Category: Law
How to get me to side with the antitrust authorities
But “sustainable fashion” is a contradiction, the DealBook newsletter reports. Being “green” in fashion would mean designers and retailers would produce less — and yet companies that band together to advance such goals may run into trouble with antitrust regulators.
In June, Reuters reported that a series of raids by E.U. antitrust authorities on fashion houses was connected to companies’ discussions of limiting sales for sustainability. The European Commission has not named the companies involved or commented further on the purpose of the raids.
“There are emerging tensions between E.S.G. and antitrust,” said William Kovacic, a former Federal Trade Commission chairman, referring to environmental, social and governance goals.
Here is more from the NYT, via the excellent Kevin Lewis.
The “Little Scandinavia” Prison Project
The Scandinavian Prison Project…seeks to empirically assess what happens when certain practices and principles from Scandinavian corrections are implemented in an American prison setting. The project focuses on an ongoing collaboration between the Pennsylvania Department of Corrections (PA DOC), the Norwegian Correctional Service (Kriminalomsorgen), the Swedish Prison and Probation Service (Krimnalvården), and the Danish Prison and Probation Service (Kriminalforsorgen).
…The “Little Scandinavia” unit differs from the regular conditions of confinement at SCI Chester in many important respects. With single cells, custom furniture, a communal kitchen, redesigned common areas, and an outdoor green space, the unit looks unlike any other. Moreover, the officers on the project have, in addition to travelling to Scandinavia to work alongside peer mentors, received training in conflict resolution, suicide prevention and other relevant skills. The uniquely low ratio of trained staff to incarcerated men is intended to facilitate positive interactions and encourage meaningful communication between the people living and working on the unit.
…Importantly, we chose to use a lottery as opposed to the more common (and to some more intuitive) approach of only allowing the most motivated or best-behaved incarcerated people to move to the unit for two main reasons. First, from an ethical perspective, we believe it is more fair and transparent to the incarcerated men to allow all—irrespective of their past behavior and current standing with staff or management—an opportunity to take part in new, potentially beneficial programs in the prison if they wish to do so. Second, using a lottery means that we can meaningfully compare the group of men housed at “Little Scandinavia” to those in the general population. Having two groups that are as similar as possible—with the exception of their conditions of confinement—is important when seeking to develop evidence on the direct impact of the unit on both in-prison and out-prison outcomes, including recidivism and other measures of community reintegration. The research team will also focus our efforts in the months and years to come on following the staff who work on the unit. In particular, we are interested in learning more about how the changing working environment impacts their stress levels, motivation, and professional identities.
I am very interested in the results of this experiment. Although people say that America is different, I think less brutal prisons and more work on reintegration can work here in principle. One issue is that I can see the experiment working both better and worse as an island in a sea of American prisons as opposed to in full equilibrium.
Kudos to Arnold Ventures for being one of the supporters of the research.
The photo isn’t from the Ikea catalogue but a room in a high-security Norwegian prison.
Hat tip: Matt Bruenig. Photo Credit.
*The Rise and Fall of the EAST*
The author is Yasheng Huang of MIT and the subtitle is Examination, Autocracy, Stability, and Technology in Chinese History and Today. Forthcoming from Yale University Press in 2023. Excerpt:
For many years, I struggled to come up with a coherent explanation for the power, the reach, and the policy discretion of the Chinese state. There is coercion, ideological indoctrination, and probably a fair amount of societal consent as well.
Keju [the civil service exam system] had a deep penetration both cross-sectionally in society and across time in history. It was all encompassing, laying claims to time, efforts and cognitive investments of a significant swath of Chinese population. It was incubatory of values, norms, and cognitions, therefore impacting ideology and epistemology of Chinese minds. It was a state institution designed to augment the power and the capabilities of the state. Directly, the state monopolized the very best human capital; indirectly, the state deprived society access to talent and preempted organized religion, commerce, and intelligentsia. The Chinese state in history and today is an imprinted version of this Keju system.
Chinese state is strong because it reigns without a society.
Among the other interesting features of this book, including many, are:
There is a very useful discussion of Sui Wendi, the man who reunified China (and is barely known in the West).
Just how much the exam system expanded in the 17th century, to support a larger and growing Chinese state.
Why Chinese bureaucrats in the provinces tend to be generalists and the ministerial officials tend to be specialists.
Oliver Williamson is applied and cited throughout.
