Agree, I felt initial discomfort reading it because it goes against the grain of the simplistic technical style that is most of hacker news. Surprised it got to the front page.
Interesting article. Assumes a fair amount of background knowledge of the reader that may not be reasonable and definitely has a unique style.
It is interesting that many of the comments critique it for being meandering, lacking in utility. I think the author is talented enough to write it that way intentionally. Its oblique direction and far flung references help make the point. The reactions against this style made the argument more compelling.
> that same positivism was leading less to liberation than to disenchantment, smashing the sacred icons and reducing the world to what can be instrumentalized, commodified, and calculated
I understand the concerns and I am not sure I would allow myself to be recorded until I knew more.
However, I do think we are in a situation where everybody knows that healthcare costs need to come down that doctors and medical professionals are spread too thin, forced to see evermore patients in the same number of hours, and yet for every attempt to improve efficiency there is a “no, not that way“ response.
If I paid all my doctors $1200/hr and doubled how much time they spend with or on me, that'd still pale in comparison to healthcare expenditures attributed to me between actual insurance payments and actual money leaving my bank account. Doctors being spread too thin is very much a separate issue.
I definitely agree that medical professionals are spread too thin and automation seems like it would be a boon but, as the article points out, the introduction of automation likely won't translate to more doctor-patient time it'll translate to doctors seeing more patients.
The solution not only introduces a problem (decreased privacy) but could reinforce the existing problem it's trying to solve.
> it'll translate to doctors seeing more patients.
This is also a good thing. Even in supposedly developed parts of the world like San Francisco it can be difficult to find a PCP that is taking new patients.
Where healthcare is concerned, America is not what anyone considers "first world". Your healthcare system is more backward than most third world nations. I would rather leave the US than receive medical treatment there. I have never even considered trusting the US healthcare system. When I lived there I would rather fly home and get treated (in a third world country) than lose all my savings getting inadequate care in the US. I know people who have been through large and expensive treatment plans in the global south, who paid less for the complete treatment than Americans pay for the ambulance getting you to the hospital.
I don't think that's true at all. "Insured" doesn't mean just one thing. There are many different kinds of insurance, levels of plans, etc. Most insurance companies will do their best to deny claims or push more responsibility onto the patient.
My insurance is very good, but I see a therapist weekly and my insurance only covers about 40% of the cost. I'm fortunate that ~$500/mo isn't a problem for me, but many people in the US would find that impossible.
A few months ago I went to the ER for what turned out to be gallstones, and was still on the hook for $200 of that visit. And I took a Lyft the the hospital; I don't want to think about what my out-of-pocket cost had been if I'd needed an ambulance.
Last summer I hurt my hand in a bicycle accident, and went to PT once a week for 6 weeks. I had to pay a $35 co-pay for each visit; that's $210 for a single injury.
And this is with fairly good insurance. Many, many insured Americans just have so-so insurance. From what I hear of most healthcare systems in countries that do this right, most (if not all) of this stuff would have been completely free.
> If you're the latter, it can be mediocre to BRUTAL
Yup, and in a way that's an even worse indictment, that really puts us in worse-than-third-world territory.
Your healthcare system is more backward than most third world nations. I would rather leave the US than receive medical treatment there.
And yet the wealthiest people in the world, who can have the best healthcare anywhere they want on the planet, even with private doctors, routinely choose to be treated in Rochester, Minnesota; Boston, Massachusetts; Houston, Texas; Baltimore, Maryland; and Los Angeles, California.
The U.S. is by no means perfect, but there's a reason that there are entire medical facilities in the U.S. that cater exclusively to people from other countries. Just listen to local radio in Palm Springs and you'll hear commercials along the lines of "Tired of waiting, or simply can't get the medical care you need in Canada? Come to our hospital!"
Meanwhile, if I wanted to have my recent surgery in Canada, I'd have to wait almost a year for a slot to open up. Here I waited all of two weeks. And the newspaper headlines in the UK are full of horror stories of patients dying in hospital hallways while doctors are on strike because everything is so great.
