone says: “This doesn’t really make sense, but if we don’t do it we get problems with government regulation. And of course a bunch of other agents like insurance companies or malpractice lawyers that add complexity.”
I think you’re still talking about something different from government workers taking bribes and working with the mob. The Department of Making It Hard to Approve Drugs making it hard to approve drugs because they, like a majority of citizens in this country, think it should be hard to approve drugs is a problem but not the same problem as corruption.
The public is too uneducated to know better. Even many in the FDA are too uneducated to know better because they are insufficiently interdisciplinary.
The question is: how should the handful of smart and good people react to this state of affairs?
I say: high level operatives within medical bureaucracies should understand the price theory of economics, the germ theory of disease, and have a working definition of jurisprudentialintegrity. If asked to do evil, they should educate in a face saving way, then disagree pointedly if that doesn’t work, then remonstrate, and, at length, they should resign and blow a whistle.
Narrowly, if they weren’t just good bureaucrats but good medical bureaucrats, and they understood Koch’s Postulates and the real telos of public health systems, they would understand that Racism is not a disease with transmissible causative infectious agent that can be grown in a petrie dish and then physically put into a person to cause the person to “become Racist” somehow… and so they would never say things like “racism is a public health crisis”.
Regarding the correct name for the mobsters that BAD bureaucrats might eventually go to work for (until law enforcement properly cleans up a group of bad actors, investigating, prosecuting, and convicting some people people (who should generally get the presumption of innocence (at least by non-investigators, and non-DAs, prior to a procedurally correct conviction))) “a mobster” will often be called something like “the CEO of the City’s Sanitation Company who some allege has ties to organized crime” or some such. De facto.
Ideally, “oligarch” might be better than “mobster” since it intrinsically connotes venality (the pursuit of money for personal uses up to or past lines of propriety) and indicates the properness of “a general sense of suspicion by default” by normal people. Very few people are oligarchs, and oligarchs are weirdly powerful.
I think that a properly ordered society would contain some oligarchs, but only as one small part of a free society, with free markets, where the accumulation of personal wealth in hypothetically morally valid ways is a presumptive goal for the society. “The pursuit of happiness” and “the common wealth” are positive goods, and oligarchs are winning at that (insofar as wealth can cause happiness, which seems to be the case).
There can be good oligarchs (who commit no major fraud while vigorously pursuing validly selfish private benefit), and bad oligarchs (who violate just laws and/or coherent morality as they accumulate enormous wealth)… but also, having outright oligarchs run an essential bureaucracy (whose internal procedures inherently require jurisprudentialintegrity in its day to day administration) would sort of obviously be insane.
Yay for good oligarchs! But boo for bad oligarchs! And boo to the idea of appointing or electing any oligarchs as judges or public benefit administrators or bureaucrats who are funded by taxes (and often empowered to investigate and prosecute criminals).
If asked to do evil, they should educate in a face saving way,… Broadly, they have a duty to correct the public, and elected officials, and anyone who is actually wrong… or at least they have a duty to not enthusiastically conform to the public’s stupid, and self-harming, and commercial-propaganda-based opinions
If asked to do evil, they should do evil. Because I don’t trust the judgment of bureaucrats to decide what is evil, and we’d be better off with them following what elected officials tell them to do and not deciding to become a shadow government that slow walks everything they don’t like. This is where you get the deep state from.
You yourself mentioned claiming that racism is a public health problem. But consider how “evil” goes with racism. Failure to do something about racism is evil—in fact to some people it’s one of the worst evils possible. Calling racism a public health problem is an example of bureaucrats seeing evil and deciding that they just have to fight the evil by any means necessary.
If a officer (serving as a trusted component in a coherent social machine serving an important telos) doesn’t resign when their deontics are violated, then why the fuck were they even trusted with such power in the first place? Someone has to be the grownup. You can’t have “nothing but idiots and children” if you want good things to happen, on purpose, at scale, with high efficiency. The worst possible outcome is for actively bad things to happen, on purpose, at scale, with high efficiency.
I could write a long response, about “conventional morality that runs on vibes and makes sense to consumers of governance” vs “post-conventional morality that runs on logic and is necessary for producers of governance” but the succinct response is: you left out the MOST IMPORTANT PART of the instructions, which was to resign if the early steps of Saying No To Evil don’t work.