“A state without society is a vertically integrated organization…Keju’s powerful platform effect crowded and stymied alternative mobility channels…the Keju was an anti-mobility mobility channel.”
“In the 1890s, China’s population literacy was only 18 percent, way below 95 percent of England and the Netherlands.”
Exam competition takes up so much of individual mind space. Furthermore the competition atomizes society and makes it harder to form the kinds of collective movements that might lead to democracy.
The author sees the 1980s as the truly revolutionary time in Chinese history.
“Throughout Chinese history very few emperors were toppled by their generals or senior functionaries, a sharp contrast with the Roman Empire.”
I could say much more. This is by far the best book on Chinese bureaucracy I have read, and probably one of the best books on China period. I am sure many of the claims will be contested, but the author tries in a very serious way to be explanatory and to actually answer the questions about China you care about. So few books even attempt that!
Addendum: Note that the author also wrote Capitalism with Chinese Characteristics, another of my favorite books about China.
Firearms and Lynching
I love this paper by Mike Makowsky and Patrick Warren because it pokes so many bears. Makowsky and Warren find that greater access to firearms in the Black community reduced the rate of lynching in the Jim Crow South.
We assess firearms as a means of Black self-defense in the Jim Crow South. We infer firearm access by race and place by measuring the fraction of suicides committed with a firearm. Corroborating anecdotal accounts and historical claims, state bans on pistols and increases in White law enforcement personnel served as mechanisms to disarm the Black community, while having no comparable effect on White firearms. The interaction of these mechanisms with changing national market prices for firearms provides us with a credible identification strategy for Black firearm access. Rates of Black lynching decreased with greater Black firearm access.
Lots of black civil rights leaders were heavily armed but this is rarely mentioned let alone emphasized.
The Return of Privateering?
TexasSignal: Rep. Lance Gooden, a Republican who represents Texas’ 5th District, has introduced legislation that would allow U.S. citizens to seize the yachts, jets, and other property belonging to Russian oligarchs who have been sanctioned in response to the invasion of Ukraine. In other words, privateering.
…In the age of sail, it was common for nations to issue letters of marque licensing private citizens to raid the shipping of enemy nations. The practice died down in the 19th Century with the Paris Declaration of 1856 outlawing privateers. However, the United States never signed the Paris Declaration, and Article I of the Constitution gives Congress the power to issue letters of marque.
Gooden’s bill would require President Biden to issue letters of marque to seize yachts and other assets belonging to sanctioned Russian citizens. Gooden’s office even says that letters of marque could be issued to hackers to go after Russia in cyberspace.
There are three questions. First, should some Russian citizens be sanctioned? Second, should assets belonging to sanctioned Russian citizens be seized? Third, should privateers be able to do the seizing under a legal regime? There is a lot of room for debate on the first two questions but oddly these questions aren’t debated. Sanctions of this kind are common and broadly regarded as legitimate although likely overused in my view. The latter question arouses the most debate but is to me the easiest to answer. Sure, why not? Privateering worked well in the wars of the 19th century and we could likely have saved trillions by using bounties in the war in Afghanistan.
Here’s my paper on privateering and my story about the time I went bounty hunting in Baltimore.
Public policies as instruction
That is the topic of my latest Bloomberg column, here is one excerpt:
Minimum-wage hikes also send the wrong message to voters. Yes, there is literature suggesting that such increases destroy far fewer jobs than previously thought, and may have considerable ancillary benefits, such as preventing suicides. Still, a minimum wage is a kind of price control, and most price controls are bad. Voters may not realize the subtle ways in which minimum-wage hikes are different (and better) from most price controls. Instead, they get the message that the path to higher living standards is through government fiat, rather than better productivity.
If you think that far-fetched, consider the initiative passed by the California Senate this week. The bill would create a government panel to set wages and workplace standards for all fast-food workers in the state, and labor-union backers hope the plan will spread nationally. That may or may not happen, but those are precisely the paths that are opened up by minimum-wage advocacy. Many people hear a bigger and more ambitious message than the one the speaker wishes to send.
So what messages, in the broadest terms, should policies convey? I would like to see increased respect for cosmopolitanism, tolerance, science, just laws, dynamic markets, free speech and the importance of ongoing productivity gains. Obviously any person’s list will depend on his or her values, but for me the educational purposes are more than just a secondary factor. When it comes to prioritizing reforms, the focus should be on those that will “give people the right idea,” so to speak.
