I go out of my (sometimes significantly) to go to non-PE owned companies and services, and the experience is so much better it's like experiencing an entirely different quality of life. My 2¢ is that a decent chunk of the "dissolution of the social contract" in the US is due to the way that people are treated when they interact with these soulless entities.
This exists partially - you can often find it by searching "[company name] acquired by" + checking the acquiring firm.
The bigger problem: PE firms deliberately obscure ownership through multiple holding companies. It's part of the strategy.
Example with autism centers:
- PE firm creates "AutismCare Holdings LLC"
- That entity owns 500 centers
- Each center keeps its local brand name
- Parents have no idea they're paying a PE-optimized operation
The glossary I made includes terms like "Portfolio Company" and "Management Company" that explain this structure:
https://founderstowne.com/extraction-terms.html
A database would be valuable, but PE firms would just add more shell companies. The obfuscation is intentional.
I’d happily pay for a tool that lets me opt out of being slowly nickel-and-dimed by entities optimized for short-term yield. This feels like infrastructure: a small amount of collective effort that gives individuals leverage again. Visibility is the lever. And it could be done, it's just more organizing and involvement in local politics. The information already exists, it’s just effectively invisible, and a small translation layer could collapse it into a one-second answer, letting people avoid operators with a predictable extractive playbook, with the only real challenge being the constant, boring maintenance in an environment designed for churn and opacity. Eventually this should revolve around organizing and politics to make a difference.
The challenge: these entities are designed to be hard to identify until after you're locked in.
With autism centers specifically:
- They keep the local brand name after acquisition
- By the time you realize service quality dropped, your kid is mid-treatment
- Long waitlists at other centers make switching costly
The best "opt-out tool" is learning to recognize the patterns before signing up. Questions to ask:
- Was this recently acquired?
- Do therapists mention high turnover?
- Are there unexplained price increases?
I made a glossary of the terminology these firms use: https://founderstowne.com/extraction-terms.html
Understanding terms like "Roll-Up" and "Cost Optimization" helps you pattern-match before you're stuck.
Storage unit rental went from $90 in 2014 to $110 about 2017, but then was acquired by CubeSmart which is publicly traded: now $241 per month. I know the local taxes and they have stayed about the same all those years.
>I had a storage unit for a while until I realized that the monthly bill was more than the value of the contents.
For every one of you there's a few people using it as business storage and dozens of people who are dealing with living situation stuff (college housing vs apartment, house closing timing, job relocation, house renovation, etc, etc, etc) that trade in and out of units on like a 1-2mo timeline.
My behavioral economics pricing idea for storage unit is to charge $1 for the first month but then double every month (or something like that). You shouldn't put stuff in storage long term and you're getting ripped off.
Though less critical to our lives, PE has ruined loads of retail and restaurant options as well - Sears, Toy ‘R’ Us, Red Lobster, and Shari’s come to mind.
sears had a ceo who was obsessed with competition and pitted his units against each other. they could have created an online portal and then crushed amazon in the crib -- but didn't.
toys r us had a cto who pushed for internet stuff... and said no.
Coutry wide only 16% of dental practices are DSO, and it's not that functionally different from junior dentists getting loans to set up their practices with practices themselves as a collateral.
If we’re going to stick with private ownership of our healthcare infrastructure, patient-facing providers should at least be required to be B Corps, with one Board seat set to represent the doctors’ and nurses’ interests and a second patients’ interests. (Not sure how you’d elect the latter.)
There should also be strict leverage, related-party transaction and dividend limits. In exchange, we might provide a public lender of last resort for healthcare providers who need a lifeline.
Banning private equity from healthcare is a good headline. And if I were a candidate, I’d probably run on it. But it’s a band-aid to a broader incentive problem.
I have hope that the newer generations don’t align with “big bad guvmit”, and there’s been enough negative experiences (direct and indirect) with healthcare that people will vote for alternatives.
Also, I am saddened by the shared anxiety of healthcare in US (availability while jobless, f*** by big bills, lack of care, etc). The raw amount of shared mental stress must contribute to lower lifespans :(
I think that's going to depend on the operation. Also where I said "private" I should have included "small group" as well.
Fair point about emergency medicine. I meant healthcare (and also veterinary, dental, etc) in general. But I suppose there are some exceptions where the model doesn't fit so well.
My daughter is “on the spectrum” and dealing with these therapy places was just a huge waste of time and money. I don’t know if the places we went to were owned by private equity or what but the quality was really bad and this is in a major metropolitan area that is also affluent. The therapist seemed like good hearted people, but they were paid so miserably that there was constant turnover. The billing practices were always shady and complicated and frustrating. Not to mention most of these places have 6 to 12 months waiting list to see anybody in the first place.
If everyone wasn’t held basically at economic gunpoint to a level where they are one or two missed paychecks to living in their car, we could advocate for patients and providers to strike outside of the managers offices or in front of a news station. It’s insane how having no financial security creates a world where they can extract with abandon.
It’s part and parcel to the mental healthcare system for the last decade or so. There is no place that does better because every single provider is dependent on private health insurance which rarely pays without major and intense hassle.
I really dislike this, especially because it ultimately results in worse care for the kids.
I think the place I take my kid to for therapy is likely private equity owned, but it's also about the only place available in my area.
I know they are charging around $80 per season, and I also know that the salaries for their therapists are around $25 to $30 per hour.
That leaves a very healthy margin for everything from employee benefits to building rental to admin (which I think is probably where the majority of margin goes).
I think you're over-estimating how much slack there is in the organization.
A rule of thumb is that benefits cost an employer 25-30% of salary. So you're already pushing to 50% of revenue going to direct salary costs. Then there are employees in non-revenue roles (HR, legal, accounting, IT, etc...) and employees doing non-revenue work.
Finally, you have rent, licensing, insurance, and all the other fixed costs.
An awful lot of businesses go under from underestimating what their expenses inevitably will be. Everyone they deal with has their hand out to get paid.
I mean OP said this is $80 / season, and salary rate is 25/hr.
So to your point, if we assume 4 appointments per season at one hour per, they are actually paying $100 in salary alone to only collect $80 season pass fee - a $20 loss! This business model is not sustainable
It's worth asking if you're curious or have a good relationship with the provider. Some may be willing to tell all about their ownership or management situation if prompted politely.
I know of a childcare center that was acquired recently. Not sure if by PE or just another business, but the employees are less than thrilled with the changes.
having work in an industry affected by PE buyouts, a lot of these are transactions acted on at management level by businessmen and MBAs/consultants in their offices with no clinician input, yet the hate seems directed at front-line staff.
applying this same kind of logic that PE uses, equating healthcare workers to machines is the bane of the industry.
and then people complain why ther doctors burn out. what do you expect when you ingrained on them that every hour not booked is $80 lost, so we need to book them 24/7, cut their lunch break and squeeze every inch of life from them.
These should be useful signals to regulators. Regulation is imperfect but somehow we blame companies that take advantage, either of immature or nonexistent regulation (which might be the case here) or of poorly written regulation (e.g. circa 2000 California energy regulation that let Enron and company run wild).
These companies, in finding essentially arbitrage opportunities, are, perversely, helping strengthen regulation, but only if regulators pay attention to what is going on and do something about it, instead of just watching it happen.
No it doesn't. Nothing about what you're responding to indicates they're ignoring these things exist. Unless your argument is "lobbyists exist, so we should ban all regulations and go back to the wild west," then the sentence where the person referred to regulation as "imperfect" encompasses lobbying.
This won't be at a 5yo level, but here's an attempt: there are a two things specific to private equity that often leads to higher prices and worsening service:
1. PE aren't investors like you and me. We can go to our brokerage and buy shares of a public company, hold those shares, vote on directors and proposals, etc... Or we can buy and sell ETF/mutual fund shares that own companies. Then, we (or fund managers) can sell those shares after any period of time we want. Could be years, decades, or minutes. Whatever meets our investing goals. The same is actually true for hedge funds. We buy a a piece of a company, hold it as long as we want, then sell to take profit/loss. When PE buys a company though, they buy the whole company AND they have a specific timeline in mind. This is because PE firms are actually temporary private "investment funds": partners put in money and expect a certain return on investment after a certain period of time. At the end, that's when the fund needs to wind down and return capital + returns. So, there's already a ticking clock on anything a PE firm buys, and pressure to generate return before time runs out. They typically do this by taking a company public on the stock market (maybe again) or selling it to someone else. (This doesn't always succeed, but there are other options then, like continuation funds.)
2. PE funds also take on a lot of debt. They can't afford to buy whole companies or roll up entire industries just with their investors' funds, so they borrow a lot. Now, the companies they buy for their portfolios not only need to generate returns for their investors, they also need to do that AFTER making payments on that debt. It multiplies the pressure.
There are a lot of cases where PE bought struggling companies, and with discipline and incentives turned things around on a timeline. But there are also a lot of cases where PE bought stable but boring companies, used debt and pressure to force them to raise prices, cut services, lay off workers, and lower quality in order to generate returns at the pace required.
(Most of this I learned from reading Matt Levine columns, I'm not an expert and don't work in this industry at all, so I may have some details wrong.)
In the US, we often don't have options (by design). Be it ISP, grocery, electric, healthcare, etc. Many times the option is just two of the same type of monolith.
An individual likely (hopefully) has a moral compass.
A family introduces some perverse financial incentives but you also get long term (ie multi generation) planning and reputation concerns.
A group of practicing professionals who own the operation will hopefully exhibit some shared pride and professionalism.
A co-op or similar arrangement ties the interests directly to the local community.
The larger the public company the less overlap there will be with the customer's interests. At least they might worry about reputation and stock price though.
Pretty much the only concern PE has is avoiding litigation. Their primary motivation is maximizing value extraction over the short or medium term.
Worse than PE? I very much doubt that but I guess the answer will depend on the voters, how the healthcare ventures themselves are structured, how much open corruption the local culture tolerates, and similar.
However AFAIK most government solutions in the west involve public "insurance" as opposed to the direct operation of health care facilities themselves.
Just a driveby speculator but my guess is PE dillutes interest in and responsibility for the businesses.
Individuals or family holdings are more likely to have concern for their reputations in addition to finances, public companies are more likely to scrutinized offsetting what would be their much lower reputational concerns. But PE is diffuse and often distant enough to eliminate human reputational concerns while being held to far lower stadards than public companies.
The optimal version of a PE is to take a failing business and either turn it around or carve up assets and reallocate people to do something useful and profitable. The more a business is failing, the cheaper it is to takeover and for the PE to do the work of a fungus. But this process can also become a disease if it is too easy for them to takeover, taking a healthy host and carving it up. This is mimicked in real life when conditions turn a fungus into a hostile organism on something that is living; maybe it is just a little sick but the environmental conditions help the fungus more than it ought to leading to it being a killer instead of a resource freer.
The real question to ask is why can they take on so much debt? And for that, one needs to acknowledge the fact that, particularly for the well-connected, debt is easy to obtain as banks essentially create money for loans. There are constraints (otherwise the banks would make themselves trillionaires), but the constraint is not the quantity of money. This creation of money through lending leads to inflation which further supports operating via debt as those who take out loans see the real value of the loans decrease. The banks just made up the money so there isn't a direct loser from the inflation other than everyone who has to deal with increased prices. You can think of it as a broad, regressive tax on the population to fund these firms doing far more than they should.
With an actual constrained money supply tied to real wealth in the economy, the PE firms would have to focus on the best deals which means the businesses that are truly dying and their role is to turn the nonproductive assets into something productive.
---
I asked ChatGPT to critique my answer (which is unaltered above) and it said to tone down the lending being propped up by inflation and instead emphasized the following:
>Inflation can help leveraged borrowers, but in PE the bigger structural advantages are:
• Interest deductibility (a massive tax subsidy to debt)
• Limited liability (upside captured, downside partially socialized)
• Fee extraction independent of performance
• Ability to load debt onto the acquired company, not the PE fund
I then asked it to answer the question without regards to my context and it basically said PE is different because of
> • short ownership horizons
• high leverage
• strong control
• financial returns as the primary goal
Normal investor: "I'll give you money to grow your autism center. Take your time, focus on quality care."
Private equity: "I'll buy 500 autism centers using borrowed money. The centers will pay back that loan themselves. I'll also charge
them 'management fees' for my services. I need to sell these in 5 years for 3x profit, so cut staff, raise prices, extend waitlists.
Quality doesn't matter - the math does."
The special thing about PE firms: they use a playbook that prioritizes financial extraction over the actual service.
I made a dictionary of these terms because they're deliberately confusing: https://founderstowne.com/extraction-terms.html
Terms like "Roll-Up Strategy", "Debt Loading", and "Portfolio Optimization" sound sophisticated. They mean: buy many, make them pay
for it, cut costs, sell fast.
We already know that Private Equity kills people in the hospitals [1] and nursing homes [2] for profit. So why do we continue to allow them to operate Healthcare facilities?
Wait so are you doing the journalistic action? I can't wait for this to drop. Please give me more details if possible.
