Solar and wind are coming. And the power sector isn't ready - <AUTHOR> https://www.vox.com/energy-and-environment/2018/5/18/17359730/wind-solar-power-grid-electricity-managers <comment><USER2> My favorite climate change joke: "They say we won't act until it's too late... Luckily, it's too late!"

I have a startup in cleantech software, and often I feel very alone on HN. Every time the energy transition or climate change comes up on HN, it seems like most of the replies are either armchair-quarterbacking ("What they should do is..."), dismissive ("They don't take into account..."), or futile ("This isn't going to be fixed because...").

What I don't see is gravity for the magnitude of what's going to happen in the next few decades. Over 80% of the world's energy currently comes from fossil fuels[1], and the vast majority of that will switch to clean sources within our careers. It's a $10.2 trillion dollar transition that will happen in just a few decades[2].

So why the the lack of interest from "high growth" HN crowd? There's fuck ton of money to be made in the energy transition, and I'm betting that much of it is going to be in software. Intermittent solar/wind generation + storage requires a ton of software to (1) deploy enough to displace fossil sources and (2) actually work reliably. The energy transition isn't a research problem anymore, it's a scaling problem, which means software opportunity.

Maybe it's the assumption that salaries aren't competitive? Maybe it's because most business models in energy tech aren't compatible with VC? Maybe it's because you have no idea what specific problems there are that need solving? Maybe the assumption is that energy is super slow and bureaucratic?

Anyway, it's always sad to see the 2nd largest industry in the world (the 1st largest is killing people over energy) always get so categorically poo-pooed on HN. I'll keep posting[3][4] and hoping that attitude will eventually change, because we could very much use your talent in making this transition happen.

Because it really is too late.

[1]: [https://www.eia.gov/todayinenergy/detail.php?id=11951](https://www.eia.gov/todayinenergy/detail.php?id=11951)

[2]: [http://sdg.iisd.org/news/investments-in-renewable-energy- to-...](http://sdg.iisd.org/news/investments-in-renewable-energy-to-top- us7-trillion-by-2040/)

[3]: [https://news.ycombinator.com/item?id=13250336](https://news.ycombinator.com/item?id=13250336)

[4]: [https://news.ycombinator.com/item?id=15127154](https://news.ycombinator.com/item?id=15127154)

<comment><AUTHOR> Hi Dan!

0\. (We've met briefly; I work at a clean energy startup that relies on Utility API; I posted this.) 1\. It is too late to prevent civilization- impacting warming, but it is not too late to have an enormous effect on how much impact happens how quickly. 2\. "Optimism isn't principally an analysis of present reality. It's an ethic. It is not based on denial or rosy thinking. It is a moral posture toward the world we find ourselves in." [1] 3\. Ken Caldiera thinks that the tool-building you have done is the right kind of work. [2] 4\. Ya, HN has noisy nay-sayers. A lot of them simply have outdated mental models and excessive self-confidence. Can't do much about the latter, but posts like yours can chip away at the latter. 5\. If you need a dose of fact-based optimism, check out recent editions of Chris Goodall's amazing mailing list. [3]

Your work matters. Keep on keeping on! Best, Sam

[1] [https://talkingpointsmemo.com/edblog/observations-on-the- day...](https://talkingpointsmemo.com/edblog/observations-on-the-day-after) [2] [https://kencaldeira.wordpress.com/2018/07/21/on-choosing- pro...](https://kencaldeira.wordpress.com/2018/07/21/on-choosing-problems-to- work-on/) [3] [https://us9.campaign- archive.com/home/?u=a336c39e55a6260d59a...](https://us9.campaign- archive.com/home/?u=a336c39e55a6260d59adbffb0&id=ffb538443d)

<comment><USER2> Howdy! Thanks for the links. I didn't mean to come off as so fatalistic. I'm still very optimistic about our future, whether or not other people in tech participate (it will just take longer, and we'll suffer more consequences).

My point was to mostly to impress that problems exist outside of web tech, that web tech experts could help solve. The smartest people I know are in the oil industry. They know how to literally go into Nigeria, bribe the right gangs, and get the oil out. They are way better at "getting shit done" than anyone I know in silicon valley. These are the people those of us in cleantech are up against, so we're severely out-gunned.

We truly do need all the help we can get, even if it is from tech elites. I'm willing to make that deal with Worry Free[1].

[1]: Reference to Sorry to Bother You: [https://www.theatlantic.com/entertainment/archive/2018/07/so...](https://www.theatlantic.com/entertainment/archive/2018/07/sorry- to-bother-you-has-an-eerily-familiar-villain/564698/)

</comment></comment></comment><comment><USER3> I'm a bit late to the discussion, but I'm glad to see so many comments here in response to one of the Utility API founders.

Just wanted to note something very important:

As a co-founder of a very new cleantech software startup, and as a guy coming into the energy industry initially with only a background in software, you need to understand that the energy industry (especially in the US) is incredibly diverse and is really an ecosystem in itself.

The market is not just regulated utilities and their customers. There are unregulated markets, power generators, ISOs, cleantech vendors, project developers, installers, financiers, insurance companies, and plenty more players in the space. Each of these actors serves a different role in the process of getting a solar array or battery up and running on a building or out in the field.

And to echo some other comments, the hardware is pretty much all there by now, with prices getting lower by the month, and the only thing that's missing is the right software to help scale deployment of capital, energy assets, installation labor, etc.

[Impending plug is coming]

In fact, this is exactly what my company, Station A ([https://stationa.com](https://stationa.com)), is doing. We've realized that in the commercial and industrial sectors, renewables are seeing slower penetration because the high soft costs associated with project development for the medium-to-small energy consumers. This stems primarily from a lack of access to critical data, biased sales tactics (solar developers only want to sell you solar, even if it won't make a difference), and the inability for project developers to really find the right locations to develop with the right technology in a scalable fashion.

This sector is ripe for disruption purely with software, as the hardware has become so much more commoditized.

</comment><comment><USER4> At our 40 acre walnut orchard in Northern California, we water via two wells (30 foot water depth) powered by two PG&E-powered electric pumps (60hp and 20hp). There is an agricultural discount if we run them nights and weekends, so we typically run them on weekends for 12-24 hours. Summer daytime temps are often 90-95 degrees F. Nighttime watering is also helpful due to less water evaporation.

But given the duck curve, I expect PG&E will at some point encourage 10am to 3pm power usage. Then it might be cheaper, electricity-wise, to run the pumps 3 times a week, during the heat of the day, instead of overnight on weekends.

Bad: More evaporation, so more water use.

Good: Maybe cheaper, and since trees reduce their photosynthesis when it gets too hot (to decrease water loss), daytime watering may increase growth by keeping the air temperature lower.

<comment><USER5> You're in an interesting spot. You could generate your own power, since you don't need to store it.

I'd take a long look at how much power you need, and when 5 years of electric bills are more expensive than your own installation. Maybe never, but prices do keep falling.

</comment></comment><comment><USER6> For those of you skeptical that software can address this problem.

      https://en.wikipedia.org/wiki/Virtual_power_plant

Adding storage to the grid is one solution, but adding software that can better influence the demand various customers put on the grid is also surprisingly effective.

<comment><USER7> > _software that can better influence the demand various customers put on the > grid is also surprisingly effective._

Every time the smart grid comes up, I imagine the power company turning off my air conditioning because the ability to turn off my air conditioning made them feel safe to under-provision.

<comment><USER8> What if you could set parameters under which the power company could turn off your air conditioning, and you got paid as a result?

Such as:

* You may turn off my air-conditioning for $2.00/hour as long as my room's temperature is below 75 Fahrenheit.

* You may turn off my air-conditioning for $10.00/hour as long as my room's temperature is below 80 Fahrenheit.

* You may turn off my air conditioning for a maximum of 1-hour per day for $60.00/hour, as long as my room's temperature is below 85 Fahrenheit

* You may, at no point, turn off my air-conditioning between the hours of 10pm-6am.

<comment><USER9> Anecdotally, we are paid $10/mo for the utility to have the option to disable our A/C for up to a couple hours a day. They do not pay us for the time they actually disable A/C, but I don't it hasn't actually happened yet, so we are "winning" that bet. I think that customers would bid this option lower than $10, given the option, but agree others wouldn't touch it. I hope that the price mitigated the real risk of supply planning skew mentioned by the GP.

