Sunday, December 29, 2019

So that tweet was misunderstood

I'm currently experiencing the toxic hell that is a misunderstood tweet going viral. It's a property of the social media. The more they can deliberately misunderstand you, the more they can justify the toxicity of their response. Unfortunately, I had to delete it in order to stop all the toxic crud and threats of violence.

The context is how politicians distort everything. It's like whenever they talk about sea level rise, it's always about some city like Miami or New Orleans that is sinking into the ocean already, even without global warming's help. Pointing this out isn't a denial of global warming, it's pointing out how we can't talk about the issue without exaggeration. Mankind's carbon emissions are indeed causing sea level to rise, but we should be talking about how this affects average cities, not dramatizing the issue with the worst cases.

The same it true of health care. It's a flawed system that needs change. But we don't discuss the people making the best of all bad choices. Instead, we cherry pick those who made the worst possible choice, and then blame the entire bad outcome on the system.

My tweet is in response to this Elizabeth Warren reference to a story were somebody chose the worst of several bad choices:

My tweet is widely misunderstood as saying "here's a good alternative", when I meant "here's a less bad alternative". Maybe I was wrong and it's not "less bad", but nobody has responded that way. All the toxic spew on Twitter has been based on their interpretation that I was asserting it was "good".

And the reason I chose this particular response is because I thought it was a Democrat talking point. As Bernie Sanders (a 2020 presidential candidate) puts it:
“The original insulin patent expired 75 years ago. Instead of falling prices, as one might expect after decades of competition, three drugmakers who make different versions of insulin have continuously raised prices on this life-saving medication.”
This is called "evergreening", as described in articles like this one that claim insulin makers have been making needless small improvements to keep their products patent-protected, so that they don't have to compete against generics whose patents have expired.

It's Democrats like Bernie who claim expensive insulin is little different than cheaper insulin, not me. If you disagree, go complain to him, not me.

Bernie is wrong, by the way. The more expensive "insulin analogs" result in dramatically improved blood sugar control for Type 1 diabetics. The results are life changing, especially when combined with glucose monitors and insulin pumps. Drug companies deserve to recoup the billions spent on these advances. My original point is still true that "cheap insulin" is better than "no insulin", but it's also true that it's far worse than modern, more expensive insulin.

Anyway, I wasn't really focused on that part of the argument but the other part, how list prices are an exaggeration. They are a fiction that nobody needs to pay, even those without insurance. They aren't the result of price gouging by drug manufacturers, as Elizabeth Warren claims. But politicians like Warren continue to fixate on list prices even when they know they are inaccurate.

The culprit for high list prices isn't the drug makers, but middlemen in the supply chain known as "pharmacy benefits managers" or "PBMs". Serious politicians focus on PBMs and getting more transparency in the system, populist presidential candidates blame "Big Pharma".

PBMs negotiate prices between insurers, pharmacies, and drug makers. Their incentive is to maximize the rebates coming back from drug manufacturers. As prices go up, so do rebates, leaving the actual price people pay, and the actual price drug makers earn, unchanged. You can see this in the drug makers' SEC profit/loss filings. If drug makes are "price gouging", it's not showing up on their bottom line.

It's PBMs that have the market power. The largest PBMs are bigger than the largest drug manufacturers, as the Wikipedia article explains. They are the ones with the most influence on prices.

PBM's primary customer is insurance companies, but they'll happily do business with the uninsured. Free drug discount cards are widely available. There's also websites like that do the same thing. You don't need to pay them money, or even sign up with them. Simply go to the site, search for that expensive insulin you need, and print out a free coupon that gives you 50% to 80% off at your local pharmacy.

The story cited by Elizabeth Warren claims the drug in question cost $275, but according to GoodRX, it can be gotten for $68.

This coupon is good for buying lispro at Walgreens in Georgia, maybe elsewhere
Mentioning PBMs is really weird. People haven't heard of them, don't understand them, so when you mention them, people don't hear you. They continue as if you've said nothing at all. Yet, they are the most important part of the debate over high drug prices in America.