Massive respects to your journalism, I have a lot of questions regarding this tho, namely how long did it take you to build this expose and where are you gonna drop it because I searched net for Founderstowne but I didn't find anything special, are they the VC fund you are gonna expose?
After my first startup failed (didn't get PM fit) I got a bit obsessed with how to do good market research for innovation. Discovery interviews, JTBD, etc.
During my journey I took a beat and pointed my new skills at VCs. I interviewed a few dozen VCs trying to understand what they were trying to get done and what mattered to them, but with a bit of a bias trying to gauge whether they wanted to better predict market demand of their portfolio or prospective investments' products.
What I learned shocked me a bit. The sense I got was that they didn't really care about market demand or building a strong business, they mostly cared if the founder could sell the company up to food chain (series a, b, c etc).
Roughly speaking: "I don't care what value my portfolio companies create, I care about marking up my book so I can increase my take".
I don't know how much this had to do with ZIRP, but it really soured me to the VC industry. I've been committed to bootstrapping my companies ever since.
It's been submitted and will remain empty of comments until a HN user comments.
I see a post with 13 points (upvotes / positive reactions) and [flagged] (meaning the title alone upset a few people given there's been no time to read the content yet).
As with all HN submissions, YMMV - Your Mileage May Vary
Just a heads up. Oftentimes legally speaking a facade will only work if you haven't yet been found at fault.
And even if you know for a fact that you aren't at fault, an ounce of prevention is worth a pound of cure and all that. The legal process isn't exactly cheap.
Because we have governments anemic to running anything or regulating any business.
They are much more likely to continue shoveling cash into private businesses through subsidies then to want to setup and/or run the same business for a fraction of the cost.
> Because we have governments anemic to running anything or regulating any business.
This comment is weird to me. The US has one of the most effective environmental regulators in the world (EPA). The FAA and FDA are also excellent. The securities markets in the US are the global gold standard of regulation (SEC, etc.).
Certainly. These are institutions that have mostly been created during the progressive era of the US. The EPA (I believe) is the latest of these organizations.
Since roughly Reagan, the US has been either fully dismantling, defunding, or privatizing these institutions.
We've seen the FAA start to rely too heavily on the likes of Boeing to set regulation standards. The FDA has relied heavily on fees from private institutions to function and it's weakening due to that improper mixing has resulted in the likes of the Vioxx scandal.
Medicare is a good example of this. Under Clinton, rather than expanding or reforming medicare he introduced a plan to allow private insurance companies to get government dollars (medicare part c).
> These are institutions that have mostly been created during the progressive era of the US. The EPA (I believe) is the latest of these organizations.
Wiki tells me that the EPA was created by Richard Nixon in 1970. Also, it matters little when a regulatory body was created. It matters much more how it changes over time -- it is continously adapting to changes in our society and economy. For example, after the 2008 global financial crisis, securites markets regulators changes significantly to strengthen the financial system.
> Since roughly Reagan, the US has been either fully dismantling, defunding, or privatizing these institutions.
Clinton, Obama, and Biden were doing this? If so, please provide examples.
> Clinton, Obama, and Biden were doing this? If so, please provide examples.
Yup. Primarily on the 3rd prong but, especially under Clinton, there was also significant defunding that went one. "The era of big government is over".
Clinton did welfare reform, which added much stricter means testing and work requirements to welfare. The "reinventing government" program was literally a hack and slash on government agencies not unlike DOGE. The student loan reform reduced subsidies for students. He signed in the crime bill which enabled the building of private prisons and ramped up the US incarceration rates. And he created Medicare part C which created a route to send government funds to private insurers.
Obama's signature bill, the ACA, was a giant handout to insurance companies in pretty much every way. By trying to force people into buying insurance and also subsidizing insurance purchases, it was a major gift to health insurers. Even the Medicaid expansion mostly resulted in private insurers getting more wealthy as most states implement Medicaid via a private insurance contractor. After the first midterm Obama got very little done mainly due to the republican's continuing the Newt Gingrich "we oppose everything you support" strategy and the filibuster.
Biden was mostly business as usual, however both the infrastructure bill and the chips act can't be seen as anything other than just massive giveaways to private industry. The build back better act would have been the same had it passed.
> The same one who just said PE isn't allowed to buy any more residential real estate?
We'll see. That was just an EO. That doesn't really have the force of law behind it. There's not a regulatory body (AFAIK) that would or could prevent PE from gobbling up a home.
But if there's a route to stop it then I'm not opposed to it. PE buying essential goods and industries is bad for everyone.
The President's statements, and even unspoken thoughts, have the full force of law. This President, anyway-- I think the Supreme Court has a special criterion they use to determine whether Unitary Executive Theory should apply to a particular administration.
Government is probably the worst actor to run healthcare facilities. It’s not that different from PE, except with more administrative bloat. I’d be curious to compare US PE run facilities with government run facilities in Canada.
There is not an easy answer here, it basically a cost centre that whoever runs it, the welfare state is incentivized to spend as little as possible on it. PE is almost certainly a bad solution. If they can destroy a restaurant or other low impact business, I hate to think what they’d do to businesses that care for people. You’d get the healthcare equivalent of Burger King. But with government you get the equivalent of the DMV.
Canada's healthcare is generally cheaper per capita, pays healthcare workers less and has far lower administrative costs than the US. The US spends 5x the average of other wealthy countries on administrative costs [1]. This line that the government is automatically inefficient and terrible at anything at all is not true, is not set in stone and does not preclude private industry being even more greedy, stupid, amoral and inefficient than the government.
> The US spends 5x the average of other wealthy countries on administrative costs [1]. This line that the government is automatically inefficient and terrible at anything at all is not true
It's a line that tends to be mainly parroted by... the US. Quelle fucking surprise.
Free market ideologues are too dumb to understand local minima.
An ideal free market is a global minima (in theory). It's the best.
A non-ideal free market (heavily subsidised and regulated) might be close (in parameter space) to a global minima, but might be highly suboptimal compared to a local minima.
It's not even that. Free markets by themselves (as implemented thus far) DO NOT ACCOUNT FOR EXTERNALITIES.
I have yet to see reasonable fix to the tragedy of the commons in a free market situation, and that's one of the most basic things one is fucking introduced to when studying economics and game theory.
Anybody who thinks health care is best served solely privately should have to pay to be diagnosed for something; either that or they've been failed in their privately funded education.
In the past I have read some libertarian literature that suggested the answer to the tragedy of the commons was that there should be no commons. Everything should be privately owned. How that would actually work in practice is way beyond my tiny brain.
It doesn't matter if it works in practice - it's religion, so it doesn't have to be true. We sent rockets up into space and there wasn't a giant man there watching us, but people still believe God exists. We tried living in a free market and everything turned to shit, but people still believe in libertarianism.
I think the theory is that if people owned the forest, the rivers, etc, they would have an incentive to take care of them for the long term. As we've seen with how companies have had all the value sucked out of them by private equity, leaving nothing but husks, I think this is a pipe dream.
Former libertarian here. The issue with libertarianism is that it does not explain the state of the world. The world is inherently unregulated. If libertarianism was superior it would have outcompeted other systems and it would have been the dominant system right now.
Historic explanations are even more problematic. How does libertarianism explain nomadic cultures or rice growing cultures (that tend to be highly collectivist)?
Huh the government is the ideal party to do that. Because it can set its goals to best serve its constituents instead of making money.
Don't forget there are so many countries with government healthcare and their care is a lot more accessible than the US's. I've lived in many countries and a nationalised healthcare system is one of the things I select for.
Even a poor country like Cuba has one of the highest numbers of doctors per capita. Unfortunately a bit hamstrung by the US's illegal and needless sanctions so they can't get proper equipment but I've been told healthcare is still pretty excellent there.
it’s that first paragraph which is really the bugaboo. In an ideal world that first paragraph is 100% true. In reality, what you get is the government getting its own people on the inside, raking in tons of contract money and doing very little for that, then squeeze the services on the inside to win political points from their constituents by drumming up hatred for the system in which they work. While they take in "campaign contributions" from private entities who benefit from people falling out of the system or being fed up with it.
so I agree with you in theory, but in practice, there was a whole host of other issues that would need to be dealt with somehow. I don’t know that more bureaucracy is the solution, but I would like to think it can be handled.
Actual competition and monopoly breaking/preventing.
"Free" markets tend to have transparent pricing : US healthcare does not.
"Free" markets tend to have large numbers of independent players that compete with each other : This is disappearing in the US market.
We have the worst of both systems currently. It's not ran by the government to control costs to the end user. And it's ran by a few monopolistic insurance/medical companies to reap as much profit as possible.
Canadian healthcare is horrible, pretty sure public healthcare in the UK is also very bad. It’s not a given that somehow switching to public healthcare will make the US like Finland, Canada is much more likely.
Yes, when the government politicians hate public healthcare they can successfully sabotage it. That just means we need to structure it in a way that they can't. The examples given were all successful in their missions in the past before they were actively targeted.
It's all about the execution - UK NHS public healthcare was once easily the envy of the world (I'm from Australia, not the UK) and then it suffered decades of being white anted by Conservatives.
Government is probably the worst actor to run healthcare facilities
Are those your gut feelings, or do you have an argument to back it up?
In reality, the outcomes from Government operated hospitals in Scandinavian Countries do not need to hide behind those of other countries, especially not with the US
Because between the 1970s and 1990s, Western nations decided that private operations should be the default for everything except where the law specifically requires state institutions, instead of the other way round.
In many countries, essential services like hospitals, drinking water supply, airport security, schools, even prisons are now partially or fully privatized. It seems insane when you think about it, but that’s what your grandparents voted for.
How would this work the other way around? The state provides cheeseburgers and fidget spinners until someone writes a law requiring private industry to provide these things? Isn't there a sort of lack of freedom inherent in forcing people to get all their cheeseburgers from a single place?
The other way around would be having public options except where explicitly forbidden. The existence of a public option does not forbid private options. For example the existence of the USPS does not forbid UPS or Fedex or Amazon from operating delivery services, which may be preferable for many customers. But the public option guarantees that a certain level of service is available to anyone and makes it impossible for any private entity to secure a monopoly. It also is very sensible in cases of natural monopoly (power plants, international airports, prisons, wastewater treatment centers) where there's never going to be any meaningful competition that the government should own and operate the monopoly.
Ukraine an interesting moment with the recent (as in less than 10 years ago) health reform. The change was not in the ownership regime, but in funding (preallicated fixed amount vs post payment for itemised coded services).
Once the incetives got changed, a lot of doctors opened up their own practices as PE. The government still foots the bill, but the corrupt middleman of the local variety got cut from the flow
What is the appropriate level of safety? Safety is a spectrum, not a binary condition. Privately owned commercial airlines operating under strict government regulation seem to be pretty safe.
Private is the default solution for all problems. The state only provides a service when the government takes action to do so, and usually this is on top of whatever existing private infrastructure there is.
This seems like a pretty weird perspective to have?
> It seems insane when you think about it, but that’s what your grandparents voted for.
Our grandparents wanted a nice hospital and that's what they voted for. The people they elected needed funds to build the hospital, so they sought funding. The IMF and World Bank said "sure, we'll help you fund it. But in order to do so, you need to privatize your healthcare industry."
Our grandparents got a nice hospital for a while, the politicians got another 4 years in power, and a few years later we noticed that our free healthcare was gone.
This, multiplied across the entire developing world.
A mix of public and private can work with proper regulation (especially when combined with state owned private companies).
This article only refers to the US. This is the second time I've brought it up over the last week, but it'd be nice if the US and "the west" weren't constantly conflated.
Not all of us have fucked over their citizens and spiraled into borderline dictatorships that are well on their way to becoming international pariahs as much as the US have.
Everything suddenly makes a lot more sense once you realize the US is a developing country, one that happens to control the global money printer (due to a few accidents of history).
It's the only developing country that is also "first-world" or "western", and unfortunately, also the most powerful of those.
Oh, trust me, I would absolutely love for a lot more of the US to be socialized (certainly healthcare, housing, and transportation.)
Unfortunately that is virtually impossible in the current political climate, so I didn't include it.
What I was trying to say is that, as it stands, PE is the end of an entity's life. Once it's been strip-mined for all value, of course nobody wants it.
> that is virtually impossible in the current political climate
We probably need a Constitutional amendment codifying independent agencies before it can happen. We don’t need the President denying protesters medical treatment because he needs to distract from his pediphilia.
The government-owned things still suck too, they just give sweetheart contracts to whoever greases the right palms even though they suck. The money still flows to bad people, no matter what. Having it be tax money in the first place just increases the possible money available to be stolen, since government budgets can in practice only go up, plus the feds can print money.
> only possible entities who could buy a company are either a bigger company, or private equity
Communities. Forcing PE to divest from healthcare would require setting up a lending facility communities can borrow from to buy back their healthcare infrastructure. (Or have the government just buy it outright.)