Given the context here (you voted to 0 so far, and me prone to writing too much) I’ve DMed you with a few more words, that might be specifically helpful <3
The Department of Making It Hard to Approve Drugs making it hard to approve drugs because they, like a majority of citizens in this country, think it should be hard to approve drugs is a problem but not the same problem as corruption.
That’s not what I said.
Punishing companies for using explicitly legally available methods to give out drugs according to compassionate use is not the same thing as generally making it easy or hard to approve drugs.
The FDA did try to coerce companies not to do what congress and the president wanted companies to do by passing the compassionate use exception. That’s distinct from the general question of whether drugs should be hard or easy to approve. It’s not working with the mob, but it’s an agency intentionally working against the democratically legitimized institutions of congress and the presidency.
What’s seen in the US is not the same narrow issue of “there’s widespread corruption and bribery at existing government services”. But it’s an issue in the same broad class of “government services don’t seem to be doing what we want them to, and we have no clear way to fix that”.
Which is why the post-USSR approach of “slash and burn” might be applicable. Sometimes the only real way to shed inefficiency is to destroy an existing system and build it anew.
It’s something free market capitalism often does natively, by the way of competition. A well oiled, well regulated market can only tolerate this much corporate rot. But government services face no such pressure, and many governance tasks aren’t the kind that you can create a free market for.
“Slash and burn” is inherently a perilous approach, because destroying old systems pisses stakeholders off, the old systems might still provide value, building anew is expensive, and there is no guarantee that a new system will be more efficient. Which the post goes into. But if everything else fails?
I’m confused about how this relates to DOGE. Is there any credible evidence of widespread corruption in the US civil service? It seems like most of our government costs are above-the-board payments to old people and doctors, and the biggest problems with the agencies are taking their mandates too seriously. I’m all for shaking things up at the FDA, but they don’t seem to be accepting bribes or working with the mob.
I wrote this after reading the Cowen/Pahlka interview. Cowen says: Maybe the agencies should be just shut down and rebuilt by the next administration? Pahlka: That would be too much chaos. Cowen: So maybe do it in gradual way? Pahlka: We’ve tried, it does not work. And my reaction was: “Oh my, I know these discussions from the 90′s.”
It was a cool natural experiment: A bunch of countries tried reforming at the same time, used different approaches, got different outcomes. So maybe there’s something to learn there.
Or to take the FDA example: You want to do a shake-up. How exactly would you go about that? Organizations are already in equilibrium. If you shake them, they just return to the previous state. Is the only way to shut them down and rebuild them from scratch? Or is there a less destructive, gradual approach? Again, we may get some insights from previous reform attempts, even if the problems don’t match in 1:1 way.
Congress should repeal Kefauver-Harris so that “treatment X has not been proven efficacious by a wildly expensive high church effort at proof” stops being a valid reason for the FDA to ban something (the way it is (and has been since 1962) in the status quo).
The FDA’s ban on “treatments of unproven efficacy” has never been coherent, never helped people, and slowed medical innovation way way way down.
The FDA’s ban on “treatments of unproven safety” should be much much cheaper, and slowly scale up based on the size of the N who have tried a treatment, and it should only involve an attempt to measure the lack of safety, so that informed consent can be brought to bare in specific cases, by a trusted clinician, about how much danger is “worth it” in a specific case.
Chemotherapy, for example, is often brutal, and the side effects can be fatal… its just that this is a clinical cost worth clinically paying in some cases, for some cancers, with some prognoses. It isn’t “safe” it is just “probably safer than letting the cancer run to completion, and hopefully better than alternative treatments that the doctors even know about, contingent on the specific personalized diagnosis, by one or more doctors, regarding a specific tragic situation”.
For some diseases, nothing can save you from “doctor has low skill”. Medicine is intrinsically dangerous.
The FDA is a fig leaf on this… and it is a very very heavy fig leaf, that mostly only mitigates anxiety in exchange for OCD rituals, even while the form and cost of the rituals harm science and medicine and technology and “the production of more consumer surplus for patients (by getting them highly effective treatments at competitive prices based on an economic race to the marginal cost of providing the treatment)”.
The rent on health is too damn high. The FDA needs more judges, and tort lawyers of high integrity, and economists, and data scientists running statistical clearinghouses… not more molecular biologists.
This would be a huge change, and it would also probably work.
According to ChatGPT total salaries to doctors in the US are 385 billion per year. On the other total healthcare spending is 5 trillion. That suggests less than 10% of US healthcare spending is payments to doctors.
