What the article does not seem to mention is that an usual electric wheelchair costs about $65,000 (and is intended to be replaced every six years or so). This and the non-availability of replacement parts is why some wheelchair users started a project to open-source a wheelchair from standard parts:
Louis Rossmann interviewed the founder of the project here: https://www.youtube.com/watch?v=eaAj59025Kk
Private equity discovered that regulations, compliance requirements, & other similar barriers to entry are the most effective 'moats' which allow businesses to raise prices and have little impact on demand; they are now exploiting this 'hack' ruthlessly.
This is a good illustration of the difference between capitalism and a free market.
In a free market, "moats" like regulatory capture would not exist. In a market like this, where the customers--wheelchair users--are generally pretty savvy about what they need, a free market would have no trouble providing products that met customer needs at an affordable cost, because customers would have meaningful choices about who to buy from and who not to buy from, and customers would see the full cost of the products so they could make meaningful cost-benefit calculations.
In capitalism such as we currently have, none of that is happening. The government aids and abets rich people who want to siphon off even more wealth than they already have by putting regulatory barriers in place that stifle competition, and it removes visibility into actual costs by forcing all medical products and services to be provided through health insurance, even when, as in this case, there is no insurable risk involved--it's an ongoing medical need that is already known (not a risk) and which is predictable (so insurance makes no sense anyway). The result, of course, is that the customers get shafted while rich people get richer.
In free market it's also OK to cut costs as much as possible, making chair that explode and kill the user one day after the warranty expires.
That's why we have regulation: to establish the minimum standards.
Simple medical devices like wheelchairs (Class I or Class II) are also not super over-regulated, you don't need to do clinical trials to certify them. All-in-all it'll cost you around $10m, which is not at all a moat.
Liability still exists in a free market. Regulations are government's way of giving you immunity from liability laws, or not enacting them, in exchange for doing things a very specific ways. This creates moates.
> Liability still exists in a free market
Only if a wronged party has the resources (time, money, political capital) to pursue it.
Which is but one reason why it is deeply silly to rely on it to make a society go.
> Only if a wronged party has the resources (time, money, political capital) to pursue it.
In a free market, if there is a market need for more efficient achievement of redress for wronged parties, the market will produce it.
> Which is but one reason why it is deeply silly to rely on it to make a society go.
But of course relying on governments to achieve redress for wronged parties works just great. Not.
Free markets are not a panacea, nor do ideal free markets ever exist anyway. Also, free markets require regulation to prevent powerful actors from making them non-free.
the market will produce it.
Only if it's profitable. Feeding poor people, caring for the indigent, etc. isn't profitable.
> Only if it's profitable.
Are you confusing markets with business?
To profit means that you accepted a debt instead of getting something in return for your efforts. Business seeks profit because the expectation is that it will pass the debt on to the stakeholders who will then call the debt and get something in return for their efforts.
But it is people who participate in the market. If they demand profit continually, therefore not getting anything in return, that just means they're working for free. People won't feed the poor unless they can do it for free? Methinks that's not what you meant.
In a free market, if there is a market need for more efficient achievement of redress for wronged parties, the market will produce it.
In our current market, many companies have worked around redress of wronged parties by mandating arbitration in various contracts.
Don't forget the resources and money required to bring X to the limited attention of the regulators and to ensure the regulation is sufficiently up to date and not subject to capture. I would argue it is orders of magnitude more than exploring the same through liability.
And putting resources towards lowering that barrier would go significantly further than any regulation.
Regulation is by nature slow and highly susceptible to corruption or stagnation. Whereas the courts, as onerous as they may be, essentially achieve the same thing through liability but it is more dynamic, more responsive, and more likely to error correct than the former.
Liability can't magically undo damage to health. Regulation is vital when the potential damage is irreversible.
Nor can regulation. But the idea is that, in seeking to avoid liability, people will avoid doing things that would foreseeably lead to such liability.
Likewise regulation is limited to preventing foreseeable issues, and is often only implemented after somebody suffers damages.
The difference is that regulations are imposed by a third party whose interests may not be aligned with those who are actually involved in the matter. This is good in circumstances where there are externalities, for example just because I'm okay with entering an agreement with a company to use my backyard to store toxic waste doesn't mean my neighbors would be very happy. But when people are making decisions that will only affect themselves, such as what wheelchair to purchase, liability really is the more sensible consumer protection.
Is liability not a regulation? See: All of the arguments/debates about how to regulate self-driving cars in cases where the car injures someone.
> In free market it's also OK to cut costs as much as possible, making chair that explode and kill the user one day after the warranty expires.
No, it isn't, because nobody will buy chairs from a company that does that. In a free market, no company can use the get out of jail free card of "but I was following all the regulations". Businesses have to actually meet customer needs.
And in a free market, customers can't delude themselves that Big Brother is looking out for them (even though Big Brother is not actually doing that); they know that they have to enforce quality if that's what they want. That means customers know that it's on them to be savvy enough to be able to evaluate the quality of products and services.
> That's why we have regulation: to establish the minimum standards.
That's what regulators claim, but all history shows that claim to be wrong. The end result of regulations is to reduce the quality and availability of products, not increase them. The wheelchair market described in the article is a classic example: it's regulated up one side and down the other, yet customers can't get simple things like proper footrests.
> Simple medical devices like wheelchairs (Class I or Class II) are also not super over-regulated, you don't need to do clinical trials to certify them.
Doesn't this contradict your claim that regulation is the only way to avoid exploding chairs? If you don't do clinical trials, how do you know the chairs won't explode one day after the warranty expires?
Of course the answer to this is that the regulators just, you know, look at the design of the chairs to evaluate them for certification. But customers could do the same thing for themselves, at less cost (what, you think those government regulators work for free?). So the regulations are actually adding zero value. But they're certainly not adding zero cost.
> All-in-all it'll cost you around $10m, which is not at all a moat.
So you'll be going into the wheelchair business then? Looks like there's plenty of opportunity to out-compete the current incumbents.
It's all theoretical. Do you see it actually working out this way? When and where?
regulators just, you know, look at the design of the chairs to evaluate them for certification. But customers could do the same thing for themselves, at less cost (what, you think those government regulators work for free?). So the regulations are actually adding zero value. But they're certainly not adding zero cost.
I have little idea how to evaluate the safety of an electric wheelchair, and don't have the time to acquire the expertise to learn how to do that with everything I buy. But we all can chip in and pay someone, who has the expertise, to do it once rather than than millions of people doing it redundantly.
Eternal September, except it’s an Econ 1 class.
It seems like quite a rush of it today. Did someone put up the anarcho-libertarian bat signal?
Then you can choose to pay that premium for a wheelchair, or any other good or service, evaluated by a third party of your choosing. But others, with potentially different requirements, should be able to choose different third parties who evaluate by different criteria. At the very least, you should be able to disregard a third party's evaluation of safety for a wheelchair. The idea that there should be one master evaluation and all other evaluations are redundant holds no water.
What if the wheelchair malfunctions and injures someone else? What if my car malfunctions and causes an accident?
Also, I don't want to live in world of frauds and scams and other crimes, trying to navigate it, for obvious reasons. It's also an economic disaster.
You're doing an awful lot of work to empower already powerful people by removing democratic power over our society.
No, it isn't, because nobody will buy chairs from a company that does that. In a free market, no company can use the get out of jail free card of "but I was following all the regulations". Businesses have to actually meet customer needs.
Meeting customer needs is optional, what businesses might decide to do instead is change their name once a week on amazon/ebay, hire teams of robots to fake reviews, and then deceive customers into buying doll house furniture at full size prices.
It seems unlikely you are unaware of this type of behavior, so I guess you have an explanation for how an unregulated market in a modern context is supposed to deal with bad actors?
Right, that's why formaldehyde was used as a preservative, and both arsenic and lead as food coloring - despite knowing it killed people at the time.
Why would I buy something that kills me the day after the warranty expires?
Because you don’t know that it will. If it’s been out for less than a year perhaps no one has been harmed by it yet.
We might think we have regulation for minimum standards, but that's not necessarily why regulations are created.
All-in-all it'll cost you around $10m, which is not at all a moat.
Ok, I know we’re assuming electric wheel chairs, we don’t want fires or stuck accelerators, but really? This is still fairly close to literally reinventing the wheel, or adding complexity, a RC car.
It’s pretty sad to think this level of almost Stone Age technology only needs a 10 million dollar investment to bootstrap.
Capitalism refers to the system of individuals pooling money together (capital) to start a venture that they couldn't if they acted separately. The idea of a company being a person-like legal entity with its own assets and liabilities is capitalistic.
In a free marked that is absent of regulatory hurdles, it is far from guaranteed that costs would be affordable.
Freedom from regulation about how wheelchairs have to be constructed would go hand-in-hand with freedom from regulation against monopolistic practices!!!
In a completely free market, devoid of regulation, wheelchair makers can get together and fix prices. Or buy each other.
> Capitalism refers to the system of individuals pooling money together (capital) to start a venture that they couldn't if they acted separately.