</comment></comment></comment></comment><comment><USER10> Current UK status:

[http://www.gridwatch.templar.co.uk/](http://www.gridwatch.templar.co.uk/)

Is there a US equivalent?

<comment><USER11> Worldwide map:

[https://www.electricitymap.org/?page=map&solar=false&remote=...](https://www.electricitymap.org/?page=map&solar=false&remote=true&wind=false)

</comment></comment><comment><USER12> If they are expecting to lower energy costs then why do they want more subsidies? Or on the other end a carbon tax to penalize competitors? I'm sure there are policy prescriptions other than subsidies that can be beneficial to the industry but the ones that seem to get the most discussion are production tax credits and carbon tax.

<comment><USER13> It still costs money to build this stuff. And you might be asking why does coal and gas get subsidies?

<comment><USER12> They get deprecation like everyone else which helps subsidize the building of facilities as well as certain on going capital expenditures. Why do they need a production tax credit also (industry specific)? Talking simply renewables so coal & gas is another discussion.

</comment></comment></comment><comment><USER14> Power sector isn't ready, nor anyone else. Developing power to heavy usage areas from available generation areas is like building new railroads. Success will arise from new, large, government-granted monopoly operations and be slow and pricey without political support at local levels and paying to or seizing from the many literal NIMBY people affected.

[https://www.technologyreview.com/s/609766/how-to-get- wyoming...](https://www.technologyreview.com/s/609766/how-to-get-wyoming-wind- to-california-and-cut-80-of-us-carbon-emissions/)

Alternatively, of course, solar roof tiles get mandated for new construction and these problems go away.

<comment><USER15> I'm not really in favor of an energy production mandate for new homes, but even if I was, I wouldn't want to be locked into solar, or even solar roof tiles specifically by law or statute.

<comment><USER14> An economic mandate could be triggered by an imperative to balance climate- control costs with passive home production systems.

</comment></comment></comment><comment><AUTHOR> "The US electricity system is at an extremely sensitive and uncertain juncture. More and more indicators point toward a future in which wind and solar power play a large role. But that future is not locked in. It still depends in large part on policies and economics that, while moving in the right direction, aren't there yet. And so the people who manage US electricity markets and infrastructure, who must make decisions with 20-, 30-, even 50-year consequences, are stuck making high-stakes bets in a haze of uncertainty."

<comment><USER16> Anyone looking at the past 10 years of solar and wind growth and price declines who is still "unsure" what the future will bring in the next 10 years and what they should be betting on doesn't deserve to run the given power companies.

<comment><USER17> Its over- any attempt to delay solars victory with regulations, will result in solar being deployed elsewhere (offshore/ south-america) and then delivered at combat prices to the border, deforming a future energy grid even further.

<comment><USER18> That's only so if you don't take transmission losses into account. Somehow many people tend to forget that transmission isn't free or even cheap.

<comment><USER19> Indeed. Energy in chemical form is astonishingly cheap to transmit (and store), but, as electricity, it's completely different. The storage problem is part of the point of the article, of course.

I always thought this was one of the advantages of rooftop solar, that it would reduce transmission costs by bringing generation closer to consumption, especially at peak, and not necessarily because of costs due to losses in the transmission lines, but costs due to maintaining the necessary capacity in those lines (a challenge for both the SFBA and NYC, IIUC).

</comment></comment></comment></comment></comment><comment><USER20> I apologize in advance for what is pretty much a tangent, but I wanted to mention a kind of passive wind generator that has no moving parts: [https://en.wikipedia.org/wiki/Vaneless_ion_wind_generator](https://en.wikipedia.org/wiki/Vaneless_ion_wind_generator)

It's basically one half of Lord Kelvin's Thunderstorm turned sideways and powered by wind instead of gravity.

Imagine a conductive screen, like an aluminum screen door and, upwind of it, a spray nozzle that emits mist. There is a conductive ring around the nozzle that is DC-biased so that the mist droplets carry a charge. The wind moves the droplets to the screen, collecting the charge.

There are no moving parts so you wouldn't injure birds.

<comment><USER7> At first glance it seems like this would constantly consume fresh water due to evaporation.

<comment><USER21> This link indicates the process relies on water's conductivity: [http://www.amasci.com/emotor/kelvin.html](http://www.amasci.com/emotor/kelvin.html)

(and works in spite of the higher resistivity of fresh, or even deionized water)

<comment><USER7> It would be very difficult to spray saltwater through nozzles, the evaporation would cause salt buildup and clog them.

</comment></comment></comment></comment><comment><USER22> I don't know that fatalism and hopelessness are motivating for decision makers (who are seeking greater margins regardless of policy and lobbies).

Is our transformation to 100% clean energy ASAP a certain eventuality? On a long enough timescale, it would be irrational for utilities to not choose _both_ lower cost _and_ more sustainable environmental impact ('price- rational', 'environment-rational').

We should expect storage and generation costs to continue to fall as we realize even just the current pipeline of capitalizable [storage] research.

Solar energy is free.

</comment><comment><USER23> I've mentioned it before. I think I have a new low cost approach to residential solar if anyone is interested in helping or teaming up.

</comment><comment><USER24> At first glance I read "solar wind is coming" \- which is a more alarming and perhaps even less prepared for condition.

</comment><comment><USER25> For some perspective:

[https://www.youtube.com/watch?v=Kxryv2XrnqM](https://www.youtube.com/watch?v=Kxryv2XrnqM)

</comment><comment><USER26> Aw, I misread as Solar Wind is coming, got excited for some strange new form of electricity harvesting :(

</comment><comment><USER27> > President Trump has embraced fossil fuels, ...

still unbelievable</comment>


Internet Archive putting database in Canada to keep it from Trump - <AUTHOR> http://thehill.com/policy/technology/307942-internet-archive-putting-database-in-canada-to-keep-it-from-trump <comment><USER2> Article from the Internet Archive itself is currently on the front page: [https://news.ycombinator.com/item?id=13065599](https://news.ycombinator.com/item?id=13065599)

Doesn't look like this has much (if anything) to add.

</comment><comment><AUTHOR> This is a pretty biased-sounding headline but I'm putting it in as-written to conform with HN guidelines.</comment>


First Round Review: Flying Lessons - <AUTHOR> http://firstround.com/article/Flying-Lessons

<comment><USER2> It's amazing how there are many life lessons that aviation and flight school can teach an individual. The transferable skill-set in entrepreneurship and aviation in terms of staying alive are quite impressive, from launch, flight, and landings.

</comment><comment><USER3> I apply my experience as a flight instructor to my life and work almost daily. When stressed, I just try and remind myself that I survived countless brushes with death while teaching students how to land a Cessna...</comment>


Jeff Hawkins Develops a Brainy Big Data Company - <AUTHOR> http://bits.blogs.nytimes.com/2012/11/28/jeff-hawkins-develops-a-brainy-big-data-company/

<comment><USER2> So he is saying that you don't need to store all the data, just its most common learnt representations. Isn't that a fancy way of saying online learning or summary statistics?

<comment><AUTHOR> It is online learning, but as far as I understand, there is another side to it. Right now, if you get a new data stream, you have to play around to build the right models for it (mostly manually, with trial and error) before you do online learning. As the number of data streams grows, this doesn't scale well. Their algorithm adapts online to the data stream without you having to design any model.</comment></comment>


Are mutts like me welcome on HN? - <AUTHOR> I grew up in Boring, Oregon (that's not a typo).  I'm an aerospace engineer by training (public school).  I worked on designing and building electric passenger vehicles back in the 90s (the first time they were cool) but then went to b-school (Ivy league) graduating in 1999 and have been a serial entrepreneur since as founder or CEO (i.e. the "business guy").
The first hacking I did was in 1982-ish on an Apple IIe.  The last true hacking I did was in the early 90s using FORTRAN77.  I wish I were more of a hacker now, but alas I don't have the patience.
Anyone can read and post to HN (and I have been doing both for about 6 months) but I'm curious who the core folks here are and what's the view of mutts like me? <comment><USER2> I'm probably about as "un-HN" as you can get.

I live in a small industrial northern English city, about 10,000 miles from the buzz of Silicon Valley both physically and metaphorically.

I don't know how to code except a bit of really basic stuff, I don't have an education from a top university, I don't own a laptop or an iPhone or even my own home PC.