> I do think we are in a situation where everybody knows that healthcare costs need to come down that doctors and medical professionals are spread too thin
The problem is over optimization AND lack of people. As soon as there's an excuse for less staff because we have "digital record keeping" we're going to have less money and even less staff.
Having in person or remote notetakers is a great entry level job to do before you become a doctor. It could be boring but at least the terms are familiar and you get to know the person you're working with.
It's not like healthcare is an impossible problem to solve that needs more tech, we just refuse to spend money on people and (inexplicably) cannot help but dump tons of money into tech.
> The problem is over optimization not lack of people or resources. As soon as there's an excuse for less staff because we have "digital record keeping" we're going to have less money and even less staff.
At least in my area, it seems like lack of people is a problem. Sometimes it's lack of people because the pay is too low, but more of it it's lack of people because the pool of qualified people is too small. And increasing pay increases healthcare costs, and healthcare costs are already very high. If digital tools allow the available staff to see more patients while delivering the same level of care (and without burning out the providers), then that means more capacity and less times people want to see a doctor, but can't. Similar arguments for same number of patients ans greater level of care. If it's more patients, but worse level of care, then it becomes tricky.
The lack of people is too low because the organization tasked with accrediting new doctors has a financial incentive to its current members to keep the pool of doctors low.
The problem is that (as addressed by the article), any efficiency wins end up pushing more patients on the provider. So if you used to have a 15-minute appointment, and five minutes of that were spent with the doctor writing down notes, with AI transcription, now you'll have a 10-minute appointment, and the doctor will be forced to see two more patients per hour.
Yes, and also almost all of these issues could be ascribed to all digital medical record-keeping. The fact that AI transcribed it matters relatively little.
One massive way to reduce healthcare costs is to remove caps from becoming a doctor; as long as you pass the tests and meet the requirements, why are we turning doctors away? So that existing doctors can be paid well above the market rate. There's a reason there's so many doctors in politics - it's very important for them to protect this business model.
Profit margins are capped by percentage. That creates the perverse intensive for insurance companies to pursue ever increasing costs in order to increase profits.
How do you know it's not the other way around? Give consent to incorporate another technology that will keep wages the same but allow them to treat more patients and extract more profit for the shareholders?
> for every attempt to improve efficiency there is a “no, not that way“ response
They've tried everything except "train and hire more doctors" and they're just all out of ideas aside from "erode patients rights and lower overall quality of care"
The economics of medical school cost, time, and capped residency spots (some would argue this is price-fixing with artificial scarcity) make it hard to just “make more doctors”. Combine this with a highly litigious society that always demands a full doctor (when for 90% of things an NP or PA would do) plus inverted population pyramid all exacerbate the problem.
We need more doctors now and it takes 12 years to make a doctor and by then the boomer cohorts aging and medical needs will peak.
Finally, even if we could do that, the top of the funnel candidate is substantially weaker with lower test scores and higher need for remedial classes. And for the good candidates, the ROI of medical school is not as good as it once was.
2. The point of insurance is they're supposed to pay for shit
3. You figure out how to get them to pay for shit, sign an agreement that removes me of any patient responsibility of the balance bill, and assure me in writing that I will owe $0 no matter what
Very small workforce (~3k) for a fortune 500, much higher than consulting margins. One of if not the single largest AWS customer. Only software company that is also a defense prime. Also their software is has some rough edges but is very powerful. Nobody else really offers what they do.
Oracle was started to build databases for the Central Intelligence Agency, gets ~90% of its revenue from services, is a huge GSA/DISA contractor, and earns about 16x what Palantir does. I've heard people with direct ties to Palantir describe it as "Oracle but with the Web 2.0 stack".
I don't doubt they're more efficient than Oracle; you'd kind of have to be, right?
Look at revenue per employee. Revenue growth year over year. Margin etc. then just look into any command center, 90% of screens are displaying Palantir software.
This is wild. A mistake of this magnitude should result in several positions becoming vacant and many politicians being ineligible for any future offices.
If a government can’t budget accurately everything else they do is likely even less competent. Every number and statistic they report should be treated with suspicion. Without clear data who is to say they are doing anything helpful at all?