That's one aspect of capitalism, yes. But in capitalism as it is currently practiced, most of the people who are accumulating capital aren't people that are trying to start new ventures. They are people that are already rich but think they aren't rich enough, who are unable to start new ventures themselves because they have no actual skills at providing valuable products or services, so instead they find some existing venture and siphon off all its wealth. (This pattern is not new, btw; it's the same way the "robber barons" in the late 19th century operated.)
> In a free marked that is absent of regulatory hurdles, it is far from guaranteed that costs would be affordable.
Nothing is ever "guaranteed". But the article under discussion makes it obvious that with regulations in place, not only are costs not affordable, but even the very existence of products meeting customer needs is not happening. A free market couldn't possibly do any worse.
> In a completely free market, devoid of regulation, wheelchair makers can get together and fix prices. Or buy each other.
This would only happen if it were economically more efficient for wheelchairs to be made by a monopoly. I strongly doubt that is the case. It's not the case for the vast majority of products and services. If it's not economically efficient, the monopoly (or price-fixing cartel) will simply be out-competed in a free market, because it will have no way of keeping other companies from producing at a lower cost.
Historically, virtually all monopolies have been the result of government interference. (The original meaning of the word "monopoly" was a royal grant of the exclusive privilege to sell a particular product or service.) Most large corporations today are not the size they are because that is the most economically efficient way to deliver their products or services, but because it's the best way to buy government favors.
Historically, virtually all monopolies have been the result of government interference
I'm with you on this. In general, the state (by definition) functions to protect the interests of the politically dominant class, which, under capitalism, is the owning class. From the haymarket massacre to Biden's strike breaking shenanigans, this is absolutely beyond dispute. The state will always facilitate monopolies. The only way to get rid of monopolies is for the workers to organize and overthrow the dictatorship of the owning class. Until that happens, it's all Disney, Amazon, and pseudo democracy.
The only way to get rid of monopolies is for the workers to organize and overthrow the dictatorship of the owning class.
It worked very well in Tsarist Russia, but that could have been a fluke.
it will have no way of keeping other companies from producing at a lower cost.
It could get chummy with them and fix prices. It could buy them.
idea of a company being a person-like legal entity with its own assets and liabilities is capitalistic
It independently evolved in Rome and India to provide legal personhood to cities, guilds, public works and later, in the former, the Catholic Church.
private equity is just exploiting existing regulations that already make it hard for new members to enter the market & add competition no? doesn’t seem like many new regulations are being enacted to gain market dominance, working with what exists is enough?
> existing regulations
Which were put in place in response to other rich people lobbying the government for regulations that favored them and their companies. Perhaps there haven't been many recent ones put in place specifically in response to lobbying by private equity companies (though I'm not sure that's true). But that doesn't change the main point.
The problem is that the people with money have no incentive go innovate, they already have money. The people without money have reason to innovate but no means to do so. So everything stagnated.
We've seen consolidation across the whole economy (which have vastly different regulation schemes) so I'm skeptical of it being just regulation driven
I'm skeptical of it being just regulation driven
It seems to be blatantly obviously regulation in this case. There are electric wheelchairs in other countries. What's stopping them from being imported are the regulations.
Then, how would it fix things then if it wasn't private equity dominating that market?
There would still be regulations that would allow public equity wheelchair makers to jack prices.
how would it fix things then if it wasn't private equity dominating that market?
I'd start importing them for less than $500 from India [1]. (Versus $1,500 to $6,000 for these jalopies.)
[1] https://www.amazon.in/electric-wheelchair/s?k=electric+wheel...
The regulations don't just disappear to allow for such imports as in your example ...?
Well, that's the interesting thing. You likely can import and use these wheelchairs, but they can't be sold as medical devices and, subsequently, won't be covered by your insurance.
The dumb thing is these super cheap wheelchairs would likely cost the end users more money than the expensive ones as they will buy them out of pocket vs having their insurance/medicare cover most/all of the cost.
The reason these companies don't sell these wheelchairs in the US is likely because the marketing would run afowl of regulations about selling medical devices. You probably could sell these as bicycles and hobby chairs though.
they can't be sold as medical devices and, subsequently, won't be covered by your insurance.
This is something I've never really understood. Wouldn't the insurance company be ever grateful to you if you accepted a non-medical wheelchair because it's 1/10th the cost. Hell, have 5! Is there any reason insurance can't pay for them?
Not if it's owned by the same private equity firm as the wheelchair guys; then it's just another face of the same racket.
Also, medical insurance is supposed to cover bona fide medical treatments and supplies. So this likely bumps up against regulation again. If something goes wrong with the out-of-regulation device that insurance paid of as if it were a medical wheelchair (e.g. safety incident leading to injury), they could be liable.
It's the same as why dental insurance won't pay for your next door neighbor handyman to pull out your tooth with a pair of pliers.
I mean they could market similar to Not a Wheelchair I guess? https://notawheelchair.com/products/the-rig
The price difference seems to be enough for a person to fly to India and bring one with them.
Can the FDA stop a person from using one by coming to their home and confiscating it?
No and you needn't bother with the medical tourism. You're allowed to use whatever assistive device you'd like, it's only when you wade into getting insurance or the govt to pay for it that the regulations start to matter.
regulations don't just disappear to allow for such imports as in your example
My point is the regulations are leading to the duopoly, which is the source of the problem. The last private-equity owner seems to have been fine. And the market was competitive before the CMS rules in 2005. I’m not suggesting scrapping the rules. But the rules are clearly well past safety.
Perhaps you've confused which comment I was replying to with one further up, from what I can see you were trying to answer the question, and nothing else is visible:
how would it fix things then if it wasn't private equity dominating that market?
The visible answer is clearly contingent on some future regulatory landscape coming into existence, otherwise it makes no sense, so I was wondering how does it answer the original question?
It would not necessarily fix things if private equity wasn't involved, but private equity is particularly effective at identifying cases where a market or regulatory inefficiency is not being maximally exploited, and jumping in to extract profits from that. So sort of by construction, when private equity enters a particular market, things are likely to get worse for consumers. It doesn't mean that things are golden if private equity is not involved.
What exactly do you mean 'blatantly obvious'? Because to me, the issue that is blatantly obvious is that we don't have enough regulations on PE.
Let's say in this scenario you do import an electric wheelchair. You fork out a few thousand dollars on the expensive costs of said purchases. It breaks. No one in America can repair it. Or if they can repair it, you have to go through the PE-owned wheelchair market, whom charge a premium. Your options are fork out the money for repairs, import another wheelchair, or send it abroad for repairs.
Assuming that instead you create a company designed around importing said wheelchairs, PE buys you out and then sells imported wheelchairs at monopolistic prices.
The regulation is what drives the ratio, here, though. Consolidation often brings price increases and worse service for customers, but in a regulated industry, you can push this practice quite a bit further than you might consider doing in any other one.
Regulation across the whole economy is one of the principle mechanisms of consolidation.
Vested interests sell regulation to the public as a "consumer protection" mechanism, then use regulatory capture as a tool to erect barriers to entry and impose complex rules that supersede common-law jurisdiction while giving them a range of tools to evade liability. The threat of competition is restrained, and a de facto collusive oligopoly can squeeze the market dry.
That some people apparently can't see this strat with AI "safety" laws is genuinely bizarre.
How do think we should address security around AI, and the public's control over a major impact on their lives, welfare, freedom, prosperity, etc.
The first step is to stop thinking of "the public" as a monolithic entity whose interests are pursued by the government, and instead recognize that control over things that have a major impact on the lives, welfare, freedom, and prosperity need to be things they can effectively control or opt-out of as individuals.
Regulatory intervention makes it harder, not easier, for individuals to take charge of these matters for themselves. You can bet that the first casualty of a regulatory regime for AI would be to suppress development of FOSS solutions that would eventually give people the maximal control and benefit from AI, and force them into dependence on third-party solutions offered by organizations that have influence over the regulatory regime itself.
The first step is to stop thinking of "the public" as a monolithic entity whose interests are pursued by the government, and instead recognize that control over things that have a major impact on the lives, welfare, freedom, and prosperity need to be things they can effectively control or opt-out of as individuals.
If AI takes over the world, or others pump lots of GHG into the air and cause climate change, or someone sets off explosives and burns down my neighborhood, or my frozen chicken contains poisonous bacteria, or my bathroom sanitizer doesn't really sanitize - how do I opt out?
Plenty of regulations coexists with FOSS, obviously.
The arguments against all regulation are transparently weak, and the apparent dogmatism discredits everything else. Why be so dogmatically anti-regulation? Dogmatism isn't about finding truth but about serving someone's political interests. If I understand correctly what's happening, whose interests are you serving and why?
If AI takes over the world,
This is a potential concern, but no currently-existing computer system (that I'm aware of) is any kind of risk for that. Certainly, nothing OpenAI has produced is.
I'd say the currently-real unaligned-agent behaviour of our institutions is a bigger risk than currently-fictional computer-instantiated unaligned superintelligence. And we do have regulation in place to constrain the behaviour of many institutions: governments, corporations, utility operators, and so on.
The unaligned agent problem was not discovered by the AI safety people. They merely named it.
How does that work for things that can only be effectively controlled or opted out of collectively? There's not really a way for an individual to opt out of a corporation using AI in a way that negatively effects them.