The point wasn't to argue drug policy. That's the underlying misunderstanding here, that I'm arguing either a Democrat or Republican side of the health debate. Instead, I'm arguing against both Republicans and Democrats. I have little opinion on the issue other than I'd like to emulate well-run countries like Singapore or Switzerland. I'm simply pointing out that whenever I investigate politician's statements, I find inaccuracies, exaggerations, and deliberate deceptions.

Maybe I'm wrong and Warren's tweet wasn't exaggerated, but that still doesn't justify the toxic spew.

What's interesting about this is how those who most decry toxic behavior on Twitter were among the most toxic in their response. Toxicity isn't a property of what you do, but of which side you are on when you do it. Threats of violence are only bad when targeting "good" people, not when targeting bad people like me.


  1. This quote might be apropos of your situation: A weird little rabbit hole leads me to this: there seem to be a lot of people who imagine they can treat what other people say as a sort of modeling clay out of which they can fashion anything they like, and then attribute their own newly-form idea back to the original author. - Joseph Moore

  2. As the person who, I guess, first took you on that path towards your tweet, I’d say I still have a number of issues with what you’re saying. Actually, you’ve added to them a little, because I have to take issue with something new you’ve introduced.

    You say: “Mankind's carbon emissions are indeed causing sea level to rise, but we should be talking about how this affects average cities, not dramatizing the issue with the worst cases.”

    I think that misunderstands how interlinked the world is. The average city, logically, is going to be some distance above sea level. But what happens when those which are right on the sea are flooded? Do you think the people who lived and worked there will just get scuba gear and carry on? Do you think property prices and business will just continue? No: there will be huge displacement, and that might be gradual or it might be sudden, but it will be far-reaching because people want to go *somewhere*. Look at the displacement caused by the New Orleans flooding, which was only temporary. Now multiply that around the world, but permanent. Bangladesh is already planning to relocate its capital because the city is too liable to flooding by rising sea levels. So “how this affects average cities” is a meaningless phrase; there’s no “average city” when you have populations on the move.

    Similarly, you say “I'm simply pointing out that whenever I investigate politicians’ statements, I find inaccuracies, exaggerations, and deliberate deceptions“. My original challenge to you was to give examples of deliberate deceptions from Democratic politicians to rival those made by Trump in particular, and the GOP in general (since you were dismissive of Jay Rosen’s commentary about Chuck Todd, who declared himself “naive” to have allowed GOPers to spout untruths on his TV show).

    You’ve pointed to *simplifications* in what Warren and Sanders are saying. If you really think anyone would listen to a politician make a stump speech about how it’s all the fault of PBMs, I have some bad news for you. The public needs simple messages; political messaging needs clear identification of problems, and of solutions, even if once in power the problems and solutions are far trickier to enact and involve big compromises. The word among politicians is that if you have a slogan, the point at which you are so sick of saying it that you think you’d rather kill yourself than utter it again is the point at which the public begins to remember it. Simple wins. The US healthcare industry is hugely complicated, so rather than putting the audience to sleep by explaining just how complicated, you tell them it’s a Gordian knot, and you flash your sword.

    But again, there’s a significant difference between saying that price gouging in the health industry needs to be stopped, and saying that the 2016 inauguration crowd was the biggest ever, or that Mueller’s report exonerated Trump, or that Trump didn’t try to exact a self-interested quid pro quo from Ukraine’s president. One is a slogan for politicking, and the other three are disprovable lies.

    The toxicity of social media, meanwhile, is in some ways related to this problem. Simple messages travel, but they also polarise. I think your tweet on the insulin topic strayed too far into simplicity. And clearly, there are a lot of diabetics out there who, like you, desire to emulate Switzerland or Singapore. Difference is that their life depends on it.

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  5. Nowadays, even a single tweet can ruin your reputation; Recently i have published a post on about journalists' security and shared on twitter it goest viral and believe me I never think that post can also be viral on twitter.