I guess you could make it work as a window-dressing bill. Force PE to divest. Leave unsaid that you’re letting billionaires and family offices buy it up to continue the same shit. But actually solving the problem means ponying up cash to buy this stuff back. Even if it’s out of bankruptcy. (I’m not even touching the politics of paying PE and its lenders with public money.)
If you change rules to make the PE business model unprofitable, since it's in many ways toxic to society, you can result in them then needing to sell, for much less than they'd like most likely, or adapt and become less toxic.
> you can result in them then needing to sell, for much less than they'd like most likely
I’m imagining harder. Forced divestiture. Good amount of the hospitals and nursing homes would be bought of out bankruptcy.
But they still need to be bought and funded. And I think nobody wants to have a conversation about how much that costs and who winds up paying for it, particularly with many of PE’s hospitals being in rural America.
> we should have kept taxing the rich the we did during WW2 and the few decades following it?
Genuine question: source for any of the rich having paid more in the 50s than they did in the 90s? My understanding is that while published rates were high, effective rates were roughly flat until the Bush and Trump tax cuts.
The average effective tax rate stayed flat from 1945-2015, but the effective tax rate for the 0.1% and 1% fell during that time period. Bottoming out around the Bush years (although the graph only goes to 2015 so another source is needed to see how the Trump tax breaks have played out). The top for the 0.1% was almost 50% and the bottom was almost 20%. Now those almosts are working in the opposite directions so you should look at the graphs.
Now the 1% is paying more of the overall taxes, about 40%, but that number is also skewed (and can be misleading) by the absolute massive disparity between what the top and bottom make now. Plus of course reporting and tax compliance has changed a bit, plus a whole host of other confounding factors that this 40% statistic subsumes, but it's worth mentioning because it's always brought up in these discussions.
Yes, and the rest of the article discussed how they actually have revisited some of their numbers and links to their reports where you can read about their methodology and decide if it's comprehensive enough.
To quote the article: "Debates over measuring effective tax rates have been lively because measuring taxes and incomes is complex and involves judgement calls (and the political stakes are high.) We applied a simple and replicable method to a single, publicly available source of data to estimate the effective tax rates of high-income taxpayers that avoids making assumptions about grey areas like unrealized capital gains and corporate tax burdens."
> The point is that PE should never have purchased these things in the first place
You can change the present. Not the past. Private equity owns these things. If you want them to not own it, you have to buy it back. Even if out of bankruptcy. Even if via eminent domain. Then you have to run it. All of that costs money.
You're missing the point. It's too late to unwind those transactions.
In theory state or federal governments could seize ownership of those healthcare provider organizations. But then legally the government would be forced to compensate the current owners at fair market value.
Your citation's statistics [1] actually says the exact opposite of your claim!
It shows a -0.2pp DECREASE in in-hospital mortality, with no significant change on 7 or 30 day mortality. The authors suggest this could be due to:
* selecting for healthier patients - the paper shows an average change of 0.1 years younger for patients. this is not significant!
* transferring out sicker patients - 30 day mortality would show this (it doesn't), and the transfer rate does not change meaningfully
So based on the evidence you have provided, private equity purchasing hospitals saves lives. Maybe that is wrong, but it is the conclusion of that evidence.
They also don't claim PE is killing people in the conclusion; did you read the paper?
They've had more bloodstream infections, surgical infections, and falls. Everything which traces back to staff cuts and lack of hygiene.
Also they dumped the complicated, and probably expensive cases to real hospitals
In contrast, transfers to other acute care hospitals increased 12.2% at private equity hospitals compared with control hospitals
A 1 month average age difference is not medically significant.
They had more bloodstream infections yep. Surgical infections was NOT statistically significant. And again, mortality went down!!
The “dumping cases” thing is incredibly suspicious.
So they’re so motivated by money that they … don’t keep patients who would spend a lot?
On top of that, the 30 day mortality doesn’t show an increase, which is what you’d see if they dumped deaths onto other hospitals.
Medicare reimburses by DRG, which is a payment for the average cost patients with that diagnosis and comorbidities have.
Usually those hospitals send the patients they expect to become to cost more than the DRG Reimbursement (Complications, too old, too many comorbidities) off to public hospitals. At least that's how it works in Germany.
At the same time, they are very aggressive with upcoding their diagnoses to get more reimbursement.
They started slapping my kids hands, forcibly shoving him back in his chair, and grabbing my kids face and torquing his neck. Jon Paul Saunders, a leader in ABA, swore up and down 'this is the best in ABA'. When I looked at the data, my kid had all but stopped screaming/crying with other RBT's, but was more than double the crying/screaming with the rbt's doing the slap, push, face yank teqnique.
At this point, my son had done 18 months of ABA and was being used to train new RBT's (high turnover field of course). The prescribed hitting was creating behavioral problems at home, but was being used to justify extensive hours of ABA.
I dont think a profit driven model is great for these kids.
>“Private investors making a little bit of money while expanding access is not a bad thing, per se,” Singh said. “But we need to understand how much of a bad thing this is and how much of a good thing this is. This is a first step in that direction.”
Who gets to say what "a little bit of money" is here?
If anyone wants to see how private equity has transformed the veterinary industry check out www.privateequityvet.org/vet-list - over 7000 practices mapped across the US so far. Our dog died at the hands of a recently acquired PE practice :(
You are implying people should shut up about it because it's not novel information. I think "are you surprised?" is a very lame and unoriginal response I see everywhere and doesn't even care to engage with the problem. I think HN's rules suggest you should put in more effort than this.
The confusion in this thread about "how PE firms operate" is understandable - the language of private equity is deliberately opaque.
I recently compiled a dictionary of 181 Wall Street terms because I kept seeing the same pattern: people get confused by the jargon,
then give up trying to understand what's actually happening.
A few terms that explain the autism center acquisitions:
• Roll-Up Strategy: Buy multiple small centers, consolidate, cut "redundancies" (staff)
• Debt Loading: The acquired company pays for its own acquisition via loans
• Portfolio Optimization: Euphemism for cutting costs that affect care quality
• Management Fees: PE firm charges the autism centers for "managing" them
• Exit Strategy: The goal is never to run autism centers - it's to flip them in 3-5 years
The glossary is here if useful: https://founderstowne.com/extraction-terms.html
The pattern is identical whether it's autism centers, veterinary clinics, or software companies. Once you know the vocabulary, you
start seeing it everywhere.
Private equity goes where the money is. Nothing is magically non-exploitative just because it's done by a bunch of small businessmen instead of a private equity company. There's a reason why Private Equity bought so many dialysis clinics. There's a reason why they're doing this.
It's easy to scam the government out of money for this because a bunch of well-meaning "useful idiots" will say "pay whatever it takes; give them as much money as they need; it's for human lives!" and none of that is true. It's all about using different battalions to rent-seek on normal tax-paying Americans.
Tim Walz lost his hope for re-election over this but he's not the only one. In time we will discover a large array of healthcare scams and home-care and autism/child mental health are going to be near the top.
Yes, as soon as I hit the "...children who are largely insured by Medicaid programs..." part of the article, I figured that this is happening because some PE firms ran the numbers and discovered they could use autistic kids to squeeze as much money from medicaid as possible.
If your dialysis clinics have the worst outcomes in the industrialised world, it should make you go hmmm.
And usually it's not a problem, of "Throwing more money at it", but lack of regulations and enforcing them.
That said, Physician Owned Clinics have better outcomes, there is no reason why that shouldn't be the standard model of operating them. Usually they have more moral scruples about worsening care for profit.
Also there is naturally more competition, if there are multiple small operators instead of only Fresenius Nephrocare or DaVita
The data [https://www.transonic.com/renal-disease-in-us] says that kidney transplants for dialysis patients happen LESS frequently in the USA than in Europe, yet the survival rate is very close - 39% USA vs 41% Europe. This implies that dialysis in the USA is very close or _better_ quality than in Europe - as there is a large difference in transplant rates but only a small difference in survival rates.
Maybe the above data is wrong, but CBS don't seem to provide any better data
Survival rates for ESRD are higher in Europe than the U.S. This could be explained by the inferiority of national standards of care, a higher prevalence of patients with diabetes and differences in practice patterns.
Let's look at actual journals
For those with ESKD onset from 2004 to 2008, unadjusted 5-year survival of all patients with ESKD (treated with dialysis or transplantation) was 41% in the USA, 48% in Europe, and 60% in Japan, despite patients being 2–3 years older on average in Europe and Japan than in the USA, and Japan having very few transplant patients.
The US had a much higher KRT incidence, prevalence, and mortality compared to Europe, and despite a higher kidney transplantation rate, a lower proportion of prevalent patients with a functioning graft.
The dialysis clinics are bad and make all the money because it’s Medicare fraud dude. Well meaning morons say “whatever people need we should pay for them” not thinking for a second that some unscrupulous fuck is the one getting the money.
We have something like this going on in Australia right now.
The NDIS is our disability welfare scheme, and it's costs have exploded as oversight has failed to keep pace with exploitative actors. Few questions asked welfare for our vulnerable would be nice, but sadly it doesn't look sustainable in most places.
ah yes, another market where the private equity scum have realised that "the market is inefficient" and that the existing businesses aren't "extracting maximum consumer surplus"
fortunately the UK doesn't have this problem for people as the state run healthcare system has set the price floor at zero
it hasn't stopped the private equity scum completely though, instead they have bought up most of the country's formerly independent vets
> From only 10% in 2013, almost 60% of veterinary practices are now owned by large companies
they then immediately "optimise the demand curve", doubling/tripling their prices, meaning there are now people that can no longer afford to treat their pets
Reading the headline all I can think about is that many people with autism are not capable of communicating, or if they are, only in a limited way. Literally people who do not have a voice to speak for themselves.
Private equity in healthcare shows particularly clearly how far capitalism is willing to go. Profiting from the suffering of humans and animals, while probably still feeling good and even heroic about it, disgusts me.
I can see your perspective, but healthcare isn't always a zero sum game. It can be empathetic and useful while also being profitable. It often isn't, but it can be.
There is plenty of evidence that Hospitals, Nursing Homes operated by private equity have way more worse outcomes than those of other operators, even for-profit ones
Yes. It starts benign "no major changes!" and soon stock is reduced, staff get cut, and cost cutting rules are enacted by people who never have to witness the effects on the patients who slip into worse outcomes. And if it crashes into the ground they can float away on golden parachutes.
Why can't we just leave some things out of the whole madness?
It's not like we don't have enough stuff that can be made profitable already.
Just let your customers be healthy, have a roof over their head, water, electricity, internet. They'll have more time and money to spend on all the other profitable stuff.
Come to think of it, I don't think I've ever experienced a product or service that took a turn for the better, after the company was acquired by PE.
There might have been a time where PE bought up mismanaged companies, and turned them around - but the PE acquisition spree we've seen for the past 10 years or so...it seems exclusively to cause enshitification. And it is happening everywhere. There will always exist some niche PE firms for every sector out there, nothing is safe.
> The primary concern is that private equity firms may prioritize financial gains over families, said Daniel Arnold, a senior research scientist at the School of Public Health.
...may? How are they not already by gobbling them up in a calculated way. Targeting states with lax insurance claim scrutiny
If corporations are people than PE firms should be executed like the leaches on society they are. Nothing makes me see red like the fact that basic services are increasingly being captured by these disgusting rats so they can squeeze every last cent out of society possible.
Even with the losses a lot more is provided per dollar because its done at-cost, and the majority still going to the most desperate.
If we wanted to worry about the bigges source of theft though it is wage theft by a large margin over all other forms of threat combined. And the healthcare industry is ripe with labor abuses.
Or do you mean like Republican Senator from Florida Rick Scott who was elected AFTER he was involve in $1.7 billion dollars in Medicaid fraud (largest in history) and whom the Republican party embraces and endorses and has in a position of power today?
https://www.justice.gov/archive/opa/pr/2003/June/03_civ_386....
Yes, like those. "Stealing money put aside to help the less fortunate" is bad and should be stopped, regardless of the political beliefs of whoever is doing it. The right question to ask is "is this fraud", not "which side are the perpetrators on".
Can we join together and agree fraud should be stopped rather than protecting people based on which team they are on? It's fine to question whether something is fraud or not, but once it's clear, let's shut it down and punish those responsible.
In the Democratic party, Tim Waltz, with zero proof against him personally, withdrew from the election we was running for when there was an impression of abuse.
The Republican party EMBRACED the head man involved in the largest theft in Medicare history, and he is a powerful Senator for them.
This is very much political, as I highlighted. One party acts with responsibility, the other doesn't care except for soundbites and wielding accusations as a weapon and abuse as a boogie man to say 'we can't have government, because people like our Senator steal from it' (it happens to also be the part that hates government, shockingly).
What did you think was going to happen when you've got guaranteed payments and a growing customer base as people celebrate their "neurodiversity" whilst at the same time demanding subsidies and yelling "ableist" at anyone who criticises them or the system?