How does that work for things that can only be effectively controlled or opted out of collectively?
I can't think of many such things. Do you have any examples?
There's not really a way for an individual to opt out of a corporation using AI in a way that negatively effects them.
Refrain from doing business with that corporation? If they are transgressing against your person or property, that's where the law comes into play.
Regulatory intervention makes it harder, not easier, for individuals to take charge of these matters for themselves.
That strongly depends on the details. In particular, regulation that compel clear disclosure of information to individuals.
Imagine how impossible it would be to "take charge for yourself" if none of the food in the grocery store had any ingredient/nutrition/allergen information, and bottles of pills didn't tell you the active ingredients and amounts.
I don't really have a problem with laws that require accurate disclosure of those details. I do have a major problem with laws that usurp decision-making agency away from individuals.
How do think we should address security around AI
The same way we address security around cars: we don't ban individuals from working on project cars, or driving them on public roads - instead, we have standards for OEMs and individuals, and prosecute negligence.
AI safely is similar to GM lobbying for laws making it illegal to tweak your own car or changing your own brake fluid for "public safety".
we don't ban individuals from working on project cars, or driving them on public roads - instead, we have standards for OEMs and individuals, and prosecute negligence
I'm not quite sure what you mean, or what in AI safety you see as analogous.
For other technology, certainly building and using certain things is illegal - you can't make hand grenades, lots of chemicals; I'm pretty sure you can't own certain instruments of crime, counterfeit money, etc. Many things you can do; it's not all or nothing.
I'm not quite sure what you mean
IMO, for the general public, current AI models are much closer to cars than they are to anti-personnel weapons, when plotted on risk/benefit axes. FWIW, vehicle regulations are not an all-or-nothing affair either - there are things that remain verboten.
Those who claim AIs are too dangerous to be in the hands of the public have ulterior motives, and/or are far more optimistic than I am on the speed and ease the chasm between LLM and general intelligence will be bridged - if it at all.
Lots of people see it. It's very clear to me and many others that a lot of the AI safety push is about going straight for regulatory capture and effectively outlawing competition.
Yup. Sam Altman stood before congress and practically begged them for a regulatory moat. Straight up rent-seeking behavior.
I don't think people give Meta enough credit for their roll in that. Microsoft/OpenAI got cozy and thought they had a huge moat made of $100K hardware to protect their $10B investment. Then Meta shadow drops Llama and within weeks regular folks were running GPT3 level LLMs on consumer hardware. That was such a huge win for opensource and consumers.
Zuckerberg invented engagement farming social media to ruin the mind of humanity and drive the political discourse to madness, so anything he wants to do to redeem himself is great.
People have an appalling understanding of free markets. So many things that are considered "market failings" (like this article / housing / etc) are almost entirely driven by regulation and red tape.
It’s interesting. The regulation ostensibly protects vulnerable classes from exploitation and lets them use reimbursement structures to defray cost. At the same time it causes costs to go up and allows people to buy their way across the moat.
I wonder if regulation that stipulated that a change of ownership of some percentage would require recertification of the entity would stem this a bit. Or restrictions on buying HIPAA covered businesses with patient data. Might pose a problem to folks in the business today, but could slow down the massive acquire-and-merge train in these industries.
Not all regulation causes costs to go up. Some causes costs to go down, for example, by correcting inefficiencies created by raw game-theory market competition. Some reduce costs by creating a safer environment for investment, reducing risk. Regulation serves market participants too.
Regulation always increases costs, it's just that not all costs are easily visible
Is that established theoretically by someone?
What's the invisible cost when cigarette advertising is banned, eliminating the arms race to out-advertise the competition?
In this case it’s regulation on who can sell DME paired with how payor negotiations are handled. So even if you had cash to buy many DME, you still need a prescription and sometimes forced to pay the contracted price if you are known to have insurance.
It is not just wheelchairs and nursing homes.
My eye doctor office got bought out. They pay the doctors as little as possible and maximize the number of appointments per day.
How hard is it for them to leave and start their own business?
Not every doctor also wants to be a small business owner. Usually what happens is a doctor/dentist/vet started a practice, wants to retire, and sells it to PE.
At smaller places, sometimes the owner sells to PE and stays on - they just don't want to deal with the business side of things anymore.
Quitting your job to start your own thing is never an easy step.
That sounds great for the consumers of optometry services in your area.
Sure if you like mistakes.
It's impressive that not only has private equity enshittified even nursing homes and wheelchairs, they have persuaded people to empower PE even more by reducting regulations. Do you think PE will suddenly change without regulation?
PE is responsible for PE's actions. If these services and goods decline under PE, with the same regulations as before, then the cause is clear.
The brevity of this statement belies the prescience of it. Back in my former life in PE, businesses with industry moats were actively hunted down and targeted, regardless of location. That obviously led to the three basic necessities of man - healthcare, education and housing - being the most affected sectors.
Is there anything that PE doesn't turn to shit?
They're huge in healthcare for this very reason.
We should be more vocal in our opposition
What you would expect from private equity sadly. Destroyers of value.
But, but...muh free market capitalism always leads to the best products supply for the demand...or so we've been told.
Capitalism works perfectly if you just ignore all the inevitable disasterous consequences and outright failures.
And your better alternative is........... ?
China is doing pretty well. In before a wall of text about how China is doomed or whatever.
China is doing well is a funny take post covid. The argument worked much better 10 years ago when they still had large growth.
"Doomed" I don't know but they seem quite stuck now between a lot of internal problems.
I assume you aren't aware of China's housing market bubble [1].
[1] https://en.m.wikipedia.org/wiki/Chinese_property_sector_cris...
only once they switched to free market principles under deng. iirc as their growth has been slowing it has been due to increasing state clampdown on the economy
Capitalism moderated by various systems emerging from a genuine, sophisticated democratic system would be my advice.
We have a lot of work to get from here to there though, and much of it is the undoing of mass psychological condition.
Capital will simply undermine the democracy again. It's literally that simple. Capitalism and democracy are fundamentally at odds.
This part is important:
from a genuine, sophisticated democratic system
Do you think something more powerful than capitalism is impossible?
Social democracy
Capitalism with much stronger consumer-protection regulations?
Market socialism. Or some in-between that recognizes that wealth and corporate power has a genuine responsibility to society as a whole. Myopic focus on profit as the only metric is the biggest problem, after all.
Turns out late hegemonic capitalism has a similar failure mode to late Soviet central planning.
Relaxing various rules on investment and m&a, and allowing unprecedented levels of market power concentration (it’s a lot worse in many major industries than what promoted our first big wave of “trust busting”) turns out to be less than awesome.
No. It’s only efficient when property rights are enforced, barriers to entry are low, and transaction costs are minimal.
Wheelchairs are regulated (barriers to entry), pollution is the nonexistence of property rights, and your take-it-or-leave-it noncompete agreement is a consequence of high transaction costs (job search, legal negotiations).
It is the job of government to regulate and reign in capitalism.
We are also told that democracy is the best form of government, and we are also told that our democracy is genuine, and that it must be protected. For some reason, people are unable to wonder if these various stories are true...perhaps because that skill is not innate, and is not taught in school?
... or so we've been told.
To expand on this inconsistency, it comes from different people cheer-leading "the free market" with different and conflicting sets of assumptions about what the phrase means.
For example, one economist makes an assumption of "perfect information on prices and transactions", and declares that it's the most efficient thing ever.
But another one assumes actors are free to make secret deals and private transactions, and concludes that the free-market doesn't have a cartel problem, because individual members will secretly defect and undercut so that it falls apart.
Those two assumptions are in direct contradiction, yet somehow the overlap phrase "the free market" still gets touted as having both of the incompatible features.
Private Equity really is a pox on society.
One reason they may not be able to hire is that they paid a ton to buy out all the competition and now have a bunch of investors wanting to see high rates of return. That requires cutting staff and raising prices. I'm all for a free society that allows private parties to make agreements, but PE is by definition all about breaking markets by creating a monopoly where they have large amounts of market power and where no competition can realistically occur. The end result is consumers getting screwed all over.
Private Equity really is a pox on society.
Every single non-public business is "Private Equity". How is every single small business in the entire world "a pox on society"?
Perhaps you mean "short term thinking" is a pox on society? Or in, like in this case, a duopoly is the issue? If there were 10 such companies a reputation for slow repair would drive people to other suppliers and things would rapidly get better.
PE is specifically referring to companies not listed on stock exchanges that take money from investors. I agree that we do not want to throw the baby out with the bathwater here, but there is probably merit to limiting the activity of PE funds with lots of investors or lots of money. PE often used as a scheme of raising money and conducting business in a way to avoid the scrutiny of a publicly traded company.
https://en.wikipedia.org/wiki/Private_equity
"In the field of finance, private equity (PE) is capital stock in a private company that does not offer stock to the general public. Private equity is offered instead to specialized investment funds and limited partnerships that take an active role in the management and structuring of the companies. In casual usage, "private equity" can refer to these investment firms rather than the companies that they invest in."