The errors were all within the CalPERS pension fund. The pensions are guaranteed by the state, so the fund is notorious for a complete lack of fiduciary duty, and these types of errors track with the general quality of their operation.
Alternatively, since we're spit balling, the administrators and/or accounting staff decided to strategically error on the side of a shortfall because its politically impossible to get the state to fully fund the pension obligations or to stop effectively raiding it.
Recall that funds like this are one of the largest owners of the hedge funds that drive up property values for American homes via their reckless speculation. The state (well states really -- CA is not alone) desperately needs to make more than market returns to guarantee their unfunded pension liabilities.
People understand that everyone makes mistakes and firing anyone who does only leads to people prioritizing hiding their mistakes vs. fixing them.
It’s helpful, whenever you find yourself saying something like, “the only real explanation to me”, to think of a good faith version before assuming that the most cynical take is reality.
I think there are mistakes and then there are mistakes.
There is a point where the postmortem needs to stop being blameless.
Getting things like this wrong is an existential risk to a important institution. We can’t be genuinely concerned about lost faith in institutions and also not hold them to the highest levels of accountability.
We developed chronic overspending habits when interest rates were historically low. This made servicing the debt cheap and deficit spending reasonable. Why wouldn’t the government borrow at 0.14% (!!!) with GDP growth at say 3-4%.
Now the math doesn’t work with a federal fund rate of 4-5%. And now as our debt rolls over it gets refinanced at the higher rates. Debt servicing is roughly 20% of the government budget and will soon be 25-35% in ~10 years assuming we don’t further accelerate deficit spending (which seems unlikely).
US govt needs to cut dramatically to avoid this and the otherwise likely “solution” otherwise is inflation to make the debt effectively less expensive which also raises interest rates.
We can’t tax our way out of this. Only 60% of US households earn enough to pay federal income tax. The top 1% of earners already pay roughly half of all tax revenue, top 10% is roughly 75%. Furthermore, there is profligate waste in government, inefficiency, no matter where the taxes came from even if we could materialize them.
The government needs to shrink dramatically. This type of change is best done gradually but immediately to avoid later shocks (eg: Medicare suddenly disappears)
Most (but not all) other developed countries have both a larger government and a smaller deficit per capita. A smaller government is not the only solution.
They are almost all also going bankrupt. Also, those governments may be efficient but the US is not. You do not get a more efficient government by making it larger.
Debt-to-GDP of Germany is around 63%, that is notably less bankrupt than the US at 120% which is approaching Italy (that went from 154% in 2020 to around 135% now).
According to the tables in that source, the top 0.001% pay about 25% income tax, which of course is income after they've had their accountants smooth over everything. The highest income tax percentage seems to be at the top 1% level. I assume this is due to higher income earners having better/more aggressive tax accountants.
If the people with 90% of the income pay less than 90% of the total income taxes, something is wrong. Every lower income should be paying less, as a percentage of their income.
I think we can debate on how progressive (in terms of as you earn more you pay more) the US tax brackets should be. They are already fairly progressive relative to peer nations.
However, I am skeptical that higher taxes or just taxing the rich or high earners more will solve the deficit or government efficiency issues.
Also I disagree with 90% of income should pay 90% of taxes. People who are better capital allocators than the government should be incentivized to allocate over paying taxes.
> Also I disagree with 90% of income should pay 90% of taxes. People who are better capital allocators than the government should be incentivized to allocate over paying taxes.
We've spent the past 50 years lowering the taxes on those who have the most income/wealth with only negative outcomes to show for it.
I think the mistake you're making is assuming that those best at accumulating capital are also the best at allocating it. If they were, I expect we'd see a lot more investment into new technologies and markets rather than the large increase in rent-seeking we have seen instead.
That’s not the point the point is to illustrate that right now for every tax payer 20% of every dollar collected is spent on interest. Not even on the principal just on the interest expense.
This is such a Boomer way of looking at this. First of all, hardly anyone pays that much. Secondly, the more correct way of viewing such a situation is that you make a shitload of money.