So politicians pretend to care by throwing more money at their cronies and get away with it because won't someone PLEASE think of the children. And then people pat them on back and vote for them in the next election, and blame "capitalism" while the people they've just voted back in make millions.
They even say "We're also dealing with children who are largely insured by Medicaid programs" and yet still people are failing to join the dots...
I know this is the conventional view. But is it possible that the prevalence of autism has been somewhat exaggerated and overdiagnosed? There's a CLEAR profit motive here...
Yes, but also we've gotten better at diagnosis. Both things are likely true to varying degrees.
That said, Elon is one of the most obviously autistic people I've ever seen. He's not a great example of overdiagnosis. In fact, if autism hadn't already been discovered they'd have taken one look at him and invented Elontism.
No it's not over exaggerated at all. Autism is highly prevalent and everywhere. The industry made a mistake, it originally assumed autism was a rare condition, but now we're starting to see that it's a personality trait because it's so common. We're coming to similar realizations for other things like the concept of gender as well as society modernizes and gets rid of out-dated thinking practices.
Autism is not a personality trait. Many people are severely disabled by it and are essentially non-functional.
Only about 15-20% have full time jobs. The suicide rate is incredibly, almost unbelievably, high. I think it was something like 80% have attempted suicide.
Personally I think we need more subtypes again. Its weird to lump high functioning aspergers folks like the richest man in the world into the same category as those who have to wear helmets and be physically prevented from harming themselves.
The sources they cite in that article aren't medical professionals. Simger is at least a scientist, but she's a sociologist with an opinion, and Silverman is just a writer with an opinion.
Lots of unqualified people claim lots of things, that doesnt mean you ignore the actual doctors when it comes to medicine and ASD is literally defined as a disorder. You can not be diagnosed with it without some negative impact to your life.
They do also quote a few qualified doctors but the doctors use the word "disability" an awful lot and make no such claims.
Even then, the two folks that do argue for the "social model" of disability are still not arguing that it isnt a disability, they essentially just claim it would be nicer for people if we pretend it isn't - then they go on to to talk about how even among the autistic without learning disabilities the suicide rates are 9 times higher. They cite that as proof that its society making it worse, I see it as proof that autism isn't freaking good for you any more than depression is. Humans are social animals and social diseases are still diseases. More to the point, some of us wear helmets and spend 12 hours a day in a ball rocking back and forth. Thats not "societies problem".
The whole thing reminds me of when I was diagnosed and my neuropsych asked me if I wanted it to be included in my file. He explained that many/most of his very high functioning clients preferred it not be in their medical record, as they didn't want the stigma.
I honestly think we are still under-reporting the numbers for the high functioning, and its largely because some people are too scared to accept who/what they are. IMO those people need to face reality, not ask society to play pretend. The actual name of the diagnosis includes the word "disorder" and you literally cant have autism if you dont have problems.
Pretending that you are fine and it s just a personality trait is counterproductive, but if it helps you sleep at night go for it, I guess. Just be careful. Pretending like all your problems are societies fault won't actually change who you are or reduce your symptoms.
Also note that scientists and doctors are no longer on the frontlines of the change that's sweeping across society. It's activists who realize that identity and community is more important than cold logical arguments.
>Pretending like all your problems are societies fault won't actually change who you are or reduce your symptoms.
No, I don't pretend it's societies fault that I am who I am. It's societies fault for not being inclusive of who I am and not completely normalizing my condition so I feel included.
> Also note that scientists and doctors are no longer on the frontlines of the change that's sweeping across society. It's activists who realize that identity and community is more important than cold logical arguments.
What I'm about to say is very negative, but please don't think it's directed at you. I'm just jaded and have seen some things.
I can respect that you see a problem and want to solve it, and I even agree that it's a problem. The suicide rate, for example, can at least partly be blamed on the way society (especially children) treat people who are different. That said, I can't help but feel that you are missing a few key things.
1) It's a medical condition. Better activism doesn't lead to better patient outcomes. It just puts conflicting pressures on already overtaxed doctors that make it hard for them to treat patients properly. See what's happening to trans folks for an example.
2) Forcing people to use different words to describe you doesn't make them respect you more, it just frustrates them that they can't speak plainly.
Take the medical term "Mongoloid" for example. It was used to describe the people we now call "Intellectually Disabled" until it became an insult. So doctors invented a new term: "Moron." Moron almost immediately became an insult, so they invented "Mentally Retarded." Mentally retarded became an insult, and was actually *outlawed* in 2010 (Literally outlawed, check out Rosa's law). A few weeks ago I heard my niece make fun of my nephew by calling him "mentally challenged" and doing a hand gesture. He was no less offended than he would have been if she'd used any of the other terms.
The history of that sickness is a history of euphemisms: Simpleteon, Cretin, Imbecile, Mongoloid, Retard, Idiot, Defective, etc... The've all been socially acceptable designations at one point, but each time a new one is created it also turns into an insult. It's not the phrasing that is the problem here, and it can't be fixed by adjusting the language we use (although I'm sure we'll keep inventing new euphemisms forever). There's a fundamental aspect of "not being smart" that people find insulting so whatever you call them BECOMES THE INSULT. We can't change that, it's just how humans are.
Similarly, autistic people are *Weird*. We just don't fit in well, and neither scolding the kids on the playground for using the wrong terms or blasting some Joe Six-Pack on twitter are going to change their minds.
Even if we get them to change their words, the words will become insults by virtue of being tied to the "weird people". When you finally convince everyone to call us "neurodiverse" it will mean that neurodiverse has become an insult. When we convince them it's just a "personality type" it we be regarded as a bad personality type.
Changing other people just doesn't work. You have to change what you expect from them if you want to be happy. It's all your really in charge of.
> 1) It's a medical condition. Better activism doesn't lead to better patient outcomes. It just puts conflicting pressures on already overtaxed doctors that make it hard for them to treat patients properly. See what's happening to trans folks for an example.
What? Activism by trans people is directly responsible for the improvement of the lives of trans people (see informed consent for example).
"In the last five years, more anti-trans legislation has been proposed in the United States than in the previous 200 years combined." [0]
You have to look at the real world, not the world that (presumably) we both wish we lived in. In real life, activism just leads to counter-activism.
I'm not saying that trans folks aren't better off now than they were a decade ago, but I am saying that for every action there is an equal and opposite reaction. If you have a medical condition that needs treatment you probably don't need a line of dummies lining up to block you as you walk in because you've turned your condition into "Activism."
Some things are made worse by turning it into politics.
We're on hackernews. Half of us in here probably joke about being autistic ourselves. That doesn't mean we need to give Pfizer and Blackstone billions of dollars for pills and treatment.
Not all of us are convinced that each and every component of human diversity needs to be treated as an ailment and medicated. Autism, as the name implies, is a spectrum. But we've widened the spectrum so far that its become meaningless. There are profoundly autistic people who can't speak who would not recognize my diagnosis of autism simply because I have trouble looking people in the eye.
You mention gender, and that's a perfect example: we've widened it to include every possible thing. And when it comes to the over-diagnosis/overmedication question: You can be just fine with the idea that gender is a spectrum, but also believe that giving hormones and surgery to teenagers is utterly insane.
No they weren't. Autism is as a result of endocrine disruptions through environmental contamination along with a significant amount of heredity transmission. Same reason why T rates, sperm rates, fertility, are cratering.
It doesn't seem like you're trying to have a good faith discussion when your final sentence reads like a willful conflation of an academic and Alex Jones's comments, which were that atrazine is being intentionally put into the water supply by the government as a form of chemical warfare in order to reduce the population by making people gay.
Im adding a second comment for the frogs thing, since its really a separate issue.
I'm very liberal and never made fun of the researcher who identified that atrazine makes frogs gay. It does objectively mess with amphibian development.
I did, and still do, mock Alex Jones for insisting that it was government conspiracy "chemical warfare operation" designed to do... something. That makes exactly as much sense as his Sandy Hook nonsense or pizzagate.
Services that PE has ruined in my city by rent-seeking:
I go out of my (sometimes significantly) to go to non-PE owned companies and services, and the experience is so much better it's like experiencing an entirely different quality of life. My 2¢ is that a decent chunk of the "dissolution of the social contract" in the US is due to the way that people are treated when they interact with these soulless entities.I wish there were some kind of public database that allowed easy lookup of whether a given company is owned by a private equity firm.
It should be integrated with the ways that people find those businesses, including maps, Web search, and "AI chat".
This exists partially - you can often find it by searching "[company name] acquired by" + checking the acquiring firm.
I’d happily pay for a tool that lets me opt out of being slowly nickel-and-dimed by entities optimized for short-term yield. This feels like infrastructure: a small amount of collective effort that gives individuals leverage again. Visibility is the lever. And it could be done, it's just more organizing and involvement in local politics. The information already exists, it’s just effectively invisible, and a small translation layer could collapse it into a one-second answer, letting people avoid operators with a predictable extractive playbook, with the only real challenge being the constant, boring maintenance in an environment designed for churn and opacity. Eventually this should revolve around organizing and politics to make a difference.
The challenge: these entities are designed to be hard to identify until after you're locked in.
Are you using LLM's to help write these comments?
> Questions to ask
Identifying them at least it's a better thing than not. The lock-in challenge can be solved too, also through organizing, activism and politics.
I agree! I think this kind of resource would be very useful to a lot of people!
Storage unit rental went from $90 in 2014 to $110 about 2017, but then was acquired by CubeSmart which is publicly traded: now $241 per month. I know the local taxes and they have stayed about the same all those years.
Storage units are the way station to the thrift store / city dump.
I had a storage unit for a while until I realized that the monthly bill was more than the value of the contents.
>I had a storage unit for a while until I realized that the monthly bill was more than the value of the contents.
For every one of you there's a few people using it as business storage and dozens of people who are dealing with living situation stuff (college housing vs apartment, house closing timing, job relocation, house renovation, etc, etc, etc) that trade in and out of units on like a 1-2mo timeline.
Source: Almost bought one.
I’m beyond peeved by the inability to get any sort of price guarantee from these places more than 3 months in advance.
I’ve even offered to pay for several years in advance at their “current” rate, and they won’t accept it.
My behavioral economics pricing idea for storage unit is to charge $1 for the first month but then double every month (or something like that). You shouldn't put stuff in storage long term and you're getting ripped off.
Though less critical to our lives, PE has ruined loads of retail and restaurant options as well - Sears, Toy ‘R’ Us, Red Lobster, and Shari’s come to mind.
many of those deserved to die.
sears had a ceo who was obsessed with competition and pitted his units against each other. they could have created an online portal and then crushed amazon in the crib -- but didn't.
toys r us had a cto who pushed for internet stuff... and said no.
Sears was around long before the bad CEO was even born. Saying it "deserved to die" isn't fair to history.
Water used to be managed by a local cool here where I live. I had been for decades.
A few months ago i got an email saying that PE had acquired it.
I was paying between ~$25/month before. Today i got the first bill from new management for $89.
Same volume/usage, nothing significantly different.
Sigh.
Definitely complain to you local water/utility regulator, and your state representative.
Regional regulators have to approve the transfer of ownership of water utilities. The best time to fight this sort of thing is as early as possible.
I had no idea about any of this. I’ll talk with my neighbors and see if there’s anything we could do
Toy Stores for kids should be on the list
Coutry wide only 16% of dental practices are DSO, and it's not that functionally different from junior dentists getting loans to set up their practices with practices themselves as a collateral.
If we’re going to stick with private ownership of our healthcare infrastructure, patient-facing providers should at least be required to be B Corps, with one Board seat set to represent the doctors’ and nurses’ interests and a second patients’ interests. (Not sure how you’d elect the latter.)
There should also be strict leverage, related-party transaction and dividend limits. In exchange, we might provide a public lender of last resort for healthcare providers who need a lifeline.
Banning private equity from healthcare is a good headline. And if I were a candidate, I’d probably run on it. But it’s a band-aid to a broader incentive problem.
The issue is, at least in the US, if we ban PE/VC from healthcare, who is going to do it?
Americans are deeply divided on the big bad guvmit
>Americans are deeply divided on the big bad guvmit
But insurance companies are a-ok
Socialism is ok as long as it doesnt benefit minorities.
Like bank bailouts and farm grants.
The same way they ran before PE and VC
I have hope that the newer generations don’t align with “big bad guvmit”, and there’s been enough negative experiences (direct and indirect) with healthcare that people will vote for alternatives.
Also, I am saddened by the shared anxiety of healthcare in US (availability while jobless, f*** by big bills, lack of care, etc). The raw amount of shared mental stress must contribute to lower lifespans :(
A lot of people who got the bad side of healthcare system are not there to tell the story. Or they wont have capacity or money to have kids, etc.
Also poor people who having serious health problems dont have time to be politically active.
My impression on the newer generation is either socialist or republican with little in between.
What's wrong with private practices again? Personally I prefer them but (purely my own impression) it seems like they are dwindling.
> What's wrong with private practices again?
Administrative overhead. And some things resist it, e.g. ERs.
I think that's going to depend on the operation. Also where I said "private" I should have included "small group" as well.