I'm referring to the large investor firms that go around buying out companies not listed on the stock exchange to capture entire markets, milk it for all it's worth, and then dump the shriveled corpse. This is very rarely good for the end customers or the employees who get outsourced. The owner gets millions though and it allows the PE firm to sell an asset class to investors.
On the one hand, I don't think it's right to restrict the rights of the business owner. If they have a company with $20M in revenue and PE offers $60M to buy them out...fair game right? On the other hand, it takes perfectly profitable companies providing value, extracts that wealth from happy consumers of the product to people already wealthy and then leaves the consumer with a crappy, expensive, and barely supported product. If this happens just a few times...it sucks, but no big deal. Once it starts happening all over America, then we start running into systemic problems like not being fleeced every time you want to go to a concert. It's not like a competing firm can just pop up either in a lot of cases as there are huge barriers to entry. There is no recourse other than not ever seeing your favorite artist again.
Well, a private equity firm owned the wheelchair company for a decade. It was only when a different PE firm came in that the service allegedly declined.
What's the barrier to entry?
Power wheelchairs are regulated (FDA) as medical devices.
I can buy an electric wheelchair at Walmart for $750. What is the issue?
As the sibling comments noted, we're talking about bespoke wheelchairs for people with severe mobility disability (MS, ALS, etc). Things like Stephen Hawking's chair.
Still, they shouldn't cost more than a high end Ebike.
I don’t know what the median/average price is for these, only the range.
Bit, a high end e-bike is $12-$15k. Which also seems ridiculous to me. And I’m a cyclist with several nice bikes (none of which were more than $7k).
And I’m a cyclist with several nice bikes (nine of which were more than $7k).
"Nine", or did you mean "none"? I'm just checking if it was a typo, or if I should be jealous. :-)
None. Only 4 in the basement that belong to me right now. 4 more as the wife’s.
Anything custom will cost more than a similar complexity mass-produced item.
Oooh, I missed this distinction.
You can also buy pharmaceuticals at Walmart. What is your argument?
That's a powered scooter, not an electric wheelchair. They may look the same to a layperson, but they're not - one is highly regulated and has a lot of people making a lot of money off them, the other is a scooter.
Some of these wheelchairs are 75k. They're custom made to your body size for maximum comfort and the features are customized to your disability.
These aren't off the shelf mobility products. Each one is assembled to specification.
Regulation.
This is one of the market failures caused by excessive regulation.
To make a chair you requires so much paperwork that only a small number of business can do it.
I especially like the regulations that make sure only those who need the chair get it, to reduce medical costs, but in the process all the paperwork dramatically drives up the costs.
Almost as troubling, from the article "Customized wheelchairs typically last five years, but most chairs need a major repair or two during that time."
What the actual fuck? Power wheelchairs run the spectrum for a few thousand USD to ten thousand plus. And they only last ~5 years, and even then with several major repairs in that period?
That sounds like an absolutely atrocious durability/reliability record.
Think about it. For many users, they're in these chairs 12+ hours a day. They're not cars that get driven for an hour a two a day.
My fridge has been running 24/7 for 15 years and has never had an issue.
Most fridges are never moved after installation, until they're recycled. Of those that are moved, most are moved away from the wall for cleaning and then moved back. Very few fridges are moved a significant distance on a daily basis.
And yet my motorcycle has gone 80,000 miles without ever needing any maintenance except for a new chain and new sets of tires. Well, I've had to replace the headlight and levers and shift peg because I've crashed it off-road multiple times but that's not the motorcycles fault. I bought it for $1000 used.
Sure, but I would have expected them to be modular enough to keep running more than 5 years. More so given they cost as much as a used car.
This is a function of CMS/Medicare paying for a new wheelchair every 5 years. Functionally my wheelchairs have lasted longer. I still use my 8 year old chair with thousands of miles on it as a backup chair when I travel.
I deal with wheelchairs, electric wheelchairs, oxygen systems, CPAPs, spirometry, and more every day.
Electric wheelchairs are built to be very rugged and dirt simple.
There are 2 problems:
The first problem is insurance. People expect their insurance to cover everything. If they need a new set of 35 AH SLA batteries, they will throw their old chair away and ask for a new chair on insurance.
The second problem is that wheelchair users are disabled. As an able-bodied nerd with a socket set and a few wrenches, I can repair an electric wheelchair. A disabled person usually can not do that. They can not even follow the (good) advice to use an external charger instead of the (garbage) charger built into most wheelchairs; they physically can not get to the relevant parts.
Home oxygen companies send people out on short notice to debug, repair, or replace home oxygen equipment. If you want insurance to cover electric wheelchairs, then rent them instead of selling them and include service visits.
The problem with shipping an electric wheelchair back for service is that this thing weighs almost 100 pounds without batteries and is a very odd shape. Before anyone complains, you want it to be heavy so it will not tip over when the human (who is high up) leans over, takes a corner, or drives sideways on a slope.
If you want a less-insurance-intensive solution, pass a right-to-repair law that (1) requires all electric wheelchair parts to be marked with a manufacturer and part number, and (2) requires all electric wheelchair makers to sell parts for a decade or two after they stop selling the chairs. If they use industry-standard parts, and mark the parts as such, they should be relieved of the obligation to carry the parts for 20 years. Here's an example: Include a label on the chair saying that all bolts are either m6x60mm or m4x25mm and that all red and black electrical connectors are PP75 series Anderson Power Poles.
Here is a case that drove me nuts: I was dealing with an electric wheelchair that had some odd version of Anderson PowerPoles connecting the batteries and motors. These connectors had been knock-offs, and the reseller of these (Chinese-made) connectors lost a patent lawsuit to Anderson (before their patent expired.) One connector broke and was impossible to replace. I would gladly pay $100 for a single connector, but they do not exist. Before someone says to replace both ends of the connector, this is a connector mounted in a custom bracket with almost zero clearance as the chair's seat fits right on top of the bracket, connectors, and wires.
One connector broke and was impossible to replace.
This is not a solution that would help the wheelchair user, but if you have a set of inexpensive ($10 bought in the US, less from china) 3" digital calipers, you could likely measure the socket and get it 3D printed. I've done it for obsolete electrical connectors in cars and while it takes time and some effort, it's very doable.
These are high-current (30-50A range) connectors though (for the wheelchair traction batteries). Getting the positioning correct so that the spring tension in the metal terminals creates a reliable/low-resistance/non-sparking connection is a shared contribution from the geometry of the metal terminal and the plastic housing (as opposed to most low current (0-5 Amp) electrical connections, where the connection geometry is most commonly provided by the metal geometry alone and the plastic's contribution is just keeping them "organized and close enough to mate").
Like this: https://upload.wikimedia.org/wikipedia/commons/6/63/Powerpol...
I’ve worked on cars and other mechanical things for most of 3 decades. I’ve never needed a sticker telling me what size standard bolts were.
On the broken, ruled as patent-infringing part, what do you want to happen that would comply with patent law? If it was compatible with Anderson, you’d just buy that. Since it wasn’t and the original company isn’t allowed to keep making them…
I’ve worked on cars and other mechanical things for most of 3 decades. I’ve never needed a sticker telling me what size standard bolts were.
On the broken, ruled as patent-infringing part, what do you want to happen that would comply with patent law? If it was compatible with Anderson, you’d just buy that. Since it wasn’t and the original company isn’t allowed to keep making them…
That is true of professional mechanics. A disabled guy with a screwdriver who never changed his own oil needs some help.
I did a poor job picking examples. Let's take about the complicated parts.
The joystick controller on most electric wheelchairs uses a very particular connector. If I do not know the brand and model number on that, I am probably screwed.
"Trim" pieces are often required to prevent a disabled person's limp limb from being sucked into a gap near a tire. Trying to order replacements for those is almost impossible.
If they need a new set of 35 AH SLA batteries, they will throw their old chair away and ask for a new chair on insurance.
One connector broke and was impossible to replace. I would gladly pay $100 for a single connector, but they do not exist. Before someone says to replace both ends of the connector, this is a connector mounted in a custom bracket with almost zero clearance as the chair's seat fits right on top of the bracket, connectors, and wires.
So.. which is more prevalent.. users throw away their chairs because they expect to live high on the hog off insurance, or users throw away their chairs because any form of replacement is often met with these arbitrary and senseless complications?
I can not say which is more prevalent.
So.. which is more prevalent.. users throw away their chairs because they expect to live high on the hog off insurance, or users throw away their chairs because any form of replacement is often met with these arbitrary and senseless complications?
Those who can work on chairs themselves do so. Those who can not work on chairs do not.
If you have on idea what kind of connector a 12V 35AH battery would have, and have no way to disassemble your chair to replace the batteries, then you can not realistically replace those batteries. Add in living off $1,400 a month and you see why someone would ask for a free wheelchair instead of paying $250 for an uncertain chance at repairing their wheelchair.
Banning private equity (not sure how) is necessary to prevent enshitification of all health care and related services.
Yes, because communism (what else is “banning private equity”?) NEVER results in “enshitification” of ANY kind.
Seriously, the issue here can most likely be tracked to private equity taking advantage of existing regulations. Not sure why MORE state involvement in the economy would be the solution.