The mere fact that you are uncertain about such effects does not mean you can or should ignore them. They are there, whether you like it or not.
Water problems in Jackson, Mississippi
I am now reading quite a few analyses of the problem, and so few mention price! Even when written by economists. I find this article somewhat useful:
“We are a city with very high levels of poverty, and it’s difficult for us to raise the rates enough to do large scale replacement type projects and not make it unaffordable to live in the city of Jackson,” said former city councilman Melvin Priester Jr.
Yet the cost of Jackson’s poor quality water is still passed on to families who don’t trust the tap and purchase bottled water — which can cost a family of four $50-$100 a month — to drink instead.
The city raised water rates in 2013, but the Siemens deal penned the same year came with an onslaught of problems, including the installation of faulty water meters and meters that measured water in gallons instead of the correct cubic feet. This made any benefits of the rate increase virtually impossible to see.
The results have been nonsensical. Over the past several years, the city has mailed exorbitant bills to some customers and none to others. Sometimes, the charges weren’t based on how much water a household used and other times, city officials advised residents to “pay what they think they owe.” Past officials said the city lacked the manpower and expertise in the billing department to manually rectify the account issues with any speed.
In trying to protect people during the persistent billing blunders, the city has at times instituted no-shutoff policies, which demonstrate compassion but haven’t helped to compel payment.
Today, more than 8,000 customers, or nearly one-sixth of the city’s customer base, still aren’t receiving bills. Nearly 16,000 customers owe more than $100 or are more than 90 days past due, a city spokesperson told Mississippi Today. Jackson water customers owe a total of $90.3 million.
As a result, the city continues to miss out on tens of millions of water revenues. In 2016, when officials first uncovered the issue, the city’s actual water sewer collections during the previous year was a startling 32% less than projected — a roughly $26 million shortfall.
And most generally:
“The nature of local politics is that city governments will tend to neglect utilities until they break because they’re literally buried,” he said. “One of the things that is a perennial challenge for governments that operate water systems is that the quality of the water system is very hard for people to observe. But the price is very easy for them to observe.”
From WSJ here is some important background information:
Unlike bridges, roads and subway lines, clean drinking water isn’t primarily funded by taxes. More than 90% of the average utility’s revenues come directly from constituents’ water bills.
In other words, the price is too low, and government failure is the reason why. A higher price is no fun for a relatively poor set of Jackson buyers, but the city’s per capita income is 22k or so, and plenty of countries in that income range have satisfactory water systems where you can shower without closing your mouth. You just have to get the institutions and incentives right. It is remarkable to me how few people in the public sphere are making theses relatively straightforward points.
Trade Adjustment Assistance might be going away
The program that Mr. Ogg looked to for help, known as Trade Adjustment Assistance, has for the past 60 years been America’s main antidote to the pressures that globalization has unleashed on its workers. [TC’s aside: this first sentence is quite false.] More than five million workers have participated in the program.
But a lack of congressional funding has put the program in jeopardy: Trade assistance was officially terminated on July 1, though it continues to temporarily serve current enrollees. Unless Congress approves new money for the $700 million program, it will cease to exist entirely.
And:
Some academic research has found benefits for those who enrolled in the program. Workers gave up about $10,000 in income while training, but 10 years later they had about $50,000 higher cumulative earnings than those who did not retrain, according to research from 2018 by Benjamin G. Hyman, an economist at the Federal Reserve Bank of New York.
Still, those relative gains decayed over time, Mr. Hyman’s research shows. After 10 years the incomes of those who received assistance and those who did not were the same…
Here is the full NYT article. With the China shock largely behind us, perhaps phasing this out is the right thing to do?
That was then, this is now
Poland’s top politician said Thursday that the government will seek equivalent of some $1.3 trillion in reparations from Germany for the Nazis’ World War II invasion and occupation of his country…
“We will turn to Germany to open negotiations on the reparations,” Kaczynski said, adding it will be a “long and not an easy path” but “one day will bring success.”
He insisted the move would serve “true Polish-German reconciliation” that would be based on “truth.”
That is an article from today!
Will open science matter?
Yesterday I posted this link, about how federally funded science will have to be made open access right away. I’m all for this, as it has some upside and no downside that I can see. Still, at the margin I am not sure it will make a huge difference.