Fair point about emergency medicine. I meant healthcare (and also veterinary, dental, etc) in general. But I suppose there are some exceptions where the model doesn't fit so well.
are they? it's mostly boomers plus the ones that corpo-owned social media are able to hit
look at the F500 list and note how many healthcare companies are in the top 50 (even top 10), then ask yourself how much they could spend on marketing
Thats essential Democratic Socialism and would lead to minorities benefitting.
As such, liberals and conservatives agree its a bad idea.
My daughter is “on the spectrum” and dealing with these therapy places was just a huge waste of time and money. I don’t know if the places we went to were owned by private equity or what but the quality was really bad and this is in a major metropolitan area that is also affluent. The therapist seemed like good hearted people, but they were paid so miserably that there was constant turnover. The billing practices were always shady and complicated and frustrating. Not to mention most of these places have 6 to 12 months waiting list to see anybody in the first place.
Exactly the same experience with long term care for elderly relatives. It's all about getting their money. Care is perfunctory.
If everyone wasn’t held basically at economic gunpoint to a level where they are one or two missed paychecks to living in their car, we could advocate for patients and providers to strike outside of the managers offices or in front of a news station. It’s insane how having no financial security creates a world where they can extract with abandon.
It’s part and parcel to the mental healthcare system for the last decade or so. There is no place that does better because every single provider is dependent on private health insurance which rarely pays without major and intense hassle.
I really dislike this, especially because it ultimately results in worse care for the kids.
I think the place I take my kid to for therapy is likely private equity owned, but it's also about the only place available in my area.
I know they are charging around $80 per season, and I also know that the salaries for their therapists are around $25 to $30 per hour.
That leaves a very healthy margin for everything from employee benefits to building rental to admin (which I think is probably where the majority of margin goes).
I think you're over-estimating how much slack there is in the organization.
A rule of thumb is that benefits cost an employer 25-30% of salary. So you're already pushing to 50% of revenue going to direct salary costs. Then there are employees in non-revenue roles (HR, legal, accounting, IT, etc...) and employees doing non-revenue work.
Finally, you have rent, licensing, insurance, and all the other fixed costs.
An awful lot of businesses go under from underestimating what their expenses inevitably will be. Everyone they deal with has their hand out to get paid.
I mean OP said this is $80 / season, and salary rate is 25/hr.
So to your point, if we assume 4 appointments per season at one hour per, they are actually paying $100 in salary alone to only collect $80 season pass fee - a $20 loss! This business model is not sustainable
I assume that was meant to be "session"
Which is why successful business means being a sociopath.
Anthem Blue cross pays $125-$150/hr. $80/hr is cheap.
It's worth asking if you're curious or have a good relationship with the provider. Some may be willing to tell all about their ownership or management situation if prompted politely.
I know of a childcare center that was acquired recently. Not sure if by PE or just another business, but the employees are less than thrilled with the changes.
having work in an industry affected by PE buyouts, a lot of these are transactions acted on at management level by businessmen and MBAs/consultants in their offices with no clinician input, yet the hate seems directed at front-line staff.
applying this same kind of logic that PE uses, equating healthcare workers to machines is the bane of the industry.
and then people complain why ther doctors burn out. what do you expect when you ingrained on them that every hour not booked is $80 lost, so we need to book them 24/7, cut their lunch break and squeeze every inch of life from them.
These should be useful signals to regulators. Regulation is imperfect but somehow we blame companies that take advantage, either of immature or nonexistent regulation (which might be the case here) or of poorly written regulation (e.g. circa 2000 California energy regulation that let Enron and company run wild).
These companies, in finding essentially arbitrage opportunities, are, perversely, helping strengthen regulation, but only if regulators pay attention to what is going on and do something about it, instead of just watching it happen.
This fails to recognize the existence of lobbyists and regulatory capture.
No it doesn't. Nothing about what you're responding to indicates they're ignoring these things exist. Unless your argument is "lobbyists exist, so we should ban all regulations and go back to the wild west," then the sentence where the person referred to regulation as "imperfect" encompasses lobbying.
Can anyone explain me like im 5 - what is the alternative and what’s so special about private equity firms in this context?
Like those centers are going to be owned by someone one way or another - what is so special or bad about equity firms vs alternatives?
Genuine question. Because I don’t have a clue how this works in US.
This won't be at a 5yo level, but here's an attempt: there are a two things specific to private equity that often leads to higher prices and worsening service:
1. PE aren't investors like you and me. We can go to our brokerage and buy shares of a public company, hold those shares, vote on directors and proposals, etc... Or we can buy and sell ETF/mutual fund shares that own companies. Then, we (or fund managers) can sell those shares after any period of time we want. Could be years, decades, or minutes. Whatever meets our investing goals. The same is actually true for hedge funds. We buy a a piece of a company, hold it as long as we want, then sell to take profit/loss. When PE buys a company though, they buy the whole company AND they have a specific timeline in mind. This is because PE firms are actually temporary private "investment funds": partners put in money and expect a certain return on investment after a certain period of time. At the end, that's when the fund needs to wind down and return capital + returns. So, there's already a ticking clock on anything a PE firm buys, and pressure to generate return before time runs out. They typically do this by taking a company public on the stock market (maybe again) or selling it to someone else. (This doesn't always succeed, but there are other options then, like continuation funds.)
2. PE funds also take on a lot of debt. They can't afford to buy whole companies or roll up entire industries just with their investors' funds, so they borrow a lot. Now, the companies they buy for their portfolios not only need to generate returns for their investors, they also need to do that AFTER making payments on that debt. It multiplies the pressure.
There are a lot of cases where PE bought struggling companies, and with discipline and incentives turned things around on a timeline. But there are also a lot of cases where PE bought stable but boring companies, used debt and pressure to force them to raise prices, cut services, lay off workers, and lower quality in order to generate returns at the pace required.
(Most of this I learned from reading Matt Levine columns, I'm not an expert and don't work in this industry at all, so I may have some details wrong.)
That sounds to me then that the problem is not only that PE are incentivized only by profits.
But also by the system that disconnects end user’s satisfaction (families with kids on spectrum in this case) from the profit.
In other words if users of those centers were part of the profit equation - PE would not be a problem at all. Am I right?
If so then the real evil are people who created and support such a system I guess.
In the US, we often don't have options (by design). Be it ISP, grocery, electric, healthcare, etc. Many times the option is just two of the same type of monolith.
The acquisition of the company can also be financially "meta-strategic", where it doesn't actually matter what service the company provides, but how its assets can be structured or leveraged to extract more value for the PE's stakeholders: - https://www.businessinsider.com/red-lobster-endless-shrimp-b... - Here on HN: https://news.ycombinator.com/item?id=40233029
An individual likely (hopefully) has a moral compass.
A family introduces some perverse financial incentives but you also get long term (ie multi generation) planning and reputation concerns.
A group of practicing professionals who own the operation will hopefully exhibit some shared pride and professionalism.
A co-op or similar arrangement ties the interests directly to the local community.
The larger the public company the less overlap there will be with the customer's interests. At least they might worry about reputation and stock price though.
Pretty much the only concern PE has is avoiding litigation. Their primary motivation is maximizing value extraction over the short or medium term.
Isn’t the government a worst alternative?
No. This idea is the result of decades of propaganda.
The government has to answer to the people. PE firms do not: they answer only to money.
Worse than PE? I very much doubt that but I guess the answer will depend on the voters, how the healthcare ventures themselves are structured, how much open corruption the local culture tolerates, and similar.
However AFAIK most government solutions in the west involve public "insurance" as opposed to the direct operation of health care facilities themselves.
Why?
Just a driveby speculator but my guess is PE dillutes interest in and responsibility for the businesses.
Individuals or family holdings are more likely to have concern for their reputations in addition to finances, public companies are more likely to scrutinized offsetting what would be their much lower reputational concerns. But PE is diffuse and often distant enough to eliminate human reputational concerns while being held to far lower stadards than public companies.
The optimal version of a PE is to take a failing business and either turn it around or carve up assets and reallocate people to do something useful and profitable. The more a business is failing, the cheaper it is to takeover and for the PE to do the work of a fungus. But this process can also become a disease if it is too easy for them to takeover, taking a healthy host and carving it up. This is mimicked in real life when conditions turn a fungus into a hostile organism on something that is living; maybe it is just a little sick but the environmental conditions help the fungus more than it ought to leading to it being a killer instead of a resource freer.
The real question to ask is why can they take on so much debt? And for that, one needs to acknowledge the fact that, particularly for the well-connected, debt is easy to obtain as banks essentially create money for loans. There are constraints (otherwise the banks would make themselves trillionaires), but the constraint is not the quantity of money. This creation of money through lending leads to inflation which further supports operating via debt as those who take out loans see the real value of the loans decrease. The banks just made up the money so there isn't a direct loser from the inflation other than everyone who has to deal with increased prices. You can think of it as a broad, regressive tax on the population to fund these firms doing far more than they should.
With an actual constrained money supply tied to real wealth in the economy, the PE firms would have to focus on the best deals which means the businesses that are truly dying and their role is to turn the nonproductive assets into something productive.
---
I asked ChatGPT to critique my answer (which is unaltered above) and it said to tone down the lending being propped up by inflation and instead emphasized the following:
>Inflation can help leveraged borrowers, but in PE the bigger structural advantages are: • Interest deductibility (a massive tax subsidy to debt) • Limited liability (upside captured, downside partially socialized) • Fee extraction independent of performance • Ability to load debt onto the acquired company, not the PE fund
I then asked it to answer the question without regards to my context and it basically said PE is different because of
> • short ownership horizons • high leverage • strong control • financial returns as the primary goal
Here is the link to the short conversation if interested: https://chatgpt.com/share/6963a0de-7a04-8012-8c36-afef5dd74f...
Normal investor: "I'll give you money to grow your autism center. Take your time, focus on quality care."
We already know that Private Equity kills people in the hospitals [1] and nursing homes [2] for profit. So why do we continue to allow them to operate Healthcare facilities?
[1] https://jamanetwork.com/journals/jama/fullarticle/2813379
[2] https://www.nber.org/papers/w28474
Releasing an almost-3,000-page expose on private equity this week.
It's hard to argue against those who say private equity ruins everything. It's astonishing. And massively depressing.
You can download for free when you search the 'net for Founderstowne.
I'm looking forward to reading your book! Part of my expose of PE in the veterinary business can be found at https://www.privateequityvet.org
Wish I had your knowledge before writing...
Pages in my book related to how private-equity screwed over the vet industry: 250. 442. 1001.
I think people will be blown away that the company that makes M&Ms owns a ton of vets.
Wait so are you doing the journalistic action? I can't wait for this to drop. Please give me more details if possible.
Massive respects to your journalism, I have a lot of questions regarding this tho, namely how long did it take you to build this expose and where are you gonna drop it because I searched net for Founderstowne but I didn't find anything special, are they the VC fund you are gonna expose?
Can I post a direct link here... don't want to be accused of spam?
I expose just about everyone as a "roman a clef" (a work of "fiction":>).
I'm 58 years old. Entrepreneurial builder. Disgusted by VC/PE. Been writing this book since 1987.
After my first startup failed (didn't get PM fit) I got a bit obsessed with how to do good market research for innovation. Discovery interviews, JTBD, etc.
During my journey I took a beat and pointed my new skills at VCs. I interviewed a few dozen VCs trying to understand what they were trying to get done and what mattered to them, but with a bit of a bias trying to gauge whether they wanted to better predict market demand of their portfolio or prospective investments' products.
What I learned shocked me a bit. The sense I got was that they didn't really care about market demand or building a strong business, they mostly cared if the founder could sell the company up to food chain (series a, b, c etc).
Roughly speaking: "I don't care what value my portfolio companies create, I care about marking up my book so I can increase my take".
I don't know how much this had to do with ZIRP, but it really soured me to the VC industry. I've been committed to bootstrapping my companies ever since.
The direct link is: https://www.Founderstowne.com
It's not a peak HN submit time, that said: https://news.ycombinator.com/item?id=46572285
I see an empty post.
It's been submitted and will remain empty of comments until a HN user comments.
I see a post with 13 points (upvotes / positive reactions) and [flagged] (meaning the title alone upset a few people given there's been no time to read the content yet).
As with all HN submissions, YMMV - Your Mileage May Vary
Sure, why not, share your work!
Also, the two links in your profile do not work
Just updated. Thanks for the heads up.
Please name names when you do.
I name names. (Mostly.)
When I get sued (and I will), I'll employ "roman a clef" and slightly fictionalize the names.
By the way, VCs are not exactly any better than PE firms.
I've tried to reach out Marc Andreesen to see if he can 100% pivot to building instead of extracting. I'm encouraged by his latest fund.
Just a heads up. Oftentimes legally speaking a facade will only work if you haven't yet been found at fault.
And even if you know for a fact that you aren't at fault, an ounce of prevention is worth a pound of cure and all that. The legal process isn't exactly cheap.