It doesn't sound like you understand what Private Equity means. Allow me to assist you in your quest for enlightenment.
Private equity describes investment partnerships that buy and manage companies before selling them.
And it sounds like you’re a communist, unless how you can explain how you can ban “investment partnerships buying companies” without doing away with private ownership more broadly?
The issue people have isn’t with “private equity”. If it was a publicly traded company doing this people would be equally upset.
Notice my “not sure how”
There is a very negative behavior right now by companies that call themselves private equity to buy up your local vet, doctors office, etc. Then they fire staff, reduce services, and increase costs.
We the people are losing, even if some of our 401ks grow because those funds invested in these PE vehicles.
This practice imho should be banned. How? I don’t know. But the U.S. will become shittier and shittier because of it.
You just need to get super aggressive with anti-trust actions.
Any company with more than 25% market share in a category gets broken up. Period. At all levels.
This prevents the "12 companies all buying from the single upstream supplier" problem.
Our whole economy is feeling increasingly Soviet. Somehow our business leaders have decided that the best business is one that does not serve its customers, and that providing a good or service efficiently and effectively is poor management because it is "leaking value" to counterparties.
I guess the next phase is going to be you need to know people if you want your medical device delivered, your car repaired, or for your internet to quit dropping.
In Capitalist Realism, Mark Fisher talked about how capitalism through the institution of the corporation developed the very byzantine bureaucracies and middle men that had long been called out as failures of the Soviet system, and in some ways, proved to be even more inefficient.
Welcome to capitalism
My brother in Christ you are witnessing the consequences of capitalism
Sigh. I dealt with NSM a few years ago to get a new manual wheelchair. The tech who fitted me for it, and delivered it, was great, but very obviously always in a rush. The chair itself was not made to spec, so it was just not useable for me as-is. After many months of trying (and failing) to get NSM to help me mod it and get it as close to spec as possible, I gave up and just continued using my old chair.
But even more frustrating than that? NSM continued sending me phony bills for parts that I did not order. I just trashed them until it went to collections. (Fortunately, the collection agency they use is even more incompetent than they are, and I've been able to put them off with standard anti-collections form letters.)
I figured I'd go with Numotion when insurance is ready to re-up me for a new chair, but reading this article, it doesn't seem that would be any better.
Maybe The Paradox Project (by JerryRigEverything) is for you: https://notawheelchair.com/products/the-paradox-project
Thank you - definitely always nice to see people trying new things in this space. It might be a bit risky to rely on a wheelchair that doesn't have a good support ecosystem, though, unfortunately.
This actually touches on something that seems to have changed in the past 10-15 years: in my experience, shops now absolutely refuse to touch wheelchairs that they did not themselves provide. I'm lucky that I can generally do my own maintenance, because even something simple like a deep cleaning is met with worries of voided warranties, etc. etc. I'm not sure when this changed, but throughout the aughts I was able to get service at shops in multiple different cities without any issues.
"Grau wants more wheelchair users to come into the shop, as repairs happen much faster — only two week’s wait, on average. Wheelchair users are loath to adopt this, as coming into the office can be physically treacherous for them"
vs. a technician fixing the chair in the house.
But how about something in between? A medium-skill employee who takes the chair from their home to the repair facility? They would need to carefully document what's wrong with it, so they need a little skill but not as much as a full skill repair tech.
It seems like a good job for non-profits. Anyone with a suitable car should be able to volunteer and help their community.
I'm not a wheelchair user, but I can imagine it being a non-starter to have your wheelchair just taken away from you. What if the tech doesn't bring it back? You're just stranded! Even if they do bring it back, there's potentially a lot of time stranded.
The problem isn't regulation, the problem is that the regulation isn't simple or cheap enough for small companies to get regulated.
Yeah. Don't complain about regulation existing. Complain about regulations being controlled by private equity. Complain about private equity existing. Complain about capitalism. Not about the existence of government.
We frequently hear about "private equity" doing something sociopathic.
We sometimes don't even hear the names of the companies, just "private equity".
Do we need to systematically trace and publish which individuals and institutions benefit from the nasty companies?
We should publish the b-school, and b-school networking graph through the career of a malicious individual.
People will take action faster if they knew Thaddeus Wrappesalot went straight from lacrosse captain to executive chairmen hiking veterinarian costs.
Not bugs, deliberate software additions. Not bugs, intentional from v1. Not bugs, deeply contrived. Oh, sorry, wrong meeting...?
How extremely odd. I did not post this comment here, but in my comments listed, it sends me here as its parent.
PE is such a cancer
Public company CEO here. One of my rules that has served me well is "don't ever be on the other side of a transaction from private equity". They have blatantly anticompetitive playbooks where they buy up all the competition in a market and then raise prices as a cartel. Mostly recently, the DOJ has opened a criminal probe into RealPage for price fixing in real estate. What a scourge on capitalism.
Private Equity = we have a bunch of money and use it to control markets and politics.
Almost a new form of feudalism.
Get back to work IT surfs while we continue to extract wealth from your labor.
A good comic on the difference between what most people think when they hear wheelchair vs what wheelchair users need to be independent: https://www.tumblr.com/calvin-arium/184341867538/its-here-th...
Private equity is great for exposing the flaws in our economic system. The consequences are of course awful and it would be better that they didn't happen. But since they are happening, hopefully more people will start to realize it. When exposed to this kind of thing you can generally have one of two reactions:
The first is that you say that this kind of thing is good. It's all part of capitalism. The market will work it out. People will say this kind of thing with a straight face.
The second is to say that it is bad. But why is it bad?
The first stage is you believe that there are bad apples. Private equity is simply a few bad actors who may or may not need to be dealth with by way of legislation, regulation and/or prosecution. Lots of people believe this because they still fundamentally believe in our current economic system.
The second stage is you realize that private equity isn't an outlier and isn't a few bad apples. It is exactly what our system is designed to produce: to financialize and rent-seek in every aspect of our lives as a means of extracting wealth from the poor to the already vastly wealthy.
Private equity is taking over every aspect of your life by buying up homes, mobile home parks, vets, medical practices, hospitals, etc. There probably isn't a single aspect of our lives that hasn't been tainted by private equity.
And the playbook is exactly the same:
1. Jack up the prices, usually by cornering a market by either buying up all the competition or through legislatively creating enclosures;
2. Cut costs. Use noncompete agreements and and the like to suppress wages; and
3. Load up the entity with exploding debt and sell it to the market before the debt explodes.
This is capitalism working as intended. No more, no less.
On wheelchairs in particular, it's truly disgusting what we as a society put wheelchair users through. One of the most egeregious examples is how airlines will routinely destroy wheelchairs.
We are steadily marching towrads a future where almost all of us will be a permanent underclass devoid of any kind of security. Every aspect of our lives will be at the mercy of our overlords. Capitalism inevitably leads to neofeudalism.
I can design and build these, source parts, whatever. This is what I have done for a living for 20 years. If anyone wants to solve this problem reach out, contact info is in my bio.
Vulture capitalism - def. (noun): A strategy applied to a company or multiple companies in a market category whereby profits are maximally extracted without regard to long-term sustainability of customer relationships, brand reputation, or company viability.
Not saying it's not a viable possible strategy for the investor, but that it's perhaps a suboptimal strategy if greater net profits were desired long-term.
And yet, you can buy nice electrified wheelchairs on Aliexpress for less than $3000.
My guess is, like for hearing aids from costco, you won't get reimbursed by insurance if you buy it yourself.
Also fun, in Oklahoma, most (2/3rds or so) of the certified professionals who do the fittings are employees of NSM or NuMotion.
When are we going to have mass protests against the private equity takeover of everything? Besides climate change and war, I’m hard pressed to think of anything that will have as much of a negative impact on society.
If you want to hear more about the negative impact of private equity on various industries, like retirement homes etc, I'd recommend the book Plunder. Eye-opening stuff.
"In 2005, CMS announced requirements for testing of electric-powered wheelchairs as part of efforts to modernize coding (5–7). In this century, CMS, in what might be classified by some as an uncharacteristic move, has provided leadership in evidence-based classification of wheelchairs.
Globally, the International Standards Organization (ISO) manages the wheelchair standards. ISO and the RESNA standards committee work collaboratively. ISO and RESNA have often been driven by outside sources to expedite their work and to address needs of consumers and other organizations. In the 1990s, the European Community Medical Device Directive provided impetus to make a number of changes to ISO standards and to create new standards in response to stricter regulation. The European Committee for Standardization (CEN) went its own direction for a while and over time, CEN and ISO standards have begun to merge. American National Standards Institute (ANSI)/RESNA was a driving force for a long time and often had different standards than ISO. However, this has dwindled in the past decade. Concomitantly, the wheelchair industry has exploded over the past 10 years, and the standards have simply not kept pace. There is a clear and present need for change in standards development and support in the United States.
Most of the participants in wheelchair standards development are employed by the wheelchair industry, an inherent conflict. Unfortunately, wheelchair users and clinicians have traditionally not had the financial support to participate in sufficient numbers. Interestingly, the same companies that participate in the standards committees develop internal tests not represented by ISO or RESNA as part of their product development programs to protect them against legal liability. Test laboratories do the same thing, creating a number of tests that differ from or improve on ISO or RESNA standards. None of the existing standards (ISO, CEN, or RESNA) is comprehensive enough to cover all areas of wheelchair evaluation."