Who says when the research is “ready” to be posted? No matter what you put in the fine print, de facto that is a decision made by the scientists. If scientists wish to delay open access publication, I doubt if this will stop them. “The paper simply isn’t finished yet.” The law cannot in practice dictate otherwise. Of course scientists already put plenty of works on-line and open to the public, and this private calculation will continue, but with only modest changes.
The actual main effect will be to enable scientists to resist commercial attempts to monopolize publication rights in closed access form. Presumably such contracts now will be illegal. But think about the new equilibrium: there will be a final, published, canonical version of the article published in The Journal of Botchagaloup. There will be an open access, not yet published, non-canonical (no proper pp. at the very least) version on the scientist’s home page. And very often there will be an illegal copy of the canonical version on SciHub, the pirate site for scientific papers. Plus the data copies that circulated before the commercial publisher made the authors take them down.
How is that so different from the status quo? Some scientists who didn’t get a crack at the data the first time around won’t have to wait as long to access it. And maybe scientists will make more of an effort for the open access version of their papers to be closer to the canonical versions published in commercial journals. This could prove a modest benefit, though you, as an outside scientist, wishing to cite “p.43” just won’t know how canonical the open access version will be. And presumably for-profit commercial journals will add extra stages to the final production process, if only to keep interest in the product they are selling, relative to the open access versions on-line. So I don’t think it will “do under” for-profit scientific publishing, not to mention that many articles are not federally funded by the U.S. government.
A more radical policy change would have been to require the journals to make their final versions of the papers open to the public, and in the final, canonical versions. That would create greater benefits, but also run the risk of putting those journals out of business. As I understand the new dictate, it does not do this.
The new law also will give scientists leverage against private companies that wish to buy up the research rights and not publicize the results. Probably this is a benefit, though that doesn’t hold a priori, as it does raise the cost of private sector involvement by forcing them to share the information more. And some unscrupulous scientists might try to get a better deal from the companies by releasing a different and inferior version of “the public research results” to the open access community. Still, on net I expect these are benefits.
Addendum: You may recall that Fast Grants had its own version of an open access requirement. I think this worked quite well! But it is interesting why it might have proven effective. I think we credibly signaled that people with open and early good results would be plausible candidates for additional funding, and soon, and indeed some of them were. To the extent that the federal government can signal the same, good incentives will be all the stronger. But this new OSTP order does not coordinate future funding decisions per se, and I don’t see any clauses that the NIH, NSF, and others are bound to revise their funding policies accordingly, to favor researchers who come out with speedy, open results. So the benefits here could be much greater if the entire federal science apparatus could signal its prioritization of speed and openness. We are still quite far from this. Nonetheless, this policy is a marginal improvement and a step in the right direction and its creates some preconditions for matters getting better yet.
As Goes India, so Goes Democracy
We lost China. It is imperative that we not lose India.
By we, I mean the West and liberal democracy broadly speaking. Many of us thought that China would liberalize naturally as the Chinese people grew rich and demand followed Maslow’s hierarchy. Many other countries had followed this path. But China doesn’t have a liberal history, technology provided irresitible tools for social control, and democracy no longer looks to be as important for riches as it once did. With China lost and the United States in relative decline, the liberal world very much needs India as a large, multi-ethnic, and free democracy. Liberal democracy is also India’s best hope and bulwark against being ripped apart by internal divisions. But much remains in the balance. Suketu Mehta has a very good essay on this issue:
…Indian democracy is one of the 20th century’s greatest achievements. Over 75 years, we built, against great odds, a nation that for the first time in its 5,000-year history empowered women and the Dalits, people formerly known as untouchables. We largely abolished famine. We kept the army out of politics. After independence, many people predicted that we would become Balkanised. Yugoslavia became Balkanised, but India stayed together. No small feat.
But I write this today to tell you: things in India are more dire than you realise. India is a country that is majority Hindu, but it is not officially a Hindu state. The people who are in power in India today want to change this. They want India to be a Hindu ethnocratic state, where all other religions live by Hindu sufferance.
This has practical consequences: people of other religions are actively harassed, even lynched on the streets; their freedom to practice their religion in their own way is circumscribed. And when they protest, they are jailed and their houses bulldozed. Most worrying, much of the judiciary seems to be sympathetic to the Hindu nationalist agenda, and issues its verdicts accordingly.