I don't work at a company that makes mashups out of widgets using the Google and Twitter APIs then turns them into Facebook apps.

But I still work in a startup, even though it's not in the web field. We're a new regional digital radio station on a platform called DAB. I love the startup atmosphere; it's so much more rewarding to come in every day and get stuck into building this thing up. It's not a web app, but it is a blank canvas for ideas and development-- we really want to do things differently to any radio station that's gone before and put to death the adage that "there are no new ideas in radio".

Personally, I take an interest in the way in which radio's using new web technologies like Twitter to have a two-way conversation with listeners and turn them into participants. I'm interested in the social news model and how it could be adapted for our medium. I want to give new life to a medium that's condemned as dying on a regular basis. We're really not "big bad old media", you know.

Some of the technical stuff on here goes way over my head, but the quality of submissions and discourse is far better than other social-news sites I could mention. I'd rather have a site that's a bit above my technical level than one that's full of conjecture about Apple laptops or pictures of cats.

</comment><comment><USER3> Welcomeness isn't defined for users so much as behavior. Or to put it another way: you are what you do. Anyone's welcome who has interesting things to say.

<comment><AUTHOR> Fair point. The more precise question I wanted to ask is what behavior is encouraged/desired on HN? Are there any published norms on, "things to say?" So far as I can tell there are no published howto's, alas the ask.

<comment><USER4> You're an aerospace engineer with an ivy league business degree who's so concerned about being courteous that you posted this topic. If you're not welcome here, I'm sure as hell not.

Welcome, you seem like a nice guy. Say what you think and I'm sure you'll be fine. The closest thing to guidelines are at: <http://ycombinator.com/hackernews.html>

To quote PG: "The focus of Hacker News is going to be anything that good hackers would find interesting. That includes a lot more than hacking and startups. If you had to reduce it to a sentence, the answer might be: anything that gratifies one's intellectual curiosity.

It may be easier to say what that doesn't include. It doesn't include most stories about politics, or crime, or sports, unless they're evidence of some interesting new phenomenon. It doesn't include videos of pratfalls or disasters, or cute animal pictures. Basically, if they'd cover it on TV news, it's off-topic."

</comment></comment></comment><comment><USER5> Once a community gets large & diverse enough that it starts wondering about its own composition, it enters a phase in which it has to start to examine a lot of unspoken conventions. Since Clay Shirky wrote about this phenomenon so well, I propose we call this stage "Shirky Completeness".

As far as I'm concerned, you've built stuff and want to build more stuff; you're polite and thoughtful. Enough for me. Welcome. :)

</comment><comment><USER6> I'm a tech guy, and I think the site could use more guys like you.

<comment><USER7> I've been surprised at just how business-saavy the "tech guys" on this site are!

<comment><USER8> It's probably a side effect of the fact that this was "Startup News" prior to it being "Hacker News".

<comment><USER9> And a lot of founders/small business owners post here too. Most are technical, but some are non-technical.

<comment><USER8> Yeah, I think you're right on the money.

Whatever the mixture is, it's a good one. I've always thought YC was impressive for it's ability to have spirited discussion without the constant holy wars that tend to erupt when you get a lot of smart people in a room.

<comment><USER9> I always tell people the best part about Hacker News is you can witness people changing their mind within a thread. How many places are like that?

</comment></comment></comment></comment></comment></comment><comment><USER10> Who said hacking has to be software hacking?

The YC application even explicitly asks for evidence of non-computer hacking abilities.

Your bio, and the fact that you enjoy posting here means that you have the hacker spirit, in all likelihood. You're more than welcome.

</comment><comment><USER11> Your bio seems like a perfect reason to reconsider thinking things like "What does this business guy think he is, some kind of rocket scientist?".

</comment><comment><USER12> I've been lurking until today. I too am concerned about not upsetting an apple cart. The rules today are pretty much the same as any other social situation.

Netiquette isn't so much different than etiquette. Treat people with respect, which you do. Add something of value, which you do. Listen to and learn from what others provide, which you are doing.

Remember, above all, this is a community (I just created an account today) like all others and I too am wondering what to say and not say.

I think the very fact that you asked the question shows that you are interested in this community remaining strong. That's what any community needs.

</comment><comment><USER13> Don't have the patience?! That's the fun part -- slowly working through the problems! Fighting the gods until you are victorious!

You should give it a whirl again, you might be surprised.

<comment><USER14> I beat the gods twice today! :D

<comment><USER15> What are you planing to do after lunch?!

</comment></comment></comment><comment><USER16> How are you a mutt? Think of yourself as multidimensional -- having knowledge of doing more than web app software.

My undergrad is in Electrical Engineering. I designed industrial data monitoring & control equipment for a few years, then started doing embedded software. Got an MS in software engineering. Did more embedded, did some MFC stuff, dabbled in cgi scripts and Zope for a while. Somewhere in there had a small 2-person side business building temperature monitoring equipment for a few years. Now working on movie camera motion control. I'm about as far from Web 2.0 as you're going to get :-)

I like it here and I also hang out on Spolsky's Business of Software forum. In both cases I get more out of the business discussion than the software discussion.

I for one welcome someone with wider scope of experience who can bring something new to the discussions.

</comment><comment><USER17> Being a hacker is more about self-determination than any institutional credentials.

You build stuff, you can code, and you want to talk about tech stuff. I'm not sure there's much else to a hacker's definition than that.

</comment><comment><USER18> You honorably recognize your talents and achievements. But you still start a topic asking your candidacy?

Then what label can you give me? I'm not an aerospace engineer, I'm not a serial entrepreneur, and I'm sure as hell that I would never build an electronic passenger car.

Everyone is welcome here. We humans are extraordinarily curious beings, curiosity & willingness to explore is the main reason why we kept visiting this site.

</comment><comment><USER19> Sure. As long as you submit your version of our traditional song of "I'm a lumberjack" on YouTube, wear the funny hat, and learn Lisp, you're as welcome as anybody else. Oh yes, there's the monthly dues. You can just send them to me and I'll hook you up.

Just kidding. I think the only requirement is to be interesting, but judging by some of my posts, perhaps even that is not required.

Welcome aboard!

</comment><comment><USER20> Don't be bashful; hacker mythology is more misunderstood than it has ever been, which is what makes it so interesting. We are all part of the elephant here and while many come and go the myth will remain ever-changing: <http://en.wikipedia.org/wiki/Blind_Men_and_an_Elephant>

</comment><comment><USER21> I'm aerospace turned hacker myself. Just curious, are there any others about in the same boat?

<comment><USER22> I'm not, but two of my cousins are aerospace engineers, and hackers in the inclusive sense. I think a venn diagram showing the essential qualities of a really good engineer and a hacker would be nearly indistinguishable from a slightly elliptical circle.

</comment></comment><comment><USER23> I prefer mutts ;) Too narrow a pedigree is not very interesting to me.

</comment><comment><USER9> I'm not a hacker and I've always felt very welcome here. As others have suggested, definitely lurk around a bit to see what the norms are.

</comment><comment><USER24> We're all painters.

</comment><comment><USER25> you are welcome enough to be on the front page :) so welcome! (though with mere 29 points (or karma, or whatever we call it) I don't think I have the 'authority' to welcome you just yet :)

</comment><comment><USER26> Welcome! I grew up in Eugene, which was pretty boring too:-)

</comment><comment><USER27> Yes ! Do you startup, er, startups that involve hackers??

<comment><AUTHOR> Is this a test? Are you one of them? ;-)

<comment><USER27> oh no - I am nobody of consequence !

But I think you are welcome here. HN started out as startup news, so someone with you interests would fit in.</comment></comment></comment>


PG's 'Startup Ideas' Post: One Missing Heuristic - <AUTHOR> http://statspotting.com/2012/11/pgs-startup-ideas-post-one-missing-heuristic/

<comment><USER2> Paul Graham has brought this up before, in _How to be an Angel Investor_ [1]:

"There is an ongoing debate between investors which is more important, the people, or the idea—or more precisely, the market. [...] The three most prominent people I know who favor markets are Marc [Andreessen], Jawed Karim, and Joe Kraus. And all three of them, in their own startups, basically flew into a thermal: they hit a market growing so fast that it was all they could do to keep up with it."

Paul Graham goes on to say:

"Thermals happen, yes, but no one can predict them."