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1929010/ 2006
Is there anything at all P.E. hasn't fucked up?
At this point I feel it really should be illegal.
Is there any market or sector that PE hasn’t made worse?
Is private equity this century's equivalent of the LBO? https://www.latimes.com/archives/la-xpm-1990-03-23-me-521-st...
To be honest - it actually seems like a risky Private Equity play as I bet the $65000 sticker price is due to the fact that Medicare is footing the bill. Medicare is likely what is requiring a regulation grade wheel chair, not the users themselves.
I bet a huge segment of the user base could easily self purchase a mobility scooter and achieve the same quality of life if the price point was such that they could out of pocket the purchase and there was decent quality/repairability/safety.
There do seem to be a fair number that are approaching "geez I might as well just buy an over the counter version" (i.e. sub-$2000) instead of going through the paperwork hassle of getting a free Medicare "prescription" for one.
In my experience, the chairs and how they’re built aren’t what adds to the price tag; the fact that an insurance company is paying is what is.
My daughter literally just got approved for a talking device that would otherwise cost us $4000. It’s a Samsung tablet with $300 software and an attached speaker and comes with some sort of repair agreement. I can buy and break 20 iPads for that price…and we did end up buying one with the software on its own.
If you want to know who’s causing waste, look to the ones who stand to benefit from it.
It’s similar to defence procurement.
If the customer is government with endless budget, inflate costs, and use regulatory capture to maintain the cash flow.
Regulatory capture is likely the most important component. People complain about government spending, but those close to progressive issues can tell you that it's just as likely, if not more likely, to be remarkably stingy when it wants to be. The issue isn't government, it's who's using government; access to capital on top of that government influence gets you a lot closer to that bottomless wallet.
This is why I'm for total deregulation of healthcare. Government fucks it up so bad hamstringing access that some hack work with 15 minutes of YouTube training plus whatever pills drop out the dark web is often better than not being able to access it at all.
Right now we basically end up going to Mexico if we can help it, where there's basically no real oversight or regulation to raise cost so long as the doc/pharmacy pays off the cartels.
Regulations should be voluntary and exist in a market with options.
I want a market where I can choose a highly regulated healthcare system or a system with no regulations and a system somewhere in between.
This doesn't really work. An unregulated market has every opportunity to undercut a regulated market in almost every dimension. Do you expect that a highly regulated market would become sustainable let alone affordable? You may as well just demand that regulations are removed.
The only way this works is if the government subsidizes the regulated market such that it is accessible (and sustainable) to an appropriate market. It also generally puts some populations at severe disadvantages, and usually those populations are disadvantaged to begin with.
This may seem good to you but, unless your fellow man is equally wealthy, it is problem detrimental to your fellow man.
Has the concept ever been really tested?
If you play the idea out (I’ve thought about this for years, perhaps you have fully considered it).
I think this works for people of all economic backgrounds.
There would be multiple competing standards for lower cost businesses, will the low standards business exist if people get sick, or will a slightly higher priced but much safer low cost standard excel in the market?
I think many of the issues you bring up already exist in the current market.
That's why I am in favour of more city states like Singapore, or at the very least towards pushing more responsibilities from the federal level to the state level. (The Catholics and EU call that concept 'subsidiarity', handle everything as locally as possible and have the higher levels only there to help when the lower levels can't handle it.)
Eg the FDA ought be to dissolved, and replaced with state level agencies. The state level agencies are, of course, free to cooperate and coordinate. Comparable to how the traffic signs work already in the US.
It's good for Hawaii and New York to have the same road signs, but they can agree on that voluntarily. No need to have a central party force them. Similarly, it's good for both states to have the same or similar rules on drugs, but no need to force them.
See also how the recent wave of cannabis legalisation has been driven by the states. I want to see more of that innovation and experimentation.
In what I suggest each state would most likely still have mandatory regulation, but it's a lot easier to move between states to find a place that suits you best, instead of moving between entire countries.
I have lots of sympathy for your position, and I would hope that at least some states would take a more laissez faire approach. But the policies you get will ultimately still be decided by what's popular with voters, and they can be a fickle bunch.
I can't wait for drugs having to be certified safe in 50 different jurisdictions, instead of one, with 50 different agencies, each with a different set of politicians putting their thumbs on the scale having their own rules for them.
That'll really bring down medical costs, and will not at all destroy the incredible economies of scale that a single 350 million person national market creates.
I also can't wait for the cross-state litigation when an upstream state's equivalent of the EPA will be paid off to allow a firm to dump toxic waste into a river, that will be poisoning the people downstream.
Yes please. We don't need to get rid of the FDA, just make it optional. If I want to trust the government's opinion of a doctor or drug, I can look for the FDA seal of approval.
Is that a good idea for an industry that seems filled with completely immoral bastards that'll screw over everyone ("they'd sell their own grandmother!") to make an extra cent, or save themselves a cent?
I could see it might be a good thing where an industry has a good reputation for fair dealing. US health care doesn't seem to fit that description though.
One issue is a big disconnect between user and payer. Government is especially prone to that, but any big organisation can have this problem.
some senator just held up a bag on bushings for use on fighter jets suring a speech..the cost for a sandwich bag full...$90k
Any idea if they're precision engineered out of something exotic? Maybe machined from single-crystal titanium or something.
Asking because there's a bit of a different between standard consumer grade stuff, and specialist high performance things designed for a specific exotic environment.
Also each one probably also has its own fully traceable and auditable supply chain, with a record of every step, including who signed off on it, when and where, from the moment it entered the refinery, and the records are guaranteed to be kept available for decades, along with storage and maintenance of the tooling and capacity to make more at short notice indefinitely. Plus the costs of getting the contract sorted and the part specced and signed off on in the first place, amortised across the relatively small initial batch.
Presumably there for political protection as much as anything else: "Bushinggate topples Senator after it's revealed a Russian company supplied the titanium" or "Scandal of the aircraft parts Anerica has forgotten how to make".
Well no wonder, he keeps sneaking in with baggies and stealing them.
I used to work at an org that audits defense programs. A surprising amount of the unreasonable cost is self-inflicted, which is a valid cost to the vendor. If it wasn’t, the auditors have the power to clawback the excess cost.
In defense procurement the costs are frequently inflated greatly by the procurement process overhead and the government imposing last minute changes of scope, requirements, or delivery dates. The government customer is also often slow or delayed on their contracted deliverables, so they can end up spending a lot of money to essentially keep idle capacity warm on the vendor side while they sort out delivery of their part. And then there are the budget rug-pulls at the 11th after the vendor has already committed significant internal resources, which are often a pure loss to the vendor. All of this is endemic to the process. The government knows they are a difficult and expensive customer to work with, and they do try to compensate vendors for the overhead costs this imposes.
People like to talk about $2000 hammers etc but if you actually look at the audits, more often than not the cost was justified. Not because a hammer should cost that much but because that is how much it ends up costing after you account for the government procurement process overhead and the way in which the government executed the contract.
Sometimes this gets taken advantage of by the vendor. The government doesn't have the ability to design and specify things properly themselves when the deal is signed. The vendor might know that things are wrong at that point but wait until afterwards to point out all the problems and correctly claim changes in scope and requirements at significant expense. At least I was told that happened on the California rail project.
People assume this serves no-one, but a well heeled public servant with good insurance (or some other member of our new moral rulers) might think it's a fair deal, especially if R&D is amorised by having poor people also forced to pay. They would pay a bit more for the extra safety.
Not only that but also lobby the government to start more wars so there’s a need for their product.
https://x.com/snmrrw/status/1717906441925751223
Just that in this case the end-customer is a person that could shop around for what he/she needs. Such a competitive market would instantly vaporate the current, rent-seeking margins
For most people on here, they're more likely to believe that the disabled people are needy & expecting way to much rather than the companies behind it including insurance being greedy as hell.
What prompted you say this in the top voted comment chain where each ancestor comment says the exact opposite of said view?
That tablet and software cost a large sum to be validated. Those CFRs get extremely expensive.
You can buy the same exact app on the app store for $300.
Wow - just curious, what's the name of the talking device?
https://www.prc-saltillo.com/
You can buy mobility scooters for under £2000. e.g. https://www.mobilitypower.co.uk/product/fastest/
$65k is an obvious rip-off.
It's a shame Medicare can't just give the users cash and allow them to choose their own wheelchair; both Medicare and the users would win.
Are you serious? Wheelchairs are not mobility scooters. I don't know much about them, but I can point out some obvious likely differences:
1)The chair has to be comfortable enough to be in almost constantly - for someone whose body may not be shaped the same as most other people's. It may need to be designed in a way that makes it easier for the user to get in and out of, unassisted. That means a substantial part of it is customized to each user, probably in consultation with medical professionals. It may need to carry medical devices/equipment.
2)The chair has to be navigable in indoor spaces with a fine degree of control, by someone who may have lower motor skills and range of motion than others. So it may need customizable response time, input smoothing, and acceleration.
