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Comment by newswriter99 | Hacker News Reader

"Eban advises consumers to research who manufactures their generics and look up any problems that regulators have found out about them."

The whole point of government agencies like the FDA is to perform inspections that consumers lack the ability, time or resources to do on their own.

I get that we're in a complicated interconnected world and you've got to look out for yourself, but that's me. There's about 300 million Americans out there and a good portion of them are busy raising kids and busting their ass working and CAN'T spend hours investigating their prescription meds and inspecting their food.

Also, it's politically incorrect to say this, but a smaller number of consumers aren't intelligent enough to even begin taking care of themselves. They need the FDA more than anyone.

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That strikes me as useful as the "security expert" who shows up on TV and tells people to "only download apps you trust".

Who really knows anything about ANY of the apps they download? Nobody has the required knowledge / time to make that determination with any amount of success.

Anyway the FDA situation reminds me of a libertarian blogger who a while back wrote a great blog that went something like "Guys, libertarians aren't supposed to hate the FDA / EPA!"

His point being that libertarians are supposed to get riled up when government gets involved in protecting people from decisions that they should make on their own, such as preventing people from jumping off anything because jumping off a cliff is bad (overly simple example but that's the idea). Situations like telling good medicine from bad where you need huge amounts of testing and industry knowledge, or having someone dump toxic waste next to your house that you can't tell ... you're permanently hurt by the time you figure it out is something libertarians should want a government involved in.

Life is complex, we can't figure everything out ourselves.

Sibling comments have given examples here, but the one-sentence summary would be that libertarians are in general opposed to licensure, and believe that a free market with certification (which would be provided by trusted private entities) is superior.

In more detail, the argument goes something like "any time you require a license, you are necessarily reducing the choices available in the free market, and more choices are good." See e.g. Milton Friedman, "Capitalism and Freedom".

I think the purist libertarian position on the FDA would be that it should be abolished and replaced with a private certification agency. But if you _must_ fund it with government money, it should be a certification body and not a licensing body.

Most of the libertarians I know are fine with the FDA doing research and providing information, maybe even requiring specific and true labeling for certain publicly sold goods. What they do not like is the FDA banning the sale of drugs or foods that they do not approve of, even with proper and true labeling. Because that is is just another attempt to take decisions away from people.

I would add that its intensely slow process is the epitome of the harmful lumbering bureaucracy that libertarians react strongly against. Factory inspections are understandable, but the approval process takes so much time and effort it's no wonder generics cost far more than they should. The FDA has the power to move more quickly, but they have no incentive to do so

Looking at the current "Kill all regulations" frenzy gripping the US I'd wager that they're brutally underfunded.

Essentially the same problem that turned the FAA into Boeing's lapdog.

Yeah I think that is understandable, it's not all or nothing with the FDA, you certainly can approve of some aspects and be libertarian, and not approve of others and be libertarian and it all still makes sense philosophically.

There's a free-market answer to the FDA problem, I don't think any real libertarian would argue otherwise (note: I'm not a libertarian).

The solution is having a brand, and building that brand based on trust. Additionally, 3rd parties you subscribe to could verify the claims of brands and their integrity.

This is similar to things like Fair Trade [1] certifications, or Kosher certifications.

I often buy brand-name drugs OTC for QA purposes. I know that for the most part, Tylenol is going to contain 500mg of the primary ingredient when I buy it. Those portions are likely to be of good purity and uniform size. The off brand, might have more or less, of similar or dissimilar quality. I trust that US-based business for the most part actually care about their customers. It's a web of trust. Do I trust non-US business with manufacturing operations overseas? Not really when it comes to medication, no.

1: https://www.fairtradecertified.org/

> The solution is having a brand, and building that brand based on trust.

You mean like Boeing's 737 MAX8 aircraft? Or Purdue pharma's Oxycotin (aka: that opioid that Purdue Pharma claimed was non-addicting, except it kick-started the entire opioid crisis because spoiler alert: its opium-based and therefore very very addicting?)

1. Big brands make mistakes.

2. Consumers don't know the brands: do you know whether or not your drugs are Purdue Pharma or not?

3. Brands are sold. The original company who made a brand may have cared very much about it. But 10 years or 20 years later, the brand may be owned by entirely new people. Either everyone has retired / moved on, so the company is simply consisting of new people... or maybe the brand was chopped-up and sold to 3 or 4 different companies. Quick: who owns Epipen right now? (That drug brand has been passed around at least 3 times in the past decade)

All of these things go into factoring your individual trust level for a brand.

Do you consider gmail.com as a brand to be more trustworthy than 'totallynothackers-email.com' for hosting your email? Of course you do.