[1] - <http://www.paulgraham.com/angelinvesting.html>

</comment><comment><USER3> I don't think he missed it. From his essay:

"Similarly, since the most successful startups generally ride some wave bigger than themselves, it could be a good trick to look for waves and ask how one could benefit from them. The prices of gene sequencing and 3D printing are both experiencing Moore's Law-like declines. What new things will we be able to do in the new world we'll have in a few years? What are we unconsciously ruling out as impossible that will soon be possible?"

<comment><USER4> Well given that PG/team has been able to create this awesome community of really intelligent people to discuss such ideas is enough to ensure that he doesn't really miss any of these fringe stories of success.

In this essay sure, but not in the complete picture out there.

</comment></comment><comment><USER5> It seems to me that that key piece of advice in pg's essay:

        "Live in the future, then build what's missing."

is just a more subtle way of expressing the "missing" heuristic described in this article:

        "Focus on enabling technologies and environmental factors."

and seems to me to be a bit of a distinction without a difference.

However, it is helpful to hear it expressed a different way, and reminds me of something I heard Gary Hoover (of Hoover online fame) say at a conference, which was that in the same way Tsunamis are the result of plate tectonic activity that happens months, weeks, or days in advance, there are things shifting within your industry that could result in "tsunamis" of change. What are they?

It seems like very obvious advice, but it is interesting to sit down and make a concentrated effort to think of what the shifts may be occurring in your industry. Sometimes they are easy to miss in that they are so obvious. (As in "fish were the last ones to discover water...").

Another way to think of it came to me from one of Tim O'Reilly's essays where he describes some key marketing advice he was given, which was to "find a parade and get out in front of it." (He attributes the success of O'Reilly media to getting behind the web and open source in its early days - [http://www.linkedin.com/today/post/article/20121002122119-16...](http://www.linkedin.com/today/post/article/20121002122119-16553-it- s-not-about-you-the-truth-about-social-media-marketing)) From that perspective, I like to think of what "parades" are happening in my industry, (energy), such as conservationism and environmental responsibility. What happens if/when 75% of the cars on the road are electric vehicles, (and are driverless)? Maybe my car is charged via solar panels or a whisper gen, and drives itself to the store where someone loads it with the groceries I ordered online? What products/services will be needed to support that? What do things look like when homes are net-zero energy, as they are meant to be in California in 2020?

It can be an interesting exercise.

Edit: Typos

</comment><comment><USER6> Also (not sure if covered) but related:

Look at stuff that has been tried and failed in the past, ask why it failed and see if anything has changed in the interim that might effect that.

Example is dropbox, they weren't the first with the idea of "have a space on your computer that is synced with the internet" but AFAIK they were the first to try it at a time when bandwidth for shifting files around was trivial.

</comment><comment><USER7> I think he missed the point. It doesn't matter what new cool thing is possible if no one will pay money for it to happen.</comment>


'I Smell Cash': How the A.T.F. Spent Millions Unchecked - <AUTHOR> https://www.nytimes.com/2017/09/08/us/atf-tobacco-cigarettes.html <comment><USER2> Best quote: "Company lawyers descended on the warehouse, seizing everything. A tobacco company had just raided the A.T.F."</comment>


Don't Be Scared About the End of Capitalism–Be Excited to Build What Comes Next - <AUTHOR> https://medium.com/fast-company/dont-be-scared-about-the-end-of-capitalism-be-excited-to-build-what-comes-next-e82c790dcfb7 <comment><USER2> Here's a version not behind the Medium paywall: [https://www.fastcompany.com/40454254/dont-be-scared-about- th...](https://www.fastcompany.com/40454254/dont-be-scared-about-the-end-of- capitalism-be-excited-to-build-what-comes-next)</comment>


Trump Signs Executive Order Compelling Disclosure of Prices in Health Care - <AUTHOR> https://www.wsj.com/articles/trump-order-would-give-consumers-more-information-on-health-care-prices-11561384725?mod=rsswn <comment><USER3> For someone who worked on price transparency in 2013 - I was personally affected with surprise billing - and spent long hours working on a price discovery / transparency tool called pricepain.com, I completely welcome this move. While it won't solve all issues at once, shining some light into the medical billing mess can only be a good thing, allow market forces to enter the picture somewhat.

<comment><USER4> I really would love to hear your experience and some details about the work you did on price transparency.

Can you share some?

I have been beaten by the surprise billing so many times that I now dedicate some of my personal time to researching the root cause and taking action, one of which is sharing my thoughts with other people in a vain hope that things will get better and improve.

I wrote a response to this article here: [https://news.ycombinator.com/item?id=20281150](https://news.ycombinator.com/item?id=20281150)

Would love any input!

<comment><USER3> That sounds very familiar. At first I thought it was a mistake. The confusion when you get several bills, one larger than the other. Then the shock, when you get the final picture of what you owe. I went back and forth with the hospital and finally got an itemized bill (I didn't know such a thing existed nor didn't understand why all bills would be itemized.) A square gauze priced at the cost of an iPad,... And then the upcoding racket. It all leaves you confused. How is this possible? Why isn't the media all over this or the state attorney? And why in the world is the insurance company part of the game? Then came the Time magazine front cover story (2013 I believe "Bills are killing us") about hospital charge masters (why was nobody going after this decades ago?)... Finally I came across Dr. Keith Smith from the Oklahoma Surgery center and finally the puzzle pieces fell into place. So one does what one has to do: roll back the sleeves and get to work. Poured a couple of months into pricepain.com after hours (a friend working at hospitals in Wisconsin helped with some initial price finding), a NYT offspring that had gathered some medical prices send a cease and desist when we copied their 'transparent prices for medical procedures in NY' eye-roll. Eventually the government released Medicaid prices - a first big breakthrough. I had discussions on HN with Better Doctor who tried something similar - eventually they pivoted and focused on other things. We pitched to YC and a medical VC fund. Latter said in 2013 'there is at least 5 others that are working on this' hahaha. Then came Obamacare and the future of free market / direct healthcare with price transparency became unclear - a super state nationalized Healthcare would have buried prices in yearly increasing taxes. So eventually I had to move on but always hoped that something like today's news - more price transparency to allow for competition and improvements of quality/service - would eventually win out.

<comment><USER5> > A square gauze priced at the cost of an iPad,...

Absurd list prices were used to screw Medicaid and Medicate. Because they often paid at 85% of list price. When commercial payers had negotiated as much as 90% _discounts_. But that doesn't work anymore, I think.

</comment></comment></comment></comment><comment><USER6> > Industry groups are mobilizing to fight back, saying any requirement that > hospitals and insurers disclose negotiated rates would go too far.

This kind of effort is what is required in order to allow for comparison shopping to occur. Maybe this even enables consumers to shop better for their insurance plans depending on their common needs. That would likely allow folks with certain recurring conditions to shop for the best insurance plan for them (thus also raising the risk level for that insurer and changing prices?) but that's a bit more like how a market is supposed to work.

I can't speak specifically to whether the order just increases legal ambiguity or whether it will be enforced, but I'm happy to see any initiative toward price transparency in medicine that will allow the public to start making better decisions.

> But the order doesn't say if hospitals would have to disclose the average of > all rates they get from insurers or the specific rate they get from an > individual's insurer. That detail matters: The average rates would have a > milder effect on local markets as insurers and hospitals still wouldn't get > clarity on rivals' specific secret rates.

PRECISELY. If everybody understands the negotiated rate, then any size organization can argue for that rate. This would make it easier for smaller- scale companies to get the same rates as larger plans and also reduce some of the incentives for large insurer / care company mergers that seem to be really rent-seeking given the industry comment on this order.

<comment><USER7> I wonder what happens when we create a market where prices are transparent, without disclosure of performance or quality too.

<comment><USER8> What do you mean? Aren't we talking about the price of hospital visits, etc., meaning the performance/quality is expected to be good?

<comment><USER9> Medical care is not uniformly good. Your parent is alluding to a theoretical race to the bottom on quality.

<comment><USER10> There is a standard of quality one can expect that is defined by malpractice law.

</comment></comment></comment></comment></comment><comment><USER11> If one argues in favor of "free market" solutions for healthcare, then one MUST argue in favor of pricing transparency. A functioning free market requires the open and honest sharing of price information for consumers to make informed choices.

Now, whether or not health care should operate under free market principles is a different discussion entirely. But the established powers seem to consistently fall back on the free market argument, but continue to keep pricing as opaque and complicated as possible.