There is also sustained and systematic harassment of writers, journalists, artists, activists, religious figures – anyone who questions the official narrative. We who have attached our names here are taking great personal risk in writing this: our citizenship of India could be revoked, we could be banned from the country, our property in India seized, our relatives harassed.
There are many others who think like we do but have told us they cannot speak out, for fear of the consequences. I never thought I’d use the word “dissident” in describing myself and my friends who have compiled this document. I thought that word only applied to the Soviet Union, North Korea, China.
It is crucial that India remains a democracy for all its citizens. India is not Pakistan, Iran, Afghanistan. Not yet. A lot of India’s standing in the world – the reason we are included in the respectable nations, the reason our people and our tech companies are welcome all over the world – is that we are seen, unlike, say, China, as being a multi-ethnic democracy that protects its minorities.
With over 200 million Indian Muslims, India is the third largest Muslim country in the world. There are 30 million Indian Christians. There are Sikhs, Buddhists, Jains, Zoroastrians, Atheists. They are as Indian as I am – a Hindu who’s proud of being a Hindu, but not a Hindu as Prime Minister Narendra Modi and the Bharatiya Janata Party seek to define me.
…The alienation of Indian Muslims would be catastrophic, for India and the world. They are being told: you are invaders, this is not your country, go back to where you came from. But Indian Muslims did not come from elsewhere; they were in the country all along, and chose which God to worship. After the Partition of India and Pakistan in 1947, they voted with their feet; they chose to stay, and build a nation.
…The country also has an enormous, restive, and largely unemployed youth population – half of its population is under 25. But only 36% of the working-age population has a job. To meet these challenges, it is crucial that the country stay united, and not fracture along religious lines, spend its energies building a brighter future instead of darkly contemplating past invasions.
In this time when country after country is turning its back on democracy, India has to be an example to countries around the world, this beautiful dream of nationhood expressed in the Hindu scriptures as “Vasudhaiva Kutumbakam” – the whole earth is a family. We should all be rooting for this incredible experiment in multiplicity to work. As goes India, so goes democracy.
Caleb Watney and Heidi Williams on drug pricing reforms
Because patents are filed before the start of clinical trials, rather than when a drug actually hits the market, drugs that require long clinical trials effectively receive shorter patent terms. This reduces incentives to develop drugs that require long clinical trials, including many preventive medicines.
A simple way to correct this is for the Food and Drug Administration to guarantee a minimum baseline of 12 years of market exclusivity for branded drugs. Importantly, this would not change or lengthen protection for drugs that would be developed anyway; most already receive 12 to 16 years of market protection, and the United States already provides this for particular categories, such as biologic drugs. For drugs with short periods of market exclusivity, this policy could make the difference between the drug being developed or not.
Here is the full Op-Ed, likely correct throughout.
Let’s make this a priority
The European Commission wants to boost output of its own raw materials needed for green energy. Its plans, which are still in their infancy, would lower regulatory barriers to mining and production of critical materials such as lithium, cobalt and graphite, needed for wind farms, solar panels and electric vehicles..
By 2030, EU demand for rare earth materials for wind turbines will increase fivefold, according to the commission, but global supply is only projected to double. Demand for lithium is likely to be almost 60 times as high as current consumption by 2050, according to the EU’s Joint Research Centre. The need for cobalt and graphite could be nearly 15 times higher.
Here is more from the FT.