In the case of medicine (or anything else that can kill you for that matter), the brand trust has been (mostly) replaced by regulator trust, or store-based trust. EG, CVS is probably going to source from reputable suppliers. You can also fill prescriptions on sketchymeds.com if you choose, especially if you're outside the US.

Brands being sold and bought are an input to the brand-trust equation. It might mean 3rd parties are the more trusted source of information in a given segment than the brand name itself (of course, you could say the same thing about 3rd parties, ad infinitum).

But even doctors, whose job is literally to keep track of these drug thingies, have gotten things wrong. See the opioid crisis + Oxycontin.

What hope do laypeople have when even the specialists with over 10-years of high-class training get these things wrong on a nationwide level?

Before the Oxycotin news, I thought Purdue was just "that chicken company" at the grocery store (Yeah, I'm ignorant. But that's the fact, at least I know I'm ignorant). I don't have the time to figure out which brand-names to trust or what not to trust.

My doctor gave me a "Tomed mandibular advancement device". I don't even know what a mandibular is. My only hope is to trust the doctor and hope it fixes my problem. I've never heard of "Tomed" before.

How the hell am I, as a customer, supposed to build a relationship with a brand, when I only buy one or two of their products per lifetime? How am I supposed to do market-research, and figure who their competitors are? If I buy a competing product, what assurances do I have that it works as well as the one my doctor gave me?

Look, I trust that the engineers are trying to build devices that improve my life. I trust my doctor is trying to improve my life. I trust my insurance company is trying to save (themselves and me) the most money. But I recognize that there are systemic flaws in the US Healthcare system, and something isn't exactly working right.

In any case, the "brand" system being proposed in this topic is clearly not a solution. Not only is it NOT working right now, I have my doubts that it would ever work under our current system. I'm just too ignorant about the companies who make medical devices and drugs, and I've got the freaking internet in my pocket to research things instantly. That's not the problem, it takes more than 5 minutes, or even an hour, of googling to review peer-reviewed journals and figure out which devices, techniques, or drugs are effective.

Ultimately, I'm going to trust my doctor and insurance company. Its all I got. I'm not going to be trusting my life to brands of which I've never used before. Its incredibly rare for me to buy any form of medical device in general, I simply don't have a relationship to any medical brand what so ever.

> Ultimately, I'm going to trust my doctor and insurance company.

You're already benefiting from the brand-trust type of system. You trust your insurance company (currently because the market is regulated, but if the market wasn't as regulated, you'd probably be choosier about who you shop with). Your insurance company pays the most for in-network doctors. Doctors probably need malpractice insurance and not be complete frauds to be in an insurance network.

I think the airline industry is a good example in the US. I could often save money by going with a smaller carrier, but I choose to spend a little more to go with the bigger carriers, primarily because I know if there are any problems, they're more likely to have extra flights to get me where I'm going.

Another good example is HVAC companies. You can pay someone working out of a truck to install a new A/C system for slightly less than the name-brand (factory authorized dealer) in your area. You're probably going to get what you pay for. Companies want to stand by their name. This is a once-in-a-while transaction that can cost multiples of 10's of 1000's of dollars (depending on size/complexity of the system, obviously).

In my case: the Tomed MAD cost me $1000.

The actual device is worth 150 EUR from Germany (where Tomed is located). The US-distributer sells it for $500. Somehow, the markup got all the way up to $1000 by the time it got to me.

Clearly, something, somewhere, has gone wrong in the system. This is a 150 EUR mouthguard that is being sold to me for $1000. As in, what I've literally paid for. Why?

> Clearly, something, somewhere, has gone wrong in the system. This is a 150 EUR mouthguard that is being sold to me for $1000. As in, what I've literally paid for. Why?

There are multiple factors, but a motivator is that US regulators are under pressure from both sides to adopt rules that make healthcare consumers less price sensitive.

On the one hand, the supplier is quite happy to be collecting $1000 rather than $150.

On the other hand, people don't like paying $1000, so they go to the government and ask them to do something about it. The government could then push for more price transparency and make sure that existing regulations aren't impairing competition and driving up prices, but that's exactly the opposite of what the people making $1000 instead of $150 want.

The alternative is to get somebody else to pay for it in enough cases that the remaining cases (i.e. yours) don't have enough political power to actually fix it. So they cause the money to come from insurance premiums or taxpayers in most cases, whose costs are in turn laundered through employer-provided health insurance or general tax revenues.

But the seller can't charge $150 retail and still get $1000 from insurance, so they set high prices and anyone without [sufficient] insurance coverage is relegated to either overpaying or using whatever kind of need-based assistance if any that the seller provides, or figuring out a way to order from overseas.