2. Do you think an ageist ad hominem improves your argument?
3. What even is your argument? That in this contrived hypothetical the person in question is making a “shitload” and that somehow invalidates that 20% of EVERY tax dollar collected is used to just pay interest on debt (not even principal, just interest)
> The top 1% of earners take in 22% of total income and pay 40% of all federal income taxes.
How misleading. Income here means AGI, i.e. taxable income as defined by the IRS. That excludes unrealized capital gains, loans against said unrealized capital gains, etc. For example, Elon Musk’s AGI was $0 in 2018 despite a massive increase in net worth. Wouldn’t call that his fair share.
> Myth No. 2: We’ll fix the budget deficit by taxing the rich
> We simply cannot. The collective net worth of every American billionaire is estimated at somewhere around $8 trillion. The projected federal deficit over the next decade alone approaches $25 trillion. Even a one-time total confiscation of every billionaire’s wealth wouldn’t come close, and you only get to do it once.
Hilarious argument. Suddenly it’s billionaires instead of the previously mentioned top 1%. Their estimated net worth is more like 40 to 50 trillion. Not to mention how much that wealth is expected grow in the next 10 years.
The entire article is similarly underhanded and clearly meant to mislead. Or perhaps to reinforce the views of readers who already agreed and weren’t going to think critically anyways. Doesn’t take a genius to guess who paid for it.
But they are part of your net worth. If somebody who becomes richer every year, passively, has "no income", then the definition of income does not match people's intuition about what constitutes fair targets for taxation.
There is a good case to be made to tax wealth rather than income, which comes closer to people's intuition about what's fair.
>Only 60% of US households earn enough to pay federal income tax.
That's the problem. It's not a spending problem per se, but the market's misallocation of resources. Too many resources are concentrated in too few hands.
That's not to say we should abandon capitalism, but rather we should change the incentives to support higher incomes more broadly, as we did in the 1950s and 1960s. It's not a coincidence that deficit spending/public debt skyrocketed when we cut the top tax brackets. That changed the incentives from encouraging paying good wages and investing in business growth to hoarding capital and the financialization of everything.
Feel free to disagree, but the historical numbers support that.
tl;dr: change the incentives to broaden the distribution of resources across the economy, strengthening the economy (70% of which is consumer spending) and increasing, in a broad-based way, tax revenues.
I am doubtful here (but eager to see data that says otherwise)
- The US median per capita income is quite high (top 2 or 3 globally IIRC). In light of that and the stat that the bottom 40% don’t pay federal income tax makes me think the tax brackets are already fairly progressive vs thinking the lower 40% is especially low earning.
- Additionally income inequality has been decreasing in recent years with lower percentile income earners increases outpacing even the relatively high inflation.
- I agree we should revert back to some policies.
- I don’t think there is much hoarding of capital, most high earners invest heavily.
>We developed chronic overspending habits when interest rates were historically low
Weird, they were historically low because the money printers went brr. So the "We" you're talking about is both Republicans and Democrats, and not much else.
So basically, the interest rate is meaningless, so everything that follows is probably just as meanginless.
>The government needs to shrink
Just because the government makes bad choices doesnt mean whatever fills the vacuum with make good choices.
Yes, both parties have objectively failed their mandate to look after the long-term interest of the American people and instead focused on short-term wasteful policies focused on their own party goals.
Governments that consistently make bad choices eventually die one way or the other.
I think Detroit is well past its “bottom”. I have visited there every year (briefly) for the past 14yrs and it has some really vibrant and cool aspects now.
My anecdotal evidence is backed up by Detroit Metro real estate outpacing the national average significantly over the past 10 years. The people and culture are great too.
Also if America is ever going to greatly increase manufacturing, Detroit (and the rust belt overall) will be a big player because the navigable waterways have not moved and it is still 10 times cheaper to move things by water than land.
Agreed. My family's from Detroit. Like so many others, they left in the mid-70s because Detroit had become unfathomably bad - the job market was shit, crime and corruption was out of control, and there was no hope for things turning around. In the mid-80s, there were countless jokes about Detroit, like this: https://www.youtube.com/shorts/iFxyAA0l0nU
Also, Singapore seems to have conclusively won the war on drugs. I would not mind those policies in San Francisco.
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