The US healthcare system has an amazing amount of middle men that take their cut. The money flows are sometimes pretty intransparent. While most of it is technically legal, it’s not above the board in every sense.
In which senses is it not transparent or not above the board?
Let’s say you are insured with your employer. The deal between the employer and the insurance company is facilitated by an insurance broker. That insurance broker gets paid a fee that’s sort of transparent to your employer but probably not to you.
That insurance broker however also gets paid some bonuses that are not disclosed to the employer. The insurance broker also gets threatened with losing access to some insurance companies if they don’t recommend the insurance company when the insurance company wants it.
The insurance broker is subject to a bunch of incentives that the employer does not know about as they are hidden from the employer.
Apart from the things that are hidden from the employer, the fact that the insurance broker takes their cut of the transaction is also intransparent to most people, which makes them think about healthcare money going to doctors and not insurance brokers.
Functionally, the payments from the insurance company to the brokers that are in addition to the fee that the broker gets for the transaction (which is disclosed to the employer) are essentially bribes.
Thanks! Interesting example.
I would guess that this specific example is less and less a problem each year, as people and companies buy more directly their insurance (and other things).
For brokers serving small employers (e.g. firms with under 50 employees) a commission rate of around 4% to 6% of premiums (so likely not including extra incentive payments) is typical (numbers again from ChatGPT). It’s less for bigger employers, but it’s real money in the system.
People and companies buying insurance directly is helpful.
You have pharmacy benefit managers that got recently quite unpopular with politicians, so there’s also progress, but the system is really big and complex and at every point someone has an interested to take their cut.
Generally you have a system where a lot of money is flowing. Both patients and doctors often don’t even now how much money is flowing for a simple healthcare service.
One interesting aspect: The government does not set the prices for individual services in medicare. They are instead set by the AMA which is an advocacy organization. So inter-AMA politics determine which services get reimbursed how much and I would expect that there’s also plenty of non-above the board actions going on there.
“Doctors” was too specific, but the largest category of spending is hospitals (30%) followed by “physicians and clinical care” (20%), and 56% of hospital spending goes to healthcare worker salaries (presumably an even larger amount goes to salaries for non-hospital workers).
Healthcare spending being somewhat opaque is a completely different problem than government agencies taking bribes and using violence though. The breakdowns for where this money goes exist if you care to look for it, and you can try to solve the problem but it turns out that “obvious waste” isn’t one of the line items. Healthcare would be cheaper if we had fewer doctors, nurses and support staff, or paid them less, but we don’t do that because the average person doesn’t think that’s a good idea (for better or for worse), not because nurses will murder us if we cut their salaries.
Compared to doctors in Germany, doctors in the US spend a lot more of their time dealing with billing issues. If you ask the average person about whether it’s a problem that US doctors spend so much time on billing issues instead of patient care, if they are a bit informed about how the system works, they will likely tell you that the would prefer that the system works in a way where doctors have to spend less time on billing issues.
After the first Trump administration passed a law allowing drugs without FDA approval being given out under compassionate care, the FDA didn’t like it. They communicated that in a way that got the drug companies not to give out drugs under compassionate care. I think you can call that fear of government violence.
I think there’s probably plenty of things that go on in healthcare setting because someone says: “This doesn’t really make sense, but if we don’t do it we get problems with government regulation. And of course a bunch of other agents like insurance companies or malpractice lawyers that add complexity.”
I think you’re still talking about something different from government workers taking bribes and working with the mob. The Department of Making It Hard to Approve Drugs making it hard to approve drugs because they, like a majority of citizens in this country, think it should be hard to approve drugs is a problem but not the same problem as corruption.
The public is too uneducated to know better. Even many in the FDA are too uneducated to know better because they are insufficiently interdisciplinary.
The question is: how should the handful of smart and good people react to this state of affairs?
I say: high level operatives within medical bureaucracies should understand the price theory of economics, the germ theory of disease, and have a working definition of jurisprudential integrity. If asked to do evil, they should educate in a face saving way, then disagree pointedly if that doesn’t work, then remonstrate, and, at length, they should resign and blow a whistle.
Broadly, they have a duty to correct the public, and elected officials, and anyone who is actually wrong… or at least they have a duty to not enthusiastically conform to the public’s stupid, and self-harming, and commercial-propaganda-based opinions in a totally blind and stupid way, and the opposite of their duty would involve going to work, later, for the mobsters, as political lobbyists for those mobsters.