3)The chair cannot, under any circumstances, make an un-commanded motion - which could easily kill the occupant (ie going into traffic, or down a steep hill, or off into water.) That has implications for the physical controls, the electronic controls, and mechanical drives (I'm guessing many chairs have electrical locking, and can use the motors for braking.) Similarly, the chair has to be very reliable, or that could kill the occupant (say, a fire or other emergency where they are) or otherwise be a major inconvenience. If you're unable to move much from your chair and, say, your cell phone is in another room - you're varying levels of screwed.
4)It has to be designed such that fire would be a very low risk.
Are they probably more expensive than they need to be? Yeah. But I'm sure it's nowhere near an order of magnitude, and your comment is pretty ignorant.
What is that based on? Do you have experience or know anyone who does? A news article or research?
Probably even a higher quality of life, because the manufacturer can make arbitrary changes to the unregulated scooter in response to market demands.
The Medicare wheelchairs are lowest bidder affairs procured as commodities regionally. There’s no margin there.
The crackdown on scooters was going after blatant and obvious fraud.
Is this why hearing aids are $4000 when they probably have $0.50 of components?
This is a great project. I didn't realize that FDA Class I regulations were this easy to comply with.
They definitely won't be once this open source effort shows any sign of success. You can't solve political problems with technical solutions. At best, you may be able to displace them, but even that is rare.
When replicators are invented, most political problems will disappear. Star Trek got it right.
Star Trek style replicators can't be invented. The laws of physics won't allow it. It will always cost more energy and be vastly less efficient to assemble a cup of coffee atom by atom than it would to just grow the beans, have them picked, packaged and shipped, and make it yourself, and unlike in Star Trek, energy in the real world isn't free.
You might say we could come close with advanced 3D printing and some kind of nanotech,but no such technology will ever be so cheap or ubiquitous as to render politics obsolete. History is replete with advancements and inventions which were supposed to usher in utopia, and all they have ever done is further the means by which the powerful enslave and control us. Technology cannot solve human nature.
humans are more sovereign than ever before in most calculable metrics.
What "calculable metrics?" By what definition of "sovereign?" Objectively, this is a meaningless statement to me.
Which countries force you where to live and what job to work at?
I would assume at least North Korea does. But every modern state requires you to at least work and to have housing, in order to generate taxable revenue and afford the means of survival.
But unless you hunt and grow your own food, own your own land and aren't subject to laws or government that owns your identity and tells you where you can go and what you can do, you aren't sovereign. If you have to spend the majority of your useful life trading your labor to a corporation, you aren't sovereign even if the market gives you the option of which feudal lord to serve as vassal to. If you require modern technological society, the infrastructure of agriculture and healthcare, for your survival, you aren't sovereign. There is a reason that word is synonymous with "ruler" or "king," it's a status that very few people, particularly in modern society, can claim.
I am sure you know the difference between free labor and slave labor.
I'm sure you know that's beside the point. Free labor isn't that free when the only alternative to trading the most useful half of your life to corporations is starvation in the streets. And the only alternative to that is dependence on a state's social safety net. Neither may be outright chattel slavery or literal feudalism but in modern society where people truly own so little, even of themselves, it isn't freedom either.
Oh, it's exactly the point. You've conflated freedom with being free from want. Freedom means being free of other people forcing you to do things. You can go about satisfying your wants any way you want to, as long as you don't force others.
That's what free labor is.
If you believe you're entitled to the fruits of the labor of others, then you've enslaved them, and that's not the moral high ground.
Energy in Star Trek is not free either, just too cheap to meter. They use fusion and matter-antimatter reactors. Once we get there we will also have more than enough energy to power the potential replicator.
Though I agree we probably won't be using it to replicate a cup of Earl Grey for a very long time.
growing the beans, having them picked, packaged and shipped and making them yourself is assembling building coffee atom by atom. What do you think those plants are doing growing those beans? What do you think pouring that hot water onto the grounds is doing?
That's because we haven't figured out how to harness it.
For example, 99.9999% of the sun's energy just disappears off into space.
We sit on a hot planet, all that's needed to drive our energy needs is to drill a hole through the mantle. But nobody has figured out how to do that yet.
I only just noticed that the wheelchair https://libertymemesfoundation.org/donations/endurance-the-o... is actually a Class 2 device. That sounds really hard to get past the FDA. I think it's pretty cool still because folks with the knowhow could make their own, but the disabled are probably SOL because you can't really make these for sale without that.
I suppose the FDA's reasoning is that they're better off having no mobility than having a device that doesn't work properly.
I don't think powered wheelchairs should be Class II, but we should be a bit kinder to the FDA.
The FDA is not comparing no mobility and simply an inoperable device, the FDA is comparing no mobility vs the possible outcomes of an malfunctioning device. Like perhaps what happens if the throttle gets stuck on forward.
The FDA serves many compromised purposes that, in sum, prioritize the interests of the capitalists who predominately control it. The same can be said for the entire US government.
Everyone keeps repeating it, but could you give evidence of that happening? Who are the commissioners? What about the staff?
The rich keep getting richer faster at the expense of everyone else.
That could have many causes. What evidence connects it to regulations? Usually, regulation limits excesses and can keep markets more open.
I can assure you that the FDA does no such thing, as I have been through a very difficult 510k at a previous employer.
Without commenting on the specific standards and regulations, the parade of horribles that could go wrong with a powered wheelchair is pretty extensive, when realizing that when a wheelchair goes wrong the user cannot move away from it. Consider the risks of a battery fire you can't escape, a drivetrain that could grab loose clothing around a pair of immobile legs, or a user whose wheelchair dies on an empty street at night at -10°F because it couldn't handle the cold for long enough. This doesn't mean the incumbents aren't fixing the regulations to ensure they've got a manufacturing moat -- this being healthcare, I assume that's exactly what they're doing -- but the FDA definitely has reasons to make sure these are regulated.
Do they?
I don’t think the FDA is in a position to asses whether those risks versus the benefits of mobility are an appropriate trade off for any individual.
The FDA is deciding that some people should have no mobility so that others have… what, exactly?
The people who bought $65,000 chairs still could — and they’d be equally reliable. But because one person needs to use it in Alaska, all people need to pay a premium… even if they live somewhere that cold rating is completely irrelevant and adding a needless $5000-10000 to the price.
While there’s a reason to regulate for truth in advertising and basic safety, eg, not catching fire on its own, the actual regulations extend far beyond that into adjudicating personal risk management without clear benefit.
I’m not a fan of technocracy — I think people themselves know what’s best for them.
Why wouldn't the FDA, which employs experts for that exact task, assess risks? Who is in a better position?
How can anyone but an expert evaluate the safety of a powered wheelchair?
Under that model, what about the people who can't afford a more reliable wheelchair because insurance is no longer obligated to cover it?
Yes, that's what I've been thinking too. Tom Quiter even mentions in the interview that there already have been companies which tried to offer cheap wheelchairs, but the quasi-monopolists had the FDA alter the regulations in a way with which the newbies couldn't comply.
However, since the MIF already attracted suppliers, I hope they can gain some leverage.
Really cool that an electric wheelchair costs more than a luxury EV and is somehow less reliable.
Wheelchair users have no bargaining power against wheelchair makers.
Car buyers have leverage.
Normally this exorbitant price would incentivize competition in a healthy market, but the private equity players presumably make that difficult. There might also be barriers to entry in the market.
I suspect in the US the lack of competition is due to regulation and liability, not VCs.
It’s more the divorce between the receiver, the seller and the buyer. Sellers are not selling to the people using the wheelchairs, they’re selling to insurance companies and the government. Both types of entities have a proclivity for overpaying.
This is also true for most drugs. If we removed private insurance companies, Medicare and Medicaid in their totality from the equation, the market rate for drugs and medical equipment would drop into the abyss compared to where they’re at now.
Consider the public schools. You have the customer (the students), the buyers (the taxpayers) and the service provider (the teachers), which are accountable to neither.
Define "accountable"? If a teacher does something awful to a student (e.g. sexually harass them), a taxpayer-funded entity (the school board, the police, or the courts depending on the severity and what happend) will reprimand the teacher.
With something less egregious like "giving a the students a bad education", we still have some level of accountability based on standardized testing and school funding. Standardized testing is far from perfect, and it can be an example of Goodhart's Law, but it's still accountability.
The schools' poor performance relative to private schools is a strong signal of lack of accountability.
Another signal is the firing of teachers for incompetence is practically non-existent.
A third signal is anytime someone from the school talks about solving issues, they always always always put it down to lack of funding, and the credulous journalists repeat that unquestioningly and the schools get their tax increase.
A fourth signal is repeatedly lowering the requirements for a diploma.
A fifth signal is getting rid of "high stakes testing".
A sixth is getting rid of the gifted tracks.
How much of that can be attributed to selection bias though? Private schools are pretty pricey, meaning you generally have to come from a fairly rich family to go to one. Rich families can afford extra tutoring that a poor family might not be able to.
A better statistic might be to compare public schools to charter schools, and that's a much less clear cut distinction. I can point you to dozens of cases where charter schools are a joke, and a bunch of cases where they're great, it's not a clearly defined "better" just because there's a profit incentive.