<comment><USER12> The US has long ago abandoned free market healthcare. I don't know why people keep calling it that.

It's some bastard child of socialized medicine where the poor and old are covered mixed with gov mandated private insurance coming from a few very large insurance companies capable of operating within the regulatory environment.

Which is basically one step removed from full blown single-payer public health insurance (as we have here in Canada) and about a hundred steps removed from "free market" health care.

I hope the US gov decides on single payer soon as I see no path towards going back to an actual market. Which would be better than the current system which features much of the worst of both worlds.

<comment><USER13> US health-care costs are out of this world. However, for the life of me I cannot begin to comprehend why every Canadian keeps using our healthcare system as example of success when incidents like these are becoming more and more common

[https://www.cbc.ca/news/canada/newfoundland- labrador/samanth...](https://www.cbc.ca/news/canada/newfoundland- labrador/samanthan-rideout-amputee-broken-foot-1.5184582)

[https://www.cbc.ca/news/canada/nova-scotia/mother-iwk- halifx...](https://www.cbc.ca/news/canada/nova-scotia/mother-iwk-halifx- hospital-mental-health-refusing-to-leave-1.5181626)

and for a description of typical hospital visit [https://www.cbc.ca/news/opinion/health- care-1.5170948](https://www.cbc.ca/news/opinion/health-care-1.5170948)

note, CBC is basically a more liberal Canadian CNN

<comment><USER12> It's always lesser of evils when you're dealing with critical gov services.

If you can't provide a better alternative then it's still an improvement.

The much larger UK NHS system where even hospitals are publicly run would be even harder to pull off in America. So single payer insurance is basically the lowest hurdle. Plus the simpler the better.

At some point the right in the US has to concede on healthcare because it's already been gutted and killed by a thousand cuts. And I say that as a libertarian leaning person. You can't honestly believe they can solve this problem by writing a thousand more small reform bills.

Plus if you give the mob public healthcare they will be much more tolerant of pro-economy policies and take a strong argument away from the people who want to gut even more industries so they function just as poorly as the pseudo healthcare market in the name of "fairness" and "equity" (mediocrity for all!). Lesser of evils.

</comment></comment></comment></comment><comment><USER14> I have good health insurance but recently my insurance declined payment for a lab test on grounds it was experimental. Turns out the insurance company was on solid grounds. At this point I was on the hook for the lab fees. But here's the interesting part: because the insurance declined payment, negotiated rates no longer apply. This means the lab gets to charge me list price. The list price is a random high price that has no relation whatsoever to reality. In my case I was charged 3x the negotiated price! This executive order helps people in my situation—you can argue that the list price is unreasonable and that the negotiated price is all you should have to pay (even though you were not party to the negotiation).

This executive order is also useful for uninsured patients because you now have a basis for arguing for a lower bill. And the courts would be sympathetic because everyone knows list prices are random numbers!

<comment><USER15> You could have refused to pay and offered them the original price or threatened to sue which you can do without benefit of a lawyer. The act of litigating it would almost certainly be higher than any differential.

<comment><USER16> That's what I did after a surgical center told me that they spoke with my insurance company and everything was fine only to later send me a bill for $150,000 for a 1hr surgery to fix a broken hand. How are you supposed to deal with in-network / out of network hospitals when you have a bone coming through your hand? It eventually went away because balance billing was made illegal in california.

</comment></comment></comment><comment><USER17> This will help but until health insurance and healthcare is disconnected from employer provided, and instead consumer focused, the pricing will continue to be shrouded and fixed.

Healthcare and health insurance should almost be separate but should not be tied to a workplace. Disconnecting health insurance from work benefits in favor of payment will help the private market and public market pricing, whichever or a combination of both that it eventually goes.

Healthcare that is consumer focused and disconnected from employer provided:

\- will have to be price transparent

\- will make starting a business easier

\- will make the US more business competitive as companies in other countries don't have to provide it

\- will allow people to change jobs more easily

\- will make ageism less of an issue

\- will get companies out of your private health

\- will allow bigger grouping by insurance companies across the nation not at the job level (right now small/medium/family/individual private insurance is seen as more risky because private insurance groups by employer and smaller is more risky)

Health insurance is personal and shouldn't be known by your employer, and re- signing up every year and anytime you get a new job is tedious, it needs to be like all other insurance (auto, home, life mostly) that it is a personal consumer choice and private.

Unbinding and de-coupling healthcare from the job is pro-business and pro- consumer health and will lead to true market price transparency.

<comment><USER18> Exactly, we really just need to change one tax policy to make this happen. It doesn't get much easier than that.

</comment></comment><comment><USER19> I'm loving this. I shop around for my healthcare needs and it's very difficult to get a quote of any kind for any service. This will increase transparency and competition and that will hopefully lower prices.

</comment><comment><USER20> That's kind of cool, though the devil is in the details and I'm not sure about the details for this case.

Essentially, free market relies on certain assumptions under which the supply/demand 'invisible hand' works properly and the benefits of free market are realized - the key economics 101 assumptions are (1) large amount of both suppliers and buyers; (2) small barriers of entry and exit; and (3) full and truthful information about market conditions. The further we get from these assumptions, the less free (and usually worse for the people) the market becomes, and often we need gov't intervention to ensure that these assumptions stay true and the market behavior stays close to theoretical free market instead of degenerating into an exploitative uncompetitive monopolistic market with hidden information - as the USA medical market is doing, and seems to need such intervention.

<comment><USER21> The healthcare market isn't even close to free, it's the most tightly regulated industry. Until that changes, nothing will get better.

<comment><USER22> People I know who have worked in commercial aviation have claimed that it takes more paperwork to put a bolt on a plane than into a human body. While this may or may not be true, commercial aviation is a counter example of a tightly regulated industry that very much a free market that challenges your assumption that regulation alone are the reason for issues in healthcare.

<comment><USER23> Commercial aviation may be a "free market", but it is full of its own problems.

</comment></comment></comment></comment><comment><USER24> I know larger cities are the norm but everyone else is acting like everyone has a choice. My town has an urgent care center and a hospital that serves the entire county. The next nearest hospital is two hours away. Even then we still have people Life Flighted out to Spokane on a regular basis from both hospitals.

All transparency will do is put a number in front of my single choice.

<comment><USER25> I don't think this is true for non immediate care though. If you had something that needed to be done in a number of weeks would you be willing to to to a different hospital to save.. a couple hundred? A couple thousand?

<comment><USER26> Exactly. For some things people fly to other countries because the price difference is enough to pay for their mini-vacation.

</comment></comment></comment><comment><USER27> This is awesome. I'm sure he will be opposed by congress, as they get a ton of money dumped in their pockets by pharma and insurance companies. Might be the first time I'll be on his side lol.

<comment><USER28> To be fair, this sort of thing should be a law, not an executive order. Not that Congress passes serious bills anymore.

</comment></comment><comment><USER29> Great use of an executive order, the executive branch is so big that having no directives from the CEO is an odd way to run an organization that large

Overwhelming even

I dont think the constitution envisioned how big of an organization the executive branch is, all with independent sweeping rule making autonomy. Only industry enthusiasts know the specifics of one agency's depth of rules. Someone elected by the people for totally unrelated reasons has no way of knowing everything these agencies are influencing

<comment><USER30> The president is not a CEO; the executive branch is not a corporation. [0] Moreover, the executive branch does not need to be "run" from the top; instead, it operates in a distributed and semi-autonomous fashion. Think not of the Cartesian brain, but the octopus.

The Constitution outlines specific responsibilities of the President in Article Two. [1] Those responsibilities:

* Command the armed forces

* Have a Cabinet (have the heads of subbranches as direct reports)

* Conduct foreign diplomacy

* Give State-of-the-Union addresses

* Not be bad at carrying out the will of the law; "faithfully execute" whatever the law tells them to do

* Get impeached if Congress says so

There are some things that the President is enabled to do at a whim, but they are not as broad as you'd think:

* Issue pardons

* Appoint judges, diplomats, etc. with Congress's approval

* Call special sessions of Congress

I agree that, in order to be aware of the full nature of the law, the President needs to be surrounded with legal professionals who can advise them on how to not violate the law. But, in Article Two, it's clearly spelled out that the President should have a Cabinet _in order to_ delegate day-to-day responsibilities further.