Because we have governments anemic to running anything or regulating any business.
They are much more likely to continue shoveling cash into private businesses through subsidies then to want to setup and/or run the same business for a fraction of the cost.
Think the word that fits there is "allergic".
Certainly. These are institutions that have mostly been created during the progressive era of the US. The EPA (I believe) is the latest of these organizations.
Since roughly Reagan, the US has been either fully dismantling, defunding, or privatizing these institutions.
We've seen the FAA start to rely too heavily on the likes of Boeing to set regulation standards. The FDA has relied heavily on fees from private institutions to function and it's weakening due to that improper mixing has resulted in the likes of the Vioxx scandal.
Medicare is a good example of this. Under Clinton, rather than expanding or reforming medicare he introduced a plan to allow private insurance companies to get government dollars (medicare part c).
> Clinton, Obama, and Biden were doing this? If so, please provide examples.
Yup. Primarily on the 3rd prong but, especially under Clinton, there was also significant defunding that went one. "The era of big government is over".
Clinton did welfare reform, which added much stricter means testing and work requirements to welfare. The "reinventing government" program was literally a hack and slash on government agencies not unlike DOGE. The student loan reform reduced subsidies for students. He signed in the crime bill which enabled the building of private prisons and ramped up the US incarceration rates. And he created Medicare part C which created a route to send government funds to private insurers.
Obama's signature bill, the ACA, was a giant handout to insurance companies in pretty much every way. By trying to force people into buying insurance and also subsidizing insurance purchases, it was a major gift to health insurers. Even the Medicaid expansion mostly resulted in private insurers getting more wealthy as most states implement Medicaid via a private insurance contractor. After the first midterm Obama got very little done mainly due to the republican's continuing the Newt Gingrich "we oppose everything you support" strategy and the filibuster.
Biden was mostly business as usual, however both the infrastructure bill and the chips act can't be seen as anything other than just massive giveaways to private industry. The build back better act would have been the same had it passed.
The same one who just said PE isn't allowed to buy any more residential real estate?
I hope they go after hospitals next.
> The same one who just said PE isn't allowed to buy any more residential real estate?
We'll see. That was just an EO. That doesn't really have the force of law behind it. There's not a regulatory body (AFAIK) that would or could prevent PE from gobbling up a home.
But if there's a route to stop it then I'm not opposed to it. PE buying essential goods and industries is bad for everyone.
It wasn't even an EO. It was a tweet.
The President's statements, and even unspoken thoughts, have the full force of law. This President, anyway-- I think the Supreme Court has a special criterion they use to determine whether Unitary Executive Theory should apply to a particular administration.
Yes, if admin == Republican.
My impression is it was also mostly a publicity stunt.
He says about 500 things a week and rarely followed through. They have gone after anyone yet so I wouldn't be thinking about "next"
[dead]
I’ve been hoping to meet one of the marks for the ol’ “tweet means he did it” thing in year 5. Hello!
NB: “single family homes” not “residential real estate”
Government is probably the worst actor to run healthcare facilities. It’s not that different from PE, except with more administrative bloat. I’d be curious to compare US PE run facilities with government run facilities in Canada.
There is not an easy answer here, it basically a cost centre that whoever runs it, the welfare state is incentivized to spend as little as possible on it. PE is almost certainly a bad solution. If they can destroy a restaurant or other low impact business, I hate to think what they’d do to businesses that care for people. You’d get the healthcare equivalent of Burger King. But with government you get the equivalent of the DMV.
Canada's healthcare is generally cheaper per capita, pays healthcare workers less and has far lower administrative costs than the US. The US spends 5x the average of other wealthy countries on administrative costs [1]. This line that the government is automatically inefficient and terrible at anything at all is not true, is not set in stone and does not preclude private industry being even more greedy, stupid, amoral and inefficient than the government.
[1] https://www.pgpf.org/article/how-does-the-us-healthcare-syst...
> The US spends 5x the average of other wealthy countries on administrative costs [1]. This line that the government is automatically inefficient and terrible at anything at all is not true
It's a line that tends to be mainly parroted by... the US. Quelle fucking surprise.
> I’d be curious to compare US PE run facilities with government run facilities in Canada.
You don't have to do that, we have US government ran facilities. It's the VA.
And if you look at the costs associated with the VA, they are much much cheaper than almost any private care [1].
And if you know a few vets, you know they almost universally love the VA. It's one of the best perks of serving in the military.
[1] https://www.herc.research.va.gov/include/page.asp?ID=inpatie...
Free market ideologues are too dumb to understand local minima.
An ideal free market is a global minima (in theory). It's the best.
A non-ideal free market (heavily subsidised and regulated) might be close (in parameter space) to a global minima, but might be highly suboptimal compared to a local minima.
It's not even that. Free markets by themselves (as implemented thus far) DO NOT ACCOUNT FOR EXTERNALITIES.
I have yet to see reasonable fix to the tragedy of the commons in a free market situation, and that's one of the most basic things one is fucking introduced to when studying economics and game theory.
Anybody who thinks health care is best served solely privately should have to pay to be diagnosed for something; either that or they've been failed in their privately funded education.
In the past I have read some libertarian literature that suggested the answer to the tragedy of the commons was that there should be no commons. Everything should be privately owned. How that would actually work in practice is way beyond my tiny brain.
It doesn't matter if it works in practice - it's religion, so it doesn't have to be true. We sent rockets up into space and there wasn't a giant man there watching us, but people still believe God exists. We tried living in a free market and everything turned to shit, but people still believe in libertarianism.
I think the theory is that if people owned the forest, the rivers, etc, they would have an incentive to take care of them for the long term. As we've seen with how companies have had all the value sucked out of them by private equity, leaving nothing but husks, I think this is a pipe dream.
Former libertarian here. The issue with libertarianism is that it does not explain the state of the world. The world is inherently unregulated. If libertarianism was superior it would have outcompeted other systems and it would have been the dominant system right now.
Historic explanations are even more problematic. How does libertarianism explain nomadic cultures or rice growing cultures (that tend to be highly collectivist)?
> Free market ideologues are too dumb to understand local minima
…or Nash equilibriums.
Huh the government is the ideal party to do that. Because it can set its goals to best serve its constituents instead of making money.
Don't forget there are so many countries with government healthcare and their care is a lot more accessible than the US's. I've lived in many countries and a nationalised healthcare system is one of the things I select for.
Even a poor country like Cuba has one of the highest numbers of doctors per capita. Unfortunately a bit hamstrung by the US's illegal and needless sanctions so they can't get proper equipment but I've been told healthcare is still pretty excellent there.
it’s that first paragraph which is really the bugaboo. In an ideal world that first paragraph is 100% true. In reality, what you get is the government getting its own people on the inside, raking in tons of contract money and doing very little for that, then squeeze the services on the inside to win political points from their constituents by drumming up hatred for the system in which they work. While they take in "campaign contributions" from private entities who benefit from people falling out of the system or being fed up with it.
so I agree with you in theory, but in practice, there was a whole host of other issues that would need to be dealt with somehow. I don’t know that more bureaucracy is the solution, but I would like to think it can be handled.
Actual competition and monopoly breaking/preventing.
"Free" markets tend to have transparent pricing : US healthcare does not.
"Free" markets tend to have large numbers of independent players that compete with each other : This is disappearing in the US market.
We have the worst of both systems currently. It's not ran by the government to control costs to the end user. And it's ran by a few monopolistic insurance/medical companies to reap as much profit as possible.
You're both right: government-run healthcare works okay, except when it's the US government.
Canadian healthcare is horrible, pretty sure public healthcare in the UK is also very bad. It’s not a given that somehow switching to public healthcare will make the US like Finland, Canada is much more likely.
Yes, when the government politicians hate public healthcare they can successfully sabotage it. That just means we need to structure it in a way that they can't. The examples given were all successful in their missions in the past before they were actively targeted.
It's all about the execution - UK NHS public healthcare was once easily the envy of the world (I'm from Australia, not the UK) and then it suffered decades of being white anted by Conservatives.
> then it suffered decades of being white anted by Conservatives
On what planet does this not happen in America?
Of course it happens in the USofA, and more widely in the Americas.
The challenge for citizens is active participation in oversight of management of the commons - rats will sneak into every granary otherwise.
That’s where they got the idea.
Government is probably the worst actor to run healthcare facilities
Are those your gut feelings, or do you have an argument to back it up?
In reality, the outcomes from Government operated hospitals in Scandinavian Countries do not need to hide behind those of other countries, especially not with the US
https://jamanetwork.com/journals/jamainternalmedicine/fullar...
A better way to put this is
"The government is the best entity to run healthcare, except, when the voters elect people who's motto is fuck you, I've got mine"
So backing up a couple of levels in the conversation here, may I paraphrase.
Not "Government is probably the worst actor to run healthcare facilities"
but:
"Americans are probably the worst actors to run healthcare facilities"
I hope it's not true.
[flagged]
Because between the 1970s and 1990s, Western nations decided that private operations should be the default for everything except where the law specifically requires state institutions, instead of the other way round.
In many countries, essential services like hospitals, drinking water supply, airport security, schools, even prisons are now partially or fully privatized. It seems insane when you think about it, but that’s what your grandparents voted for.
How would this work the other way around? The state provides cheeseburgers and fidget spinners until someone writes a law requiring private industry to provide these things? Isn't there a sort of lack of freedom inherent in forcing people to get all their cheeseburgers from a single place?
The other way around would be having public options except where explicitly forbidden. The existence of a public option does not forbid private options. For example the existence of the USPS does not forbid UPS or Fedex or Amazon from operating delivery services, which may be preferable for many customers. But the public option guarantees that a certain level of service is available to anyone and makes it impossible for any private entity to secure a monopoly. It also is very sensible in cases of natural monopoly (power plants, international airports, prisons, wastewater treatment centers) where there's never going to be any meaningful competition that the government should own and operate the monopoly.
Yes, but there's also a lack of freedom inherent in denying people healthcare and other public services because they can't afford them.
Government is fundamental. Business is art.
I wonder if who owns it is a red herring, but routing out corruption and bad incentives is the key.
Government runs anything that regulation alone cant make safe.
Ukraine an interesting moment with the recent (as in less than 10 years ago) health reform. The change was not in the ownership regime, but in funding (preallicated fixed amount vs post payment for itemised coded services).
Once the incetives got changed, a lot of doctors opened up their own practices as PE. The government still foots the bill, but the corrupt middleman of the local variety got cut from the flow
> funding (preallicated fixed amount vs post payment for itemised coded services)
Could you expand on this?
What is the appropriate level of safety? Safety is a spectrum, not a binary condition. Privately owned commercial airlines operating under strict government regulation seem to be pretty safe.
Yes exactly, so keep the current model for that. What is safe enough depends on overton window to some extent.
yeah that probably isn't what they actually meant, obviously
Private is the default solution for all problems. The state only provides a service when the government takes action to do so, and usually this is on top of whatever existing private infrastructure there is.
This seems like a pretty weird perspective to have?
> It seems insane when you think about it, but that’s what your grandparents voted for.
Our grandparents wanted a nice hospital and that's what they voted for. The people they elected needed funds to build the hospital, so they sought funding. The IMF and World Bank said "sure, we'll help you fund it. But in order to do so, you need to privatize your healthcare industry."
Our grandparents got a nice hospital for a while, the politicians got another 4 years in power, and a few years later we noticed that our free healthcare was gone.
This, multiplied across the entire developing world.
A mix of public and private can work with proper regulation (especially when combined with state owned private companies).
This article only refers to the US. This is the second time I've brought it up over the last week, but it'd be nice if the US and "the west" weren't constantly conflated.
Not all of us have fucked over their citizens and spiraled into borderline dictatorships that are well on their way to becoming international pariahs as much as the US have.
Everything suddenly makes a lot more sense once you realize the US is a developing country, one that happens to control the global money printer (due to a few accidents of history).
It's the only developing country that is also "first-world" or "western", and unfortunately, also the most powerful of those.
> why do we continue to allow them to operate Healthcare facilities?
We don’t want to pay for them. When private equity is forced to sell, someone has to buy or the providers get shuttered.
On the other hand, we’re clearly willing to blow the money and deficit on stupid stuff. But only if it goes boom, apparently.
Who do you mean by "we", here?
The only possible entities who could buy a company are either a bigger company, or private equity.
That the leavings of a PE business are unattractive to either of them is not a surprise.
That has nothing to do with what society at large (a better definition of "we") actually wants or needs.
> The only possible entities who could buy a company are either a bigger company, or private equity.
The American mind virus at work.
My (non-US) state government literally purchased a private hospital late last year. Now it’s public.
Keep telling yourself that corporations are going to save you. Maybe it’ll happen eventually.
My red state rural county setup our own ambulance district. We now get much better service than before.
Hell yeah! Some things are meant to be infrastructure. Now do fiber-to-the-premises!
Oh, trust me, I would absolutely love for a lot more of the US to be socialized (certainly healthcare, housing, and transportation.)