Yeah, so that's just not true. If you go to a poorly funded public school, the calls for funding are immediately obvious. There are holes in the ceiling, often there's no chalk/markers to write on the board, the computers will be from the late 90's and half of them just don't boot up.
You could argue that this is due to simply poor allocation, and there's probably some truth to that, but implying that they're not poorly funded is flatly wrong. Have you even seen a high school in a poor neighborhood in the last forty years?
Fair, but you've worked for private corporations haven't you? Surely you've seen employees that do literally nothing manage to hang around the company for years. I had a friend that jokingly told me when he retires he's going to get a job at Bank of America because he can just show up and do nothing at his desk while still taking home a paycheck. I don't know that that's an issue with "accountability" so much as it's an issue with "large organizations are bad at finding outliers".
The GED has been around for since the 40's. I've never taken it since I did high school the normal way, but I know several people of different age demographics that claimed it's much easier than normal high school, so I don't think this is new.
I guess I just fundamentally disagree with this being a bad thing. Understanding a subject isn't a binary yes/no like a test implies. Testing can be a good way to gauge the level of understanding a student has on a subject, but "high stakes" implies that the student will be punished in some way unless they pass, and I guess I disagree with the utility of that. Again, it becomes a Goodhart's Law situation.
Has this actually happend? My younger sister graduated from high school four years ago, she had exclusively AP classes. I'm a good chunk older than her and graduated high school in 2009, but I skipped two grades in math. Where has this happened? A quick search had a few articles calling for the removal of gifted tracks but I didn't see any indication that it actually happened.
lol. The teachers have very little say in anything. The service provider is the school board and the administrators, the teachers are just like an instrument they operate as they see fit.
You also need the unreasonable barriers to entry for the scam to work. Otherwise new entrants would still drive down the price. So the FDA is doing its part to keep prices high.
In terms of everything keeping health care costs sky high, you are correct. What I outlined is the tip of the iceberg, if the iceberg was Antarctica.
There have been a lot of acquisitions and rollups in this space. We have regulations against this, but they are not enforced, and the VCs have the money to push through this layer anyways.
It's both.
The US lacks serious competition in _most_ of it's industries right now.
Only in the industries, where the government is involved.
There have been recent monopolization plays on cheer leading, on diving schools, and grocery stores. This is not a polite machine with boundaries.
It’s the natural end result of the consumer price standard for antitrust
Isn't the auto industry notoriously jam packed with regulation?
Weirdly, not really in the US. The regulations are all a little pointless because it's a "self-regulated" industry. Look at the cyber truck - stuck floor pedals and trunk closer that cuts off fingers, or trivial to clone car fobs.
Same for Kia and Hyundai being able to sell cars with compromised security. Something other countries regulate.
I'm feeling it's not the full story here. Presumably it shouldn't be extremely hard to produce a wheelchair, right? So why aren't there more people trying to get in this business?
Perhaps the wheelchair is considered a medical device and therefore has to go through more expensive safety tests and/or liability insurance?
There's no reason to think this is true. Unless the barrier to market entry is access to huge amounts of capital, it should be no different than if the entire space owned by mom and pop shops.
Reminds me of the military industrial complex.
Ya this reminded my of a Palmer Lucky interview where he explained how the prices are created. Can't remember off the top of my head but there was substantial incentive to build with the most expensive materials, doesn't seem like the case here though.
From a friend who is a Navy engineer this is apparently on purpose is done as a form of economic stimulus. Overpay 10x for things to support the local economy around the base.
It's not surprising that a nearly bespoke vehicle would cost more than, and be less reliable than, a mass produced one. Just think of the engineering resources invested in the two vehicles and in their manufacturing processes.
Can you go into what that statement means? I'm having a hard time parsing "an usual". Seems like there are some electric wheelchairs for ~$2,000:
https://www.forbes.com/health/accessibility/best-electric-wh...
...maybe some specialized wheelchairs cost considerably more?
It's a complex set of sub-markets. Like, for example, if your kid has one...it has to be NHSTA crash test certified to put on a school bus.
Or, for people with very limited mobility, they need very special cushioning to avoid bedsore type problems.
Just 2 examples, there are many more. Though $65k still strikes me as unusual.
none of those chairs in that article is realistically a full-time use electric chair; they're more akin to 'adult scooters' than that. The purpose of most of the chairs in the article linked is to make ease of travel easier; that's why they mostly all fold.
Here's an example of a real full-time use electric chair. [0] It's front wheel drive, has standard attachment points for medical devices, a standardized controller interface that can be adapted to just about anyone, false bogey-arm suspension for stability sake, and all the certs.
It starts around 8k-ish out of pocket. I don't use electric chairs myself, so i'm unfamiliar with what insurance/medicare costs would be.
I pay ~2-4k out of pocket for a manual wheelchairs 20% co-pay through medicare, to give an example of the costs of things. Electric full-time use chairs are astronomically more expensive.
[0]: https://rehab.invacare.com/Power-Mobility/Invacare-AVIVA-FX-...
Some folks in europe have a hard time knowing when to use a or an because there are so many exceptions, (a before consonant, an before open vowel sound) particularly in areas that pronounce it as oo-sual and not you-shual.
How tf does an electric wheelchair cost that when a standard wheelchair is a few hundred and a solid e-bike is a couple grand?
These are not just powered wheelchairs, but specialized vehicles for particular needs. Someone else in the thread describes them.
Captured market. Some of the costs are paid by insurance, so it's seen as "not hurting consumers, since, hey! insurance pays for it anyway".
The article does mention this bit to sort of justify the cost:
In many cases, yeah the wheelchair is specialized and has features that each individual needs. My friend with muscular dystrophy had one of those. But the drivetrain and the lead acid batteries seemed generic enough though possibly a higher quality, but it was definitely not something that should cost $65k.
They do not. I just was fitted for one. I asked "how much is this retail, out the door, cash?"
$24,000.
So if Medicare is paying $65k, something is seriously wrong.
With all due respect, that figure is still absolutely insane.
Welcome to American healthcare. I bought a CPAP machine for $800 cash about 10 years ago but signed paperwork saying it cost $2500 and assigning them the right to collect from my insurer. I had none at the time. Don't know if the billed Medi-Cal on my behalf [scratches chin].
Can you point to any project site that has released anything along this line? Blueprints, bills of material, code? There's nothing on the site you linked having any such resources. The closest thing is a block diagram including an RS-485 motor controller, which doesn't really seem like an alternative to standard parts at first glance.
We have collected all the documentation from the WHIM Wheelchair development effort at https://wiki.replimat.org/wiki/Wheelchairs
Since the US ones are disposable anyway, here are come comparables for well under $3K (often under $1K)
https://www.aliexpress.us/w/wholesale-Electric-wheelchair.ht...
No idea if it makes more sense to buy those, design from scratch, use those for inspiration, or buy one, tear it down, and rip off the bill of materials.
I was curious what parts they were using in their design but couldn't find any actual open source design content. The website seems to be 100% fundraising copy. The idea seems good, I hope this doesn't turn out to be another piece of accessible tech vaporware.
How hard would it be to do a project like the voron printer project where it’s just the plans and BOM?
A better wheelchair seems like a fun project and if the costs are that extreme probably not so hard to do better (unless the costs are extreme because regulation prohibits a good market).
It’d be fun to take advancements in electric mobility devices to wheelchairs.
there are some projects which are there doing it for fun.
This one from Youtuber Jerry Rig Everything https://notawheelchair.com/products/the-rig
He usually reviews mobile phone durability etc, there are videos on his channel about the chair, this started as project for his wife who was paralyzed in riding accident very young.
Akin to the flamethrower that Musk was selling a while back as long you don’t call it a medical device there isn’t much regulations (hard to differentiate say a Walmart scooter style device from a actual wheelchair)
Of course if it’s not a medical device it won’t qualify for insurance or Medicare , but you can still sell it for reasonable prices
Should be "a usual" because "usual" starts with a consonant sound. Otherwise could sound like "unusual."
It would be better to simply use the adverb form "usually" and apply it to the word "cost", instead of using the adjective "usual" and applying it to "electric wheelchair".
"Electric wheelchairs usually cost a lot of money."
vs.
"A usual electric wheelchair costs a lot of money."
The second form begs the question, what is it that comprises a "usual" electric wheelchair? What would make an electric wheelchair seem "unusual"? A custom muffler? The statement creates more questions than it provides answers.
The first form however is simple and clear. What about these wheelchairs can be considered "usual"? The cost. They cost about the same. What would make a wheelchair expressed in this context unusual? The cost. It's either cheaper or more expensive. No additional unanswered questions have been created by expressing the statement in this form.
A usual one?!?
The MSRP of a 2024 Tesla Model S is $72,990.
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EDIT: Do you have a source?
This puts the Bluey episode "Granny Mobile" in context, where the grouchy granny wants to buy the used wheelchair for a mere $100. $1,200 is still an incredible deal.
Seems like the best way forward would be to give some smaller amount, lets say $30,000 to the one in need and let them shop around for the best solution and keep the (probably still sizable) difference