Finally, as a reminder, the President wasn't supposed to be chosen by the people, but by the Electoral College. [2] The Presidency should not be a popularity contest.

[0] [https://en.wikipedia.org/wiki/Corporatism#Fascist_corporatis...](https://en.wikipedia.org/wiki/Corporatism#Fascist_corporatism)

[1] [https://en.wikipedia.org/wiki/Article_Two_of_the_United_Stat...](https://en.wikipedia.org/wiki/Article_Two_of_the_United_States_Constitution)

[2] [https://en.wikipedia.org/wiki/United_States_Electoral_Colleg...](https://en.wikipedia.org/wiki/United_States_Electoral_College)

<comment><USER31> >The president is not a CEO

The president is, literally, the chief executive officer of the US government. He holds an office under the United States, and that office is executive in nature, and it is not subordinate to any other office.

<comment><USER30> You obviously are not familiar with the USA's Constitution. Please re-read it. In particular, Article Two, Section Four; "The President, Vice President and all civil Officers of the United States, shall be removed from Office on Impeachment for, and Conviction of, Treason, Bribery, or other high Crimes and Misdemeanors." This means that the President may be removed from office in certain circumstances.

In the time when the Constitution was framed, and in many times since, there is the meme of "checks and balances". [0] The overall idea is that no one branch of the Federal powers may be unilaterally or universally unabridged in its ability to act; other branches have powers which may check, veto, review, or otherwise neutralize certain actions.

So, why is the President sometimes called "chief"? Because, as Article Two also states, they are the "Commander in Chief" of the armed forces. When it comes to military decisions, yes, there is no office above the President's; however, note that the President's military powers are neither unilateral nor unlimited. Crucially, the President isn't able to declare war or allocate funds for military use without Congress' approval.

Hope this was informative. The USA's Constitution is a fascinating document worth reading, even for those not from the USA.

[0] [https://en.wikipedia.org/wiki/Separation_of_powers#Checks_an...](https://en.wikipedia.org/wiki/Separation_of_powers#Checks_and_balances)

</comment></comment></comment></comment><comment><USER32> Is the motivating idea behind this that patients can demand the same price that insurance companies are getting and ultimately lessen the monopoly insurance companies have? Maybe even just get much cheaper insurance for true emergencies and pay out of pocket for everything else?

<comment><USER33> If I can pay the negotiated rate, I'm leaving the health insurance marketplace altogether and self-insuring.

Why pay $20k+ per year in premiums when I can just save and invest that and pay low prices when needed?

<comment><USER34> Because you cannot save enough cash to be able to afford every worthwhile treatment through up-front payment. If you don't have $150k in cash and don't have insurance, you can't get chemotherapy and die a preventable death. With insurance, the worst case is paying your out of pocket maximum, _getting treatment_ , and then declaring bankruptcy or otherwise fighting attempts to balance bill you for hundreds of thousands of dollars.

<comment><USER33> Your assumption of $150k for chemotherapy treatment is exaggerated, especially in light of Trump's executive order to try to get price transparency at the level of actual insurance reimbursement.

$25k/year over ten years is $250,000, and compounded at 6% is $319,000.

So yeah, I'd easily be able to self insure for anything.

</comment></comment></comment></comment><comment><USER35> This is a really important goal, but whether simple mandates can solve it, I'm not sure. The real problem is that consumers don't _care_ about the prices, which is how all the various layers of providers and middlemen are able to jack up all the prices without limit.

High deductibles are one way that consumers can be made to care, but obviously that has its own problems. Single-payer would not fix the problem by itself, either... although using monopsony power could certainly help, if executed competently.

Merging a single-payer approach with a high deductible approach could work, and the deductibles could actually be paid via a government-filled HSA account that one could rollover into a retirement or college savings account, if unspent.

<comment><USER36> I'm not sure it's a lack of "care" and more a lack of ability to take action.

If I have a broken arm I'm not going to price comparison shop amongst hospitals.

Anecdote: I attempted to comparison shop for an mri to diagnosis a potential rotator cuff injury. While I could get the actual scan fees I couldn't get the fully burdened cost and during the visit it's entirely opaque what things will be new line items on the bill.

<comment><USER37> And if you're taken in to the ER, you're possibly not even ABLE to consent to charges. You're at the whim of the hospital staff! Did you know they charge for 'chaplain time' for having a chaplain stop by and say hi (you don't get to say yes or no, and this is obviously not medically necessary)?

<comment><USER38> Emergency care accounts for about 2% of total healthcare expenses. The issue you bring up about consent during an emergency is a real one, but it's not where all the money is going.

[https://www.politifact.com/truth-o- meter/statements/2013/oct...](https://www.politifact.com/truth-o- meter/statements/2013/oct/28/nick-gillespie/does-emergency-care-account- just-2-percent-all-hea/)

<comment><USER39> Note that your article cites at least 1 other study that says 5-6% or even as high as 10%. It would be interesting to see a breakdown here - does this include prescription medication? It seems like if you're talking about provider regulation, you shouldn't include that.

Unfortunately the article doesn't make it easy to figure this out.

<comment><USER40> Even assuming that the 10% number is the right one, it still seems good enough in my book if, in the beginning, only 90% of the expenses get addressed successfully.

</comment></comment></comment></comment></comment></comment><comment><USER41> > Industry groups are mobilizing to fight back, saying any requirement that > hospitals and insurers disclose negotiated rates would go too far.

Can't wait to hear their arguments how open pricing would only confuse consumers and cause complete destruction of the US healthcare system.

<comment><USER42> I am more interested to see which side makes those statements.

</comment></comment><comment><USER43> In the Japanese health care system, a government panel sets the prices for all medical goods and services. Private providers and private insurers must then manage their business to be profitable against known, fixed prices, and the panel is responsible for setting prices that allow for profitability while preventing gouging and rent-seeking.

They have private providers, employer-provided private insurance, and somehow manage to come in at around half the cost of the US system, for universal coverage and some of the best outcomes in the world.

If we used fixed prices, as Japan does, this sort of regulated transparency would be unnecessary.

</comment><comment><USER44> Very hesitant that this is the actual problem of healthcare. What you care about is not how much the hospital bills, but how much is leftover after insurance. And that is unknown to all parties.

<comment><USER45> There is no "the" problem of healthcare. There are many, many interlocking issues that combine to drive up prices at every step of the way in every corner of the industry.

This might help a little bit, but there is no silver bullet.

<comment><USER30> In the USA, at least, there is a singular problem: In the early 70s, the HMO Act and similar legislation was passed, bringing in the HMO-oriented system of healthcare.

A silver bullet would consist of introducing a single-payer system and winding down the HMOs.

<comment><USER44> HMO's are very successful in terms of providing cost/care solutions. The fact that they are so unpopular reveals the american preference: they want to see any doctor, at any time, with as much access as possible.

</comment></comment></comment></comment><comment><USER18> At best this is a bandaid and not a cure.

To treat the problem, you have to go straight to the root.

And that problem is: The cost of free is too damn high.

Most people in the US don't pay for their medical care or their medical insurance. It's "free", at least in terms of money out of pocket.

We need to remove the corporate tax deduction for healthcare insurance from the tax law. This in turn will solve most other problems as market forces are brought back into the picture.

Once people start selecting and paying for their own policy, they will be more price conscious on their claims, as most people already are on their auto insurance.

Once people are more price conscious, medical facilities will begin to complete again on price and insurance companies will focus on individual plans.

It all has to start with the consumer though, and currently the consumer doesn't care what the price is. They don't pay for the medical care and they don't the insurance premiums.

</comment><comment><USER46> It's crazy that a drug that prevents the spread of HIV (Truvada) is nearly $2000/month. Even if you had insurance with a high deductible plan you'd potentially need to pay $6-7k before having it covered.

The government should be giving this away for free.

<comment><USER47> >The government should be giving this away for free.

The government has no money. So you're saying the tax payers should be paying $2000/mo/recipient.

In this scenario you've made nothing cheaper. You've only externalized the costs on to us. You could argue this is for my/public good, but you didn't ask me, you didn't get a representative vote from me. In your scenario you've just decided how to spend my money. I hope you understand you've only just made the problem worse because nothing has preventing it from being $4000/mo now that they know the gov will buy an unlimited supply.

edit: To be clear since posts below don't seem to get it... You're missing a step. You've done nothing to solve the $2000/mo problem, just shifted the costs to everyone. This is the issue with healthcare, the off the cuff solutions don't actually fix the root problems.