From the comments, on corporate tax
From my email, on the new health care provisions
I saw your post on the new bill, and I actually think the healthcare components of it might be worse than the rest of it.The bill has a provision that allows the government to “negotiate” prices for drugs that are among the top 10-20 by spend in Medicare Part B (physician administered, usually IV infusions) and Part D. Since drugs that are selected in one year are not eligible for inclusion in subsequent years, this will capture more and more drugs over time. The negotiation of course happens with a gun to the head—the bill sets statutory minimum discounts of anywhere between 25-60%, depending how long the drug in question has been on market.The biggest issue with the bill is that it makes small molecule drugs eligible 9 years after approval, while biologic drugs are eligible after 13 years. This is based on some silly misconception that small molecule drugs are quicker and cheaper to develop and therefore have shorter payback periods. That may have been true when we were tackling relatively low-hanging fruit like high cholesterol, but small molecule drugs that tackle unmet needs today are nothing less than miracles. An oral pill that treats cystic fibrosis, like Vertex’s Trikafta, or sickle-cell disease, like Global Blood Therapeutics’ Oxbryta, is incredibly challenging to develop.This is going to hurt returns for small molecule drugs and skew R&D efforts away from them to biologics. Biologics like monoclonal antibodies are great, but many of them carry substantial administration costs or suffer from worse compliance/adherence because they are IV infusions that require patients to go into a care setting periodically to receive their next dose. But the real issue is they do not go generic the way small-molecule drugs do. Generics for small-molecule drugs are relatively cheap to develop, benefit from a streamlined approval process, and can be substituted for the branded drug at the pharmacy counter even if the doctor prescribes the brand, and as a result, drive 90% discounts to the brand price. Biologics, as the name suggests, are derived from living cells and thus cannot be easily proven to be equivalent to the brand—clinical trials are required and the overall expense of developing a biosimilar is 10x that of a small-molecule generic ($20M vs $200M). Between the higher development cost, lack of automatic substitution, and doctor and patient reluctance to believe these biosimilars are identical to the brand, biosimilars discount the brand price less and take a smaller share of the market, resulting in smaller savings to the system.It gets worse—many drugs these days are a “pipeline in a product,” targeting a biological mechanism that is implicated in many diseases. The most famous example might be Humira, which began as a rheumatoid arthritis drug and added psoriasis, psoriatic arthritis, ulcerative colitis, Crohn’s disease, ankylosing spondylitis, and hidradenitis suppurative over time, running trials to prove efficacy in each. Humira is a complex example—patent evergreening extended its lifetime and justified the investment in expanding its approved indications, and on a societal basis, it’s hard to know whether that’s good or bad, but hopefully we can agree that the solution to an IP issue is not to create an artificial time of expiry that discourages investment in science.The bill also includes an exemption through 2028 for orphan drugs that are approved in only one indication—these are drugs that target very rare diseases and generally charge extremely high prices to be financially viable. Some of these drugs are eventually tested in and expand to other smaller indications—but this exemption would discourage that and create an incentive to only try the drug in the largest indication and not expand the label to maintain the exemption and maximize its lifespan.Moreover, small companies that derive at least 80% of their revenue from one drug get a partial exemption from this, rendering them unacquirable by a larger drug company, since the drug is worth more as a standalone asset. This is again a failure of incentive design—it forces replication of corporate and commercial infrastructure that would otherwise have been a source of cost synergies for an acquirer.An example of the orphan disease issue is a drug called mavacamten, that Bristol-Myers acquired for $13.1B (it was the main asset of a company called Myokardia). The development plan was to first test the drug in an orphan indication, obstructive hypertrophic cardiomyopathy (oHCM), then expand to non-obstructive HCM, and eventually to a broader non-orphan heart failure market. This is a small-molecule drug, so negotiation eligibility is 9 years after launch in oHCM, or 2031–this would leave only 5-6 years for commercial launch in the heart failure market. While it probably makes sense for BMS to go ahead and test this molecule in heart failure at this point, the NPV of the molecule would be materially lower assuming a 25% discount to Medicare prices at year 9. The investment bank Jefferies estimates it at a 19% haircut—$10.6B from $13.1B. If the discount is deeper and/or spills over to commercial reimbursement, the haircut gets steeper and steeper—this overhang will reduce the number of drugs developed and/or force ever-higher launch prices since more of the value of the molecule has to be generated from the first indication.Lastly, this encourages even more gaming of the system. In theory, authorizing a generic competitor at a small discount at 9 or 13 years would protect the branded drug, as drugs with generic/biosimilar competition are exempt from negotiation. Handing the rights to produce a 10% cheaper version of your drug to Teva or Sandoz could therefore be less costly than the government’s proposed price cuts.This is sadly the story of our entire HC system—poor incentive structures layered on top of each other in an increasingly wobbly manner rendering the whole system unfit for purpose and on the verge of collapse. I should note here that this also targets one of the few industries where the US is still the undisputed global leader—can we really afford to do that? Especially when pharmaceuticals are less than a fifth of US HC spend, and the real drivers of out-of-control healthcare spending are guilds like the AMA and local monopolies (hospital systems that have consolidated heavily and are the largest employers in many congressional districts and even states, giving them both outsize negotiating power against insurers and lobbying clout in Congress).
That is from Anonymous!
That is all from Vivian Darkbloom.