Narrowly, if they weren’t just good bureaucrats but good medical bureaucrats, and they understood Koch’s Postulates and the real telos of public health systems, they would understand that Racism is not a disease with transmissible causative infectious agent that can be grown in a petrie dish and then physically put into a person to cause the person to “become Racist” somehow… and so they would never say things like “racism is a public health crisis”.
Regarding the correct name for the mobsters that BAD bureaucrats might eventually go to work for (until law enforcement properly cleans up a group of bad actors, investigating, prosecuting, and convicting some people people (who should generally get the presumption of innocence (at least by non-investigators, and non-DAs, prior to a procedurally correct conviction))) “a mobster” will often be called something like “the CEO of the City’s Sanitation Company who some allege has ties to organized crime” or some such. De facto.
Ideally, “oligarch” might be better than “mobster” since it intrinsically connotes venality (the pursuit of money for personal uses up to or past lines of propriety) and indicates the properness of “a general sense of suspicion by default” by normal people. Very few people are oligarchs, and oligarchs are weirdly powerful.
I think that a properly ordered society would contain some oligarchs, but only as one small part of a free society, with free markets, where the accumulation of personal wealth in hypothetically morally valid ways is a presumptive goal for the society. “The pursuit of happiness” and “the common wealth” are positive goods, and oligarchs are winning at that (insofar as wealth can cause happiness, which seems to be the case).
There can be good oligarchs (who commit no major fraud while vigorously pursuing validly selfish private benefit), and bad oligarchs (who violate just laws and/or coherent morality as they accumulate enormous wealth)… but also, having outright oligarchs run an essential bureaucracy (whose internal procedures inherently require jurisprudential integrity in its day to day administration) would sort of obviously be insane.
Yay for good oligarchs! But boo for bad oligarchs! And boo to the idea of appointing or electing any oligarchs as judges or public benefit administrators or bureaucrats who are funded by taxes (and often empowered to investigate and prosecute criminals).
If asked to do evil, they should do evil. Because I don’t trust the judgment of bureaucrats to decide what is evil, and we’d be better off with them following what elected officials tell them to do and not deciding to become a shadow government that slow walks everything they don’t like. This is where you get the deep state from.
You yourself mentioned claiming that racism is a public health problem. But consider how “evil” goes with racism. Failure to do something about racism is evil—in fact to some people it’s one of the worst evils possible. Calling racism a public health problem is an example of bureaucrats seeing evil and deciding that they just have to fight the evil by any means necessary.
If a officer (serving as a trusted component in a coherent social machine serving an important telos) doesn’t resign when their deontics are violated, then why the fuck were they even trusted with such power in the first place? Someone has to be the grownup. You can’t have “nothing but idiots and children” if you want good things to happen, on purpose, at scale, with high efficiency. The worst possible outcome is for actively bad things to happen, on purpose, at scale, with high efficiency.
I could write a long response, about “conventional morality that runs on vibes and makes sense to consumers of governance” vs “post-conventional morality that runs on logic and is necessary for producers of governance” but the succinct response is: you left out the MOST IMPORTANT PART of the instructions, which was to resign if the early steps of Saying No To Evil don’t work.
Given the context here (you voted to 0 so far, and me prone to writing too much) I’ve DMed you with a few more words, that might be specifically helpful <3
That’s not what I said.
Punishing companies for using explicitly legally available methods to give out drugs according to compassionate use is not the same thing as generally making it easy or hard to approve drugs.
The FDA did try to coerce companies not to do what congress and the president wanted companies to do by passing the compassionate use exception. That’s distinct from the general question of whether drugs should be hard or easy to approve. It’s not working with the mob, but it’s an agency intentionally working against the democratically legitimized institutions of congress and the presidency.
What’s seen in the US is not the same narrow issue of “there’s widespread corruption and bribery at existing government services”. But it’s an issue in the same broad class of “government services don’t seem to be doing what we want them to, and we have no clear way to fix that”.
Which is why the post-USSR approach of “slash and burn” might be applicable. Sometimes the only real way to shed inefficiency is to destroy an existing system and build it anew.
It’s something free market capitalism often does natively, by the way of competition. A well oiled, well regulated market can only tolerate this much corporate rot. But government services face no such pressure, and many governance tasks aren’t the kind that you can create a free market for.
“Slash and burn” is inherently a perilous approach, because destroying old systems pisses stakeholders off, the old systems might still provide value, building anew is expensive, and there is no guarantee that a new system will be more efficient. Which the post goes into. But if everything else fails?