Unfortunately that is virtually impossible in the current political climate, so I didn't include it.
What I was trying to say is that, as it stands, PE is the end of an entity's life. Once it's been strip-mined for all value, of course nobody wants it.
> that is virtually impossible in the current political climate
We probably need a Constitutional amendment codifying independent agencies before it can happen. We don’t need the President denying protesters medical treatment because he needs to distract from his pediphilia.
The government-owned things still suck too, they just give sweetheart contracts to whoever greases the right palms even though they suck. The money still flows to bad people, no matter what. Having it be tax money in the first place just increases the possible money available to be stolen, since government budgets can in practice only go up, plus the feds can print money.
You have a good point but you squander it with condescension and sarcasm.
They could be owned by Physicians or by the Local Government. But the US has practically banned the first one
https://www.cms.gov/medicare/regulations-guidance/physician-...
> Who do you mean by "we", here?
Voters, broadly and monolithically.
> only possible entities who could buy a company are either a bigger company, or private equity
Communities. Forcing PE to divest from healthcare would require setting up a lending facility communities can borrow from to buy back their healthcare infrastructure. (Or have the government just buy it outright.)
I guess you could make it work as a window-dressing bill. Force PE to divest. Leave unsaid that you’re letting billionaires and family offices buy it up to continue the same shit. But actually solving the problem means ponying up cash to buy this stuff back. Even if it’s out of bankruptcy. (I’m not even touching the politics of paying PE and its lenders with public money.)
If you change rules to make the PE business model unprofitable, since it's in many ways toxic to society, you can result in them then needing to sell, for much less than they'd like most likely, or adapt and become less toxic.
> you can result in them then needing to sell, for much less than they'd like most likely
I’m imagining harder. Forced divestiture. Good amount of the hospitals and nursing homes would be bought of out bankruptcy.
But they still need to be bought and funded. And I think nobody wants to have a conversation about how much that costs and who winds up paying for it, particularly with many of PE’s hospitals being in rural America.
> We don’t want to pay for them.
Perhaps we should have kept taxing the rich the we did during WW2 and the few decades following it? No, clearly that would never work!
> we should have kept taxing the rich the we did during WW2 and the few decades following it?
Genuine question: source for any of the rich having paid more in the 50s than they did in the 90s? My understanding is that while published rates were high, effective rates were roughly flat until the Bush and Trump tax cuts.
genuine answer that it's really easy to look this up. start with a search on "Roosevelt".
https://taxpolicycenter.org/sites/default/files/statistics/p...
These are literally the rates. Not effectives.
The average effective tax rate stayed flat from 1945-2015, but the effective tax rate for the 0.1% and 1% fell during that time period. Bottoming out around the Bush years (although the graph only goes to 2015 so another source is needed to see how the Trump tax breaks have played out). The top for the 0.1% was almost 50% and the bottom was almost 20%. Now those almosts are working in the opposite directions so you should look at the graphs.
https://taxpolicycenter.org/taxvox/effective-income-tax-rate...
Now the 1% is paying more of the overall taxes, about 40%, but that number is also skewed (and can be misleading) by the absolute massive disparity between what the top and bottom make now. Plus of course reporting and tax compliance has changed a bit, plus a whole host of other confounding factors that this 40% statistic subsumes, but it's worth mentioning because it's always brought up in these discussions.
>Tax Statistics and authors' calculations all other years.
So the article has no source for the data? Only two years of data comes from the IRS, where does the rest come from? Why should we trust this?
Yes, and the rest of the article discussed how they actually have revisited some of their numbers and links to their reports where you can read about their methodology and decide if it's comprehensive enough.
To quote the article: "Debates over measuring effective tax rates have been lively because measuring taxes and incomes is complex and involves judgement calls (and the political stakes are high.) We applied a simple and replicable method to a single, publicly available source of data to estimate the effective tax rates of high-income taxpayers that avoids making assumptions about grey areas like unrealized capital gains and corporate tax burdens."
>> > why do we continue to allow them to operate Healthcare facilities?
We don’t want to pay for them. When private equity is forced to sell, someone has to buy or the providers get shuttered.
Sell? The point is that PE should never have purchased these things in the first place.
> The point is that PE should never have purchased these things in the first place
You can change the present. Not the past. Private equity owns these things. If you want them to not own it, you have to buy it back. Even if out of bankruptcy. Even if via eminent domain. Then you have to run it. All of that costs money.
You're missing the point. It's too late to unwind those transactions.
In theory state or federal governments could seize ownership of those healthcare provider organizations. But then legally the government would be forced to compensate the current owners at fair market value.
Had a creepy interaction with Fraser. They absolutely did a marketing spiel and sounded nothing like a medical intervention.
When you review the findings on the standard behavioral intervention, autism, on average requires 2.5 years of 40hr/week.
Thats basically one persons job.
Your citation's statistics [1] actually says the exact opposite of your claim!
It shows a -0.2pp DECREASE in in-hospital mortality, with no significant change on 7 or 30 day mortality. The authors suggest this could be due to:
* selecting for healthier patients - the paper shows an average change of 0.1 years younger for patients. this is not significant!
* transferring out sicker patients - 30 day mortality would show this (it doesn't), and the transfer rate does not change meaningfully
So based on the evidence you have provided, private equity purchasing hospitals saves lives. Maybe that is wrong, but it is the conclusion of that evidence.
They also don't claim PE is killing people in the conclusion; did you read the paper?
The age difference was significant
They've had more bloodstream infections, surgical infections, and falls. Everything which traces back to staff cuts and lack of hygiene.
Also they dumped the complicated, and probably expensive cases to real hospitals In contrast, transfers to other acute care hospitals increased 12.2% at private equity hospitals compared with control hospitals
A 1 month average age difference is not medically significant.
They had more bloodstream infections yep. Surgical infections was NOT statistically significant. And again, mortality went down!!
The “dumping cases” thing is incredibly suspicious. So they’re so motivated by money that they … don’t keep patients who would spend a lot? On top of that, the 30 day mortality doesn’t show an increase, which is what you’d see if they dumped deaths onto other hospitals.
Medicare reimburses by DRG, which is a payment for the average cost patients with that diagnosis and comorbidities have.
Usually those hospitals send the patients they expect to become to cost more than the DRG Reimbursement (Complications, too old, too many comorbidities) off to public hospitals. At least that's how it works in Germany. At the same time, they are very aggressive with upcoding their diagnoses to get more reimbursement.
Private equity's destruction goes FAR beyond hospitals, nursing homes and vets:
Healthcare
In all these critiques, "private equity" is a stand-in for "capitalism" in general.
They started slapping my kids hands, forcibly shoving him back in his chair, and grabbing my kids face and torquing his neck. Jon Paul Saunders, a leader in ABA, swore up and down 'this is the best in ABA'. When I looked at the data, my kid had all but stopped screaming/crying with other RBT's, but was more than double the crying/screaming with the rbt's doing the slap, push, face yank teqnique.
At this point, my son had done 18 months of ABA and was being used to train new RBT's (high turnover field of course). The prescribed hitting was creating behavioral problems at home, but was being used to justify extensive hours of ABA.
I dont think a profit driven model is great for these kids.
Private equity is into this. Into that. The problem is some folks just got too much damn money. They gotta put it somewhere.
That's it. And everything they touch turns to shit to feed their insatiable, sociopathic greed.
>“Private investors making a little bit of money while expanding access is not a bad thing, per se,” Singh said. “But we need to understand how much of a bad thing this is and how much of a good thing this is. This is a first step in that direction.”
Who gets to say what "a little bit of money" is here?
If anyone wants to see how private equity has transformed the veterinary industry check out www.privateequityvet.org/vet-list - over 7000 practices mapped across the US so far. Our dog died at the hands of a recently acquired PE practice :(
Are you surprised? there's money to be made.
You are implying people should shut up about it because it's not novel information. I think "are you surprised?" is a very lame and unoriginal response I see everywhere and doesn't even care to engage with the problem. I think HN's rules suggest you should put in more effort than this.
Absolute cancer.
The confusion in this thread about "how PE firms operate" is understandable - the language of private equity is deliberately opaque.
Try to buy an HVAC or heavy motor capacitor.. guess who owns all of the manufacturers?
Private equity just makes everything worse for consumer. Squeezes every penny out.
Private equity goes where the money is. Nothing is magically non-exploitative just because it's done by a bunch of small businessmen instead of a private equity company. There's a reason why Private Equity bought so many dialysis clinics. There's a reason why they're doing this.
It's easy to scam the government out of money for this because a bunch of well-meaning "useful idiots" will say "pay whatever it takes; give them as much money as they need; it's for human lives!" and none of that is true. It's all about using different battalions to rent-seek on normal tax-paying Americans.
Tim Walz lost his hope for re-election over this but he's not the only one. In time we will discover a large array of healthcare scams and home-care and autism/child mental health are going to be near the top.
Yes, as soon as I hit the "...children who are largely insured by Medicaid programs..." part of the article, I figured that this is happening because some PE firms ran the numbers and discovered they could use autistic kids to squeeze as much money from medicaid as possible.
If your dialysis clinics have the worst outcomes in the industrialised world, it should make you go hmmm.
And usually it's not a problem, of "Throwing more money at it", but lack of regulations and enforcing them.
That said, Physician Owned Clinics have better outcomes, there is no reason why that shouldn't be the standard model of operating them. Usually they have more moral scruples about worsening care for profit.
Also there is naturally more competition, if there are multiple small operators instead of only Fresenius Nephrocare or DaVita
https://www.cbsnews.com/texas/news/death-rates-at-u-s-dialys...
CBS say this then don't publish the data!
The data [https://www.transonic.com/renal-disease-in-us] says that kidney transplants for dialysis patients happen LESS frequently in the USA than in Europe, yet the survival rate is very close - 39% USA vs 41% Europe. This implies that dialysis in the USA is very close or _better_ quality than in Europe - as there is a large difference in transplant rates but only a small difference in survival rates.
Maybe the above data is wrong, but CBS don't seem to provide any better data
Your own link says
Survival rates for ESRD are higher in Europe than the U.S. This could be explained by the inferiority of national standards of care, a higher prevalence of patients with diabetes and differences in practice patterns.
Let's look at actual journals
For those with ESKD onset from 2004 to 2008, unadjusted 5-year survival of all patients with ESKD (treated with dialysis or transplantation) was 41% in the USA, 48% in Europe, and 60% in Japan, despite patients being 2–3 years older on average in Europe and Japan than in the USA, and Japan having very few transplant patients.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6...
The US had a much higher KRT incidence, prevalence, and mortality compared to Europe, and despite a higher kidney transplantation rate, a lower proportion of prevalent patients with a functioning graft.
https://pubmed.ncbi.nlm.nih.gov/38439701/
This does seem like a direct contradiction to me, but it’s also 2 decades old
The second paper has data from 2021, I've included the first one because it's from a top journal
Then yeah, this supercedes my point, seems I am wrong
The dialysis clinics are bad and make all the money because it’s Medicare fraud dude. Well meaning morons say “whatever people need we should pay for them” not thinking for a second that some unscrupulous fuck is the one getting the money.
We have something like this going on in Australia right now.
The NDIS is our disability welfare scheme, and it's costs have exploded as oversight has failed to keep pace with exploitative actors. Few questions asked welfare for our vulnerable would be nice, but sadly it doesn't look sustainable in most places.
ah yes, another market where the private equity scum have realised that "the market is inefficient" and that the existing businesses aren't "extracting maximum consumer surplus"
fortunately the UK doesn't have this problem for people as the state run healthcare system has set the price floor at zero
it hasn't stopped the private equity scum completely though, instead they have bought up most of the country's formerly independent vets
> From only 10% in 2013, almost 60% of veterinary practices are now owned by large companies
they then immediately "optimise the demand curve", doubling/tripling their prices, meaning there are now people that can no longer afford to treat their pets
Reading the headline all I can think about is that many people with autism are not capable of communicating, or if they are, only in a limited way. Literally people who do not have a voice to speak for themselves.
Like severe autism? Yeah.
Moderate and below that I think you can live a pretty free life. Its not like down-syndrome. Autism is surprisingly normalized.
Yes, depending on whose stats you use it's 20-30% of those diagnosed. Not a small amount and people I worry about being dependent on private equity.
https://pmc.ncbi.nlm.nih.gov/articles/PMC3869868/
Ah yeah
Private equity in healthcare shows particularly clearly how far capitalism is willing to go. Profiting from the suffering of humans and animals, while probably still feeling good and even heroic about it, disgusts me.
I can see your perspective, but healthcare isn't always a zero sum game. It can be empathetic and useful while also being profitable. It often isn't, but it can be.
There is plenty of evidence that Hospitals, Nursing Homes operated by private equity have way more worse outcomes than those of other operators, even for-profit ones
Yes. It starts benign "no major changes!" and soon stock is reduced, staff get cut, and cost cutting rules are enacted by people who never have to witness the effects on the patients who slip into worse outcomes. And if it crashes into the ground they can float away on golden parachutes.