This type of regulatory corruption is obviously not a cost efficient way to provide healthcare.

And it's much the same reason branding and private certifications are ineffective. If regulators get rid of most of the charlatans then consumers become willing to trust that anything approved by regulators is safe. Then when it isn't (as with the MAX8), there is a single point of failure, both because people are then less wary of things that are potentially dangerous, and because independent private infrastructure to verify quality atrophies when government embeds their own safety standards into law, even if they do a mediocre job of it.

> ...independent private infrastructure to verify quality atrophies when government embeds their own safety standards into law, even if they do a mediocre job of it.

Pretty much the story for every aspect of government.

You've been making great arguments. I appreciate them. However, why not order the device from Germany yourself? Are there stringent regulations in place that prevent customers from purchasing across state or even country lines?

First, there's no reason for me to buy the device. I already own one (the one my doctor gave me), and I have no need for a 2nd (yet).

So... why did I buy it from my doctor at first? Well, because the doctor said I needed one. I setup an appointment with the nurse, who then gave me the device. A week later, I got a bill for $1000. Shocked at the price of the device, I ended up doing research. $500 is the cheapest I could find it in the USA, and if I include doctor fees + nurse fees, it is "reasonable" that they would mark it up a few hundred dollars above that.

In any case, I already "bought" the device before I realized. So I don't think I really have any choice aside from paying the bill.

I'll try to buy it straight from Germany in the future. But I didn't even know the name of the device until after I got it from the nurse.

I'm kinda new to this whole doctor / taking care of my health thing. But I'm just sharing my experience with everyone, so maybe other people can learn from my mistakes.

My general presumption was that my insurance company would be improving the cost-efficacy of the overall system. Apparently not however. Now, its just a $1000, and now I'm over my yearly deductible, so I've basically got free health-care for the rest of the year because of this. (So I don't consider this a big financial mistake, even if it cost $1000. Its more proof that the insurance company is slacking in its job of efficiently pricing these medical devices I'm using...)

Yeah, there's a multitude of issues with the health insurance-scam system in the US. It's easy to get swindled in the health care industry.

Brand-trust relationship dynamics don't say much about how things should be priced, but it does imply well-known and trusted brands will likely command a premium.

You can be sure Gmail is harvesting your mails for tracking or profiling purpose while you still have to demonstrate totallynohacker-email do that.

One of my email and cloud storage provider is Zaclys, a little french non-profit organisation which host owncloud/nextcloud instance and an email service for 10€/year...

I can't be sure Zaclys is not harvesting my emails, but the fact I pay them for that service reassure me about their intention. In other hand I know for sure Gmail is not trustworthy regarding my privacy.

An even better example is UL (Underwriters Laboratories), which directly tests products for safety.

I'm not sure that works if building trust requires you to try it and .. hope for the best.

Consider that the alternative, is expensive drugs that only the ultra wealthy can afford.

What is better? A situation where the poor sometimes get ineffective drugs, or a situation where the poor get no drugs?

If you picked G.) Other. You don't understand how the world works. It's the "cheap, fast, good", you picked 3 instead of 2.

Edit, would love to hear solutions.

At least in the US it appears the costs of drugs is not tied to any real market forces / competition type forces, and I don't think when drug prices were lower the FDA was doing less testing.

Pick two, cheap and good. If the FDA is correctly doing their job, it should take some time to process if the generic drugs are effective. And for non-generic drugs, the R&D involved specifies that it doesn't come fast.

I’m sorry , why are you presenting these as if they are the only options? And did you just defer to a common saying to make an assertion about how the world works instead of making a genuine argument?

That is the genuine argument.

Not Everything is cheap.

Did you want a third option where old people get medicine, but young people pay higher taxes?

Pick your solution, someone loses.

I would actually take it a step further.

I’ve done my research and I’ve decided that drug x my doctor recommended is possibly right for me. There should be absolutely no more research required.

“The generic is the same thing, just cheaper” is taken as gospel. If it turns out that’s not the case... that’s it, full stop.

I’m all for a lack of regulation, but once the FDA says it’s clear for anyone to make it they still have to check to make sure that’s what they’re making.

Edit: and this is, of course, assuming that any of this is true.

Also, good luck finding out what the enteric coating of the particular generic is made of.

Also, it's politically incorrect to say this...

That is interesting. Usually when people say this, it's from the opposite perspective. I don't often see people casting the idea that there are people who do need extra help as "politically incorrect"; I'd guess the particular political stance that doesn't like this would be a strong individualist, strong personal responsibility, small government stance.

Well, saying "some people are stupid" is definitely politically incorrect (even though factually correct - as happens in most cases where PC is involved). "Some people might need help" is perfectly safe though.

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