<comment><USER46> Uh, no. Truvada is a generic drug in many countries around the world and cost maybe $10/month not $2000/month. The US just allows Gilead to profit massively from something that is generic and in the public health interest of all Americans to be as cheap as possible. In fact, Gilead agreed to speed up the expiration of their exclusivity so that it will become generic in 2020 due to public outcry, but the fact that a life saving drug will still be $2000/month for a year or more when it could be $10 tomorrow is terrible.

<comment><USER22> > a life saving drug

I think you are technically correct that Truvada is a life saving drug but I feel you are being dishonest. If you exclude occupations where you could be exposed to HIV, most of the US users of Truvada could choose to change their behaviors and reduce their chance of contracting HIV to <1%.

There is also the general trend that US companies pay large amounts of money to develop drugs, charge US customers enough to cover R&D costs and then sell the drugs at cost internationally. Does that suck for us? Yes, but it helps the rest of the world significantly.

<comment><USER46> Wow, this is a bad take. You could literally say that about any disease. Why don't all obese people just change their behavior and then we don't need to worry about cheap insulin anymore! Why don't men stop having sex with each other and then they won't be at risk for HIV?

<comment><USER22> >Why don't all obese people just change their behavior and then we don't need to worry about cheap insulin anymore!

For type 2 diabetics, behavior changes should be a part of the treatment plan. That said, if you currently have diabetics and you don't get insulin you will die thus it does qualify as life saving medicine.

>Why don't men stop having sex with each other and then they won't be at risk for HIV?

While it is not pleasant, people are not going to die just because they have to stay abstinent. You don't even have to be abstinent, you can find a group of 10 or even 50 guys, make sure everyone is HIV negative and then you can do what ever you want, as often as you want, with no need for drugs.

Calling it a "life saving drug" is correct in many cases (NGO worker in parts of Africa) using the term "life saving drug" to advocate for people to be able to cheaply have unprotected sex with strangers is dishonest rhetoric.

<comment><USER48> If those filthy citizens would just wash their hands, we wouldn't need to waste money developing flu treatment either. You're a genius! We can save so much money.

And we can stop working on making cars safer - all we have to do is tell everyone to follow the rules of the road and almost all collisions will be prevented!

<comment><USER22> While you are taking the idea to the extreme to make a point, I agree with the underlying argument that we should work to modify behavior to improve outcomes.

A lot of money has been spent reducing tobacco use which has paid for itself in better health outcomes.

<comment><USER48> When there are multiple cost-effective public health measures that can achieve the same end, we should pursue all of them.

In the case of Truvada, we already did the hard part (inventing it). Now it's just a chemical that can be infinitely duplicated a low cost. It would be a huge wasted opportunity, a moral crime really, not to give it away for free to everyone that can benefit from it.

And the same is true for the flu vaccine, the birth control pill, the seat belt, etc. These are miraculous technological advances. If you support the use of these advances, but not Truvada, I would take a hard look at what factors might be playing into that.

</comment></comment></comment></comment></comment></comment></comment></comment></comment><comment><USER49> The entire exercise is pointless because the health care market isn't actually a free and open market. There's lots of regulation on health services (obviously, as there should be, because safety is important), but more importantly, when a person is sick or injured, they usually are not able to comparison shop. Emergencies make it impossible, but even a relatively common illness makes comparison shopping unrealistic. What we have is not a market and efforts to help comparison shopping really do almost nothing to fix things.

Has anyone else had a doctor or nurse filed the wrong paperwork for a blood test, and then you get stuck footing the bill for an obscenely expensive test you didn't need or want? It's happened to me several times. And you have to pay whatever price the test facility sets, period.

The system is broken and until the insurance industry's grip is broken, we are not going to get relief.

<comment><USER50> > but more importantly, when a person is sick or injured, they usually are not > able to comparison shop

You don't need to comparison shop reactively. You can look up some prices preemptively, and choose a preferred hospital that you know to go to when you need it. Obviously not ideal, but it does allow for _something_.

<comment><USER51> Also, just having the _ability_ to comparison shop tends to hold down prices, because firms know that you _could_ go elsewhere if they're gouging you and that information tends to escape. It's like how when the wage-fixing cartel among Silicon Valley employers was discovered, everybody at Google got an immediate ~50% pay bump. You didn't need to actively interview at Facebook, because they knew you _could_ and would rather that you not get that idea in your head.

<comment><USER52> Heck, even post facto, if you're in an emergency and you end up stuck at a hospital that charges $50K for a procedure, and then while recovering you find a nearby hospital that does it for $10K, you're not necessarily without options. It's not hard to go to the provider who actually gave you service and say "You know, they charge 20% what you do... what's the odds I can cause $40K's worth of stink in the local news if you don't cut my price down now?"

(You may want to consult with a lawyer friend a bit before making quite such a naked statement; that may constitute blackmail in your jurisdiction. But there will still be "ways" of phrasing things in your jurisdiction. Talking to a lawyer may not be all bad anyhow, whatever it is you have to say will sound more credible with some lawyer's letterhead on top. Hospitals hear a lot of amateur lawyers expound their novel legal theories every day.)

I'm not going to deny the relationship in that situation is still lopsided in the direction of the first hospital, but the situation is not necessarily 100% in their favor.

</comment></comment></comment></comment><comment><USER53> The government (federal/state) and our legislators (senate and house of representative) don't always work for us or in our favor. Our political system is not strong enough to overcome the strong lobby/interest of few. We can however design our economy around solving these problems. Make it profitable to solve health-care problems. We would willingly pay a 'prime' membership if such an organization/corporation exist. And if we have more subscribers, then we will have more payer into the system.

</comment><comment><USER54> Requiring explicit written consent to receive each service (after mandatory price disclosure) would also be welcome. I broke my ankle a few years ago, and half the bills sent to me I didn't recognize what they were for. In one particularly egregious example, some doctor literally spent less than 30 seconds near my ER bed, did not even look at the injury or the charts, and billed my insurance $700. And I've never seen him after that, received no prescriptions, no recommendations, and no treatment of any kind.

<comment><USER55> Well this Dr. probably had to pay for his student loan:P The price tag comes from somewhere...

<comment><USER54> Dude was in his late 40s from the looks of it. Definitely too old for a student loan to be an issue. Probably just got used to charging people arbitrary amounts without their consent.

</comment></comment></comment><comment><USER56> There's an unsettling aspect to this story that is being glossed right over: This is, what should have been, a simple bit of congressional legislation that could/should have been drafted in the House or Senate and sent to the president for signing. Yet it had to be drafted as an executive order. Why is the legislative branch so willing to give up the power of the pen to the president? What the hell is going on? This feels like a huge breakdown in the responsibilities of the federal government.

<comment><USER47> Excuse me for being a little cynical... But I find the timing a little convenient that only after 2016 are people concerned about Executive Orders and presidential overreach.

I'm sure this comment will be followed up with someone saying "nah I've been concerned" and that may be true, but let's look at the common mode here.

It's like the people arguing for bigger government are many of the same people arguing against government when it's someone they don't like in power and can't see past their own noses on this.

<comment><USER56> Oh good, a whataboutism. Not enough of those, lately.

I'm not everyone, and it is something that's of deep concern to me, as it should be to you. So feel free to shelve your cynicism and join me in asking our representatives to do better.

<comment><USER47> A whataboutism would be if the topics weren't directly related. How is this that?

Let me help you out. A "whataboutism" would be if I made a post saying "Well, Trump did this one good thing, but Obama passed Credit Card Reforms!" See how those are non-sequitur?

</comment></comment></comment></comment><comment><USER29> Good first step

</comment><comment><USER57> My sister suddenly needed a few surgeries and seems to now owe an effectively infinite amount of money.

I work for a startup without funding. Health care costs was one of the reasons I decided to move to Mexico. Some of the medicine is still kind of expensive to me, but for those ones it's still literally 10X less than across the border.

</comment><comment><USER58> To say the healthcare system in the US is broken is an understatement, but this is a step in the right direction. Especially, if we cannot get a single payer system passed through Congress in the near term. Who knows, if the policy is actually done right, it might lower costs.