Why does it HAVE to be profitable?
Why can't we just leave some things out of the whole madness?
It's not like we don't have enough stuff that can be made profitable already.
Just let your customers be healthy, have a roof over their head, water, electricity, internet. They'll have more time and money to spend on all the other profitable stuff.
It doesn't have to be EVERYTHING!
Because we would like people to continue providing our healthcare services?
Why should they stop doing that?
I dont know about you, but I mostly go to work so they'll pay me money. I then use that money for stuff like food.
Is the money you get from taxes worse then the one you get from private sources or what is it you want to tell me here?
Come to think of it, I don't think I've ever experienced a product or service that took a turn for the better, after the company was acquired by PE.
There might have been a time where PE bought up mismanaged companies, and turned them around - but the PE acquisition spree we've seen for the past 10 years or so...it seems exclusively to cause enshitification. And it is happening everywhere. There will always exist some niche PE firms for every sector out there, nothing is safe.
Yes it happens. It doesn't make headlines. And I'm not sure it happens often.
> The primary concern is that private equity firms may prioritize financial gains over families, said Daniel Arnold, a senior research scientist at the School of Public Health.
...may? How are they not already by gobbling them up in a calculated way. Targeting states with lax insurance claim scrutiny
If corporations are people than PE firms should be executed like the leaches on society they are. Nothing makes me see red like the fact that basic services are increasingly being captured by these disgusting rats so they can squeeze every last cent out of society possible.
You should share anger for all the taxpayer dollars being stolen and never spent on the 'victims' its supposedly meant to help.
Social programs have been funded, show poor results, then seem like dead ends because of fraud.
Stealing money put aside to help the less fortunate is far more heinous imo.
Even with the losses a lot more is provided per dollar because its done at-cost, and the majority still going to the most desperate.
If we wanted to worry about the bigges source of theft though it is wage theft by a large margin over all other forms of threat combined. And the healthcare industry is ripe with labor abuses.
> Social programs have been funded, show poor results, then seem like dead ends because of fraud.
They already got audited by DOGE, now we move on to PE
You mean like Bret Favre the millionaire conservative ex-NFL quarterback's welfare scandal stealing from the poor? https://en.wikipedia.org/wiki/Mississippi_welfare_funds_scan...
Or do you mean like Republican Senator from Florida Rick Scott who was elected AFTER he was involve in $1.7 billion dollars in Medicaid fraud (largest in history) and whom the Republican party embraces and endorses and has in a position of power today? https://www.justice.gov/archive/opa/pr/2003/June/03_civ_386....
Yes, like those. "Stealing money put aside to help the less fortunate" is bad and should be stopped, regardless of the political beliefs of whoever is doing it. The right question to ask is "is this fraud", not "which side are the perpetrators on".
Can we join together and agree fraud should be stopped rather than protecting people based on which team they are on? It's fine to question whether something is fraud or not, but once it's clear, let's shut it down and punish those responsible.
In the Democratic party, Tim Waltz, with zero proof against him personally, withdrew from the election we was running for when there was an impression of abuse.
The Republican party EMBRACED the head man involved in the largest theft in Medicare history, and he is a powerful Senator for them.
This is very much political, as I highlighted. One party acts with responsibility, the other doesn't care except for soundbites and wielding accusations as a weapon and abuse as a boogie man to say 'we can't have government, because people like our Senator steal from it' (it happens to also be the part that hates government, shockingly).
What did you think was going to happen when you've got guaranteed payments and a growing customer base as people celebrate their "neurodiversity" whilst at the same time demanding subsidies and yelling "ableist" at anyone who criticises them or the system?
So politicians pretend to care by throwing more money at their cronies and get away with it because won't someone PLEASE think of the children. And then people pat them on back and vote for them in the next election, and blame "capitalism" while the people they've just voted back in make millions.
They even say "We're also dealing with children who are largely insured by Medicaid programs" and yet still people are failing to join the dots...
> and yet still people are failing to join the dots
Where is this 'join' translated from ?
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Is it even moral to help people if investors aren't making a profit in the process? (/s)
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Makes sense. Half the people I know now have autism including Elon musk so it’s quite lucrative.
They always did, its just that you now know about it.
I know this is the conventional view. But is it possible that the prevalence of autism has been somewhat exaggerated and overdiagnosed? There's a CLEAR profit motive here...
Yes, but also we've gotten better at diagnosis. Both things are likely true to varying degrees.
That said, Elon is one of the most obviously autistic people I've ever seen. He's not a great example of overdiagnosis. In fact, if autism hadn't already been discovered they'd have taken one look at him and invented Elontism.
No it's not over exaggerated at all. Autism is highly prevalent and everywhere. The industry made a mistake, it originally assumed autism was a rare condition, but now we're starting to see that it's a personality trait because it's so common. We're coming to similar realizations for other things like the concept of gender as well as society modernizes and gets rid of out-dated thinking practices.
Autism is not a personality trait. Many people are severely disabled by it and are essentially non-functional.
Only about 15-20% have full time jobs. The suicide rate is incredibly, almost unbelievably, high. I think it was something like 80% have attempted suicide.
Personally I think we need more subtypes again. Its weird to lump high functioning aspergers folks like the richest man in the world into the same category as those who have to wear helmets and be physically prevented from harming themselves.
False the definition is fiercely contested and from many angles it can be considered a personality trait.
https://www.theguardian.com/society/2023/jul/31/autism-could...
The sources they cite in that article aren't medical professionals. Simger is at least a scientist, but she's a sociologist with an opinion, and Silverman is just a writer with an opinion.
Lots of unqualified people claim lots of things, that doesnt mean you ignore the actual doctors when it comes to medicine and ASD is literally defined as a disorder. You can not be diagnosed with it without some negative impact to your life.
They do also quote a few qualified doctors but the doctors use the word "disability" an awful lot and make no such claims.
Even then, the two folks that do argue for the "social model" of disability are still not arguing that it isnt a disability, they essentially just claim it would be nicer for people if we pretend it isn't - then they go on to to talk about how even among the autistic without learning disabilities the suicide rates are 9 times higher. They cite that as proof that its society making it worse, I see it as proof that autism isn't freaking good for you any more than depression is. Humans are social animals and social diseases are still diseases. More to the point, some of us wear helmets and spend 12 hours a day in a ball rocking back and forth. Thats not "societies problem".
The whole thing reminds me of when I was diagnosed and my neuropsych asked me if I wanted it to be included in my file. He explained that many/most of his very high functioning clients preferred it not be in their medical record, as they didn't want the stigma.
I honestly think we are still under-reporting the numbers for the high functioning, and its largely because some people are too scared to accept who/what they are. IMO those people need to face reality, not ask society to play pretend. The actual name of the diagnosis includes the word "disorder" and you literally cant have autism if you dont have problems.
Pretending that you are fine and it s just a personality trait is counterproductive, but if it helps you sleep at night go for it, I guess. Just be careful. Pretending like all your problems are societies fault won't actually change who you are or reduce your symptoms.
Singer invented the term "neurodiversity".
Also note that scientists and doctors are no longer on the frontlines of the change that's sweeping across society. It's activists who realize that identity and community is more important than cold logical arguments.
>Pretending like all your problems are societies fault won't actually change who you are or reduce your symptoms.
No, I don't pretend it's societies fault that I am who I am. It's societies fault for not being inclusive of who I am and not completely normalizing my condition so I feel included.
> Also note that scientists and doctors are no longer on the frontlines of the change that's sweeping across society. It's activists who realize that identity and community is more important than cold logical arguments.
What I'm about to say is very negative, but please don't think it's directed at you. I'm just jaded and have seen some things.
I can respect that you see a problem and want to solve it, and I even agree that it's a problem. The suicide rate, for example, can at least partly be blamed on the way society (especially children) treat people who are different. That said, I can't help but feel that you are missing a few key things.
1) It's a medical condition. Better activism doesn't lead to better patient outcomes. It just puts conflicting pressures on already overtaxed doctors that make it hard for them to treat patients properly. See what's happening to trans folks for an example.
2) Forcing people to use different words to describe you doesn't make them respect you more, it just frustrates them that they can't speak plainly.
Take the medical term "Mongoloid" for example. It was used to describe the people we now call "Intellectually Disabled" until it became an insult. So doctors invented a new term: "Moron." Moron almost immediately became an insult, so they invented "Mentally Retarded." Mentally retarded became an insult, and was actually *outlawed* in 2010 (Literally outlawed, check out Rosa's law). A few weeks ago I heard my niece make fun of my nephew by calling him "mentally challenged" and doing a hand gesture. He was no less offended than he would have been if she'd used any of the other terms.
The history of that sickness is a history of euphemisms: Simpleteon, Cretin, Imbecile, Mongoloid, Retard, Idiot, Defective, etc... The've all been socially acceptable designations at one point, but each time a new one is created it also turns into an insult. It's not the phrasing that is the problem here, and it can't be fixed by adjusting the language we use (although I'm sure we'll keep inventing new euphemisms forever). There's a fundamental aspect of "not being smart" that people find insulting so whatever you call them BECOMES THE INSULT. We can't change that, it's just how humans are.
Similarly, autistic people are *Weird*. We just don't fit in well, and neither scolding the kids on the playground for using the wrong terms or blasting some Joe Six-Pack on twitter are going to change their minds.
Even if we get them to change their words, the words will become insults by virtue of being tied to the "weird people". When you finally convince everyone to call us "neurodiverse" it will mean that neurodiverse has become an insult. When we convince them it's just a "personality type" it we be regarded as a bad personality type.
Changing other people just doesn't work. You have to change what you expect from them if you want to be happy. It's all your really in charge of.
> 1) It's a medical condition. Better activism doesn't lead to better patient outcomes. It just puts conflicting pressures on already overtaxed doctors that make it hard for them to treat patients properly. See what's happening to trans folks for an example.
What? Activism by trans people is directly responsible for the improvement of the lives of trans people (see informed consent for example).
"In the last five years, more anti-trans legislation has been proposed in the United States than in the previous 200 years combined." [0]
You have to look at the real world, not the world that (presumably) we both wish we lived in. In real life, activism just leads to counter-activism.
I'm not saying that trans folks aren't better off now than they were a decade ago, but I am saying that for every action there is an equal and opposite reaction. If you have a medical condition that needs treatment you probably don't need a line of dummies lining up to block you as you walk in because you've turned your condition into "Activism."
Some things are made worse by turning it into politics.
[0] https://gender.stanford.edu/news/continuities-and-developmen...
Private Equity would certainly benefit from it being a personality trait that also happens to "require" medication...
We're on hackernews. Half of us in here probably joke about being autistic ourselves. That doesn't mean we need to give Pfizer and Blackstone billions of dollars for pills and treatment.
Not all of us are convinced that each and every component of human diversity needs to be treated as an ailment and medicated. Autism, as the name implies, is a spectrum. But we've widened the spectrum so far that its become meaningless. There are profoundly autistic people who can't speak who would not recognize my diagnosis of autism simply because I have trouble looking people in the eye.
You mention gender, and that's a perfect example: we've widened it to include every possible thing. And when it comes to the over-diagnosis/overmedication question: You can be just fine with the idea that gender is a spectrum, but also believe that giving hormones and surgery to teenagers is utterly insane.
What do you mean I didn't know about it?
I always knew much of my family, including me, had autism.
You said "now have autism"? The "now" implies that they did not before, or that you at least did not know it before.
No, now means they have autism right now. It does not imply the did not have it before.
It can be interprted that way, but its a bit stilted. No worries though. English is famously confusing.
It reminds me of: "I used to do drugs... I still do, but also I used to." - Mitch Hedberg
Its funny because nobody expects you to use the language that way, but logically its still valid.
No they weren't. Autism is as a result of endocrine disruptions through environmental contamination along with a significant amount of heredity transmission. Same reason why T rates, sperm rates, fertility, are cratering.
https://en.wikipedia.org/wiki/Empathising%E2%80%93systemisin...
Unironically trying to villify the "Atrazine is turning the frogs gay" guy is going to look really stupid to liberals very soon.
It doesn't seem like you're trying to have a good faith discussion when your final sentence reads like a willful conflation of an academic and Alex Jones's comments, which were that atrazine is being intentionally put into the water supply by the government as a form of chemical warfare in order to reduce the population by making people gay.
You should read the criticism section of that Wikipedia article. The quotes read like a whose who of qualified autism reserachers.
Im adding a second comment for the frogs thing, since its really a separate issue.
I'm very liberal and never made fun of the researcher who identified that atrazine makes frogs gay. It does objectively mess with amphibian development.
I did, and still do, mock Alex Jones for insisting that it was government conspiracy "chemical warfare operation" designed to do... something. That makes exactly as much sense as his Sandy Hook nonsense or pizzagate.
Its cool to have autism now. People think it makes you nerdy into rockets like Elon.
Maybe these private equity firms are trying to create incubators out of these autism centers for new startup ideas..
Because autists make the best engineers? So autism center becomes a recruiting tool.