</comment><comment><USER59> I don't understand how anyone (of course, besides Big Healthcare/Big Insurance, who is scalping the common man and lining their pockets with cash with these practices) could not see this as a good thing

</comment><comment><USER54> Mark my words: later this year Trump will allow re-importation of drugs, and Big Pharma won't be able to charge 5-10x for the same thing in the US. The only reason why previous administrations haven't done this is good old fashioned corruption.

</comment><comment><USER60> I think there needs to be the concept of $5 generics. Have the common stuff readily available to anyone in any part of the US for $5 or less per month. And if the private industry in any one region doesn't meet this challenge, the government should offer it.

Lets put it this way. Being in kidney failure/dialysis. I take around 12 medications a day and I think only 1 is non-generic. I think lots of health needs could be met by affordable access to the basic stuff.

</comment><comment><USER61> Do healthcare providers think that consumers would make decisions differently if presented with pricing up front?

If so, how does their omission not fit the legal definition of fraud?

</comment><comment><USER62> I'm kind of shocked that no healthcare providers have offered price guarantees as a selling point - I know I'd be incentivized by them.

My guess as to why is that hospitals are just as confused about how insurance pays for things as the general public is. They could never accurately estimate what a patient would pay out of pocket.

<comment><USER63> > I'm kind of shocked that no healthcare providers have offered price > guarantees as a selling point

It would make sense if there was enough competition pressure. Lack of price guarantees pretty much proves lack of real competition / price finding.

<comment><USER62> Agreed.

I always look to things like Lasik surgery or plastic surgery where there is a ton of competition and real price transparency. Sure, those are elective surgeries, but so are most medical procedures people get done. We might not be able to solve it for every medical procedure, but it seems like there is a lot of low hanging fruit.

Hell, in Canada, there are private MRI facilities for people who don't want to wait for the public system. Here is one in Vancouver and _look,_ all the prices are listed.[1] Why the hell can't we have that here?

Speaking of which, I had an MRI done that a bay area hospital charged $18K for. Insurance discounted it down to $8K, but apparently I could get done in Canada for $1400 out the door.

[1][https://www.canmagnetic.com/contact- us/](https://www.canmagnetic.com/contact-us/)

</comment></comment></comment><comment><USER64> Ideally, we need to move to a system that prevents individuals from being liable for predatory pricing. There should be a law that prevents medical providers from charging their victims directly. They should be forced to only deal with the insurance companies and make it illegal to hold victims accountable.

</comment><comment><USER65> Thank god. I had to go to urgent care once and it cost me $700 for a 5min throat swab.

</comment><comment><USER66> Making a "free" market operate like one? What a novel idea!

</comment><comment><USER67> So now they can see each others prices and collude in the open and ensure no one strays or undercuts on certain deals ?

</comment><comment><USER68> _It calls for the Department of Health and Human Services to issue a rule within two months that could require hospitals to publicize information on their negotiated rates with insurers for common procedures._ <USER2>
 _Lawsuits could be likely, meaning any action could be delayed until after the presidential election._

a great idea, but it sounds like the EO may not actually change anything for a long, long time, if ever.

</comment><comment><USER69> Pricing transparency was already included in the ACA. What happened to that? Why did it fail?

<comment><USER45> It was somewhat limited. The ACA required hospitals to provide their charge- masters for their services online in "machine readable" format. These charge- master prices have limited relation to the prices faced by insurance companies or people seeking medical care.

[https://pbghpa.org/blog/aca-price-transparency-results-in- st...](https://pbghpa.org/blog/aca-price-transparency-results-in-sticker- shock-epidemic/)

</comment></comment><comment><USER70> I support this.

That being said, does Trump have that power? Executive Orders are very powerful because the executive branch is huge. But this is an EO compelling private companies to do a certain thing. That seems beyond the reach of EOs.

I'd be happily wrong here, as I said I do strongly support this. Can anyone explain why I am wrong?

<comment><USER71> It's almost guaranteed to get challenged in court, at which point the judiciary will determine whether it is congruent with existing legislation.

Worst-case it's not, and congress will probably take up a similar initiative so as not to appear ineffective.

<comment><USER26> > congress will probably take up a similar initiative so as not to appear > ineffective.

It would be nice if it worked that way, actually.

</comment></comment></comment><comment><USER72> If this ever translates into reality then it is great, and I _really_ dislike Trump both politically, and as a person. Willing to give credit where it is due, even though I strongly suspect that it is a political stunt that will get lost in committee. Would be delighted to be proved wrong however.

</comment><comment><USER73> Seems like it can only help consumers.

Kudos to Trump on this one.

</comment><comment><USER74> Not too long ago I led a team that built data products using a massive dataset comprised of more than 6B medical claims. This included Medicare, Medicaid, and private insurance. Two thoughts:

1) Trump is either bluffing or he doesn't have anyone around him that actually knows how medical billing works. If he were serious, the executive order would mandate that HHS publish the information based on the data that's already included in _every_ claim (i.e. invoice) submitted to CMS for payment.

From a policy standpoint there are already rules in the federal register that allow HHS to publicly disclose cost information at the hospital-level. I'm no lawyer but it seems to me that a well-crafted executive order could stand up in court. Even if it were struck down, putting forth such an executive order would be a shrewd political move because it would cast its opponents in a bad light. These would presumably be insurance companies, the medical billing industry, and for-profit healthcare providers.

From a technical standpoint: there are already data pipelines in place for this sort of thing. The CMS Open Data initiative already reports hospital- level aggregates. It's not that hard to comment out a few 'GROUP BY' statements in order to get a POC up and running quickly.

2) Even if the current executive order comes to pass, people will continue to receive surprise bills and experience sticker shock. That's because the total (billed) cost is a function of:

\- professional services (procedures rendered by doctors/therapists, etc)

\- facility fees (hospital bed, in-house labs, etc)

For any given hospital stay or office visit the quantity and types of items in each category can (and does) vary. The current executive order mostly addresses the latter.

Furthermore, two patients seeing the exact same doctor for the exact same thing but using different insurance companies will get vastly different bills. That's because different insurance companies require healthcare providers to bundle/group (and sometimes break out/itemize) services in their own way.

Because out-of-pocket costs are, in turn, a % of the total negotiated rate patients necessarily end up with the short stick in terms of cost transparency.

Given the current medical billing system, there's simply no way for patients to know exactly what they're going to pay ahead of time because the charges won't be finalized until the insurance company decides what they will/won't cover.

No executive order will change that. Transparency will require Congress to muster up the will to write laws that put the patient first, not last.

</comment><comment><USER75> This is a huge win for competition in health care.

</comment><comment><USER4> Price transparency in healthcare sounds great after the first few seconds of thought about the matter, ever - after all with price matching TVs and Google Home at BestBuy, Amazon and the like work so well!

It's not just fancy electronics - it works for healthcary stuff too:

Look at how cheap plastic surgery is! Free market at its best!

However, past the above sarcasm and after a few more minutes of deep reflection, it starts to unravel that price transparency just does not work if there is no free market.

And guess what: healthcare in the U.S. is no free market: [https://www.quora.com/Is-free-market-healthcare-actually- pos...](https://www.quora.com/Is-free-market-healthcare-actually- possible/answer/Subhobroto-Sinha-1)

Yes, price transparency works well in a free market

No, healthcare is no free market. Definitely not the U.S. market.

Healthcare in the U.S. is a pseudo socialized care where private healthcare dollars subsidize social care programs.

Employees on employer sponsored health plans, which are only federally regulated and rarely have the additional protections that the states they reside in afford them are nickle, dimed and squeezed for the very last dollar that can be extracted from them.

Employees are beholden to the employer choosing good plans for them, keeping those good plans around at affordable prices and continuing to be in business and able to employ these employees. TOO MANY ifs and buts if you ask me but I digress.

As long as we have something like the EMTALA or similar where services have to be rendered regardless of ability to pay, the deficit in payment recieved will have to be covered somehow!

Here are two scenarios with Price transparency:

Base Scenario:

\</comment><comment></comment><comment>-

Provider: I charge $100 cash to see a patient

Insurance company (InCo) 1: We will pay you $170 if you agree to work with us. You cannot tell our insured that you will accept $100 cash or we will blacklist you.

Provider: ok

Insurance company (InCo) 2: We will pay you $120 if you agree to work with us. You cannot tell our insured that you will accept $100 cash or we will blacklist you. Provider: ok

Medicare: We will pay you $70 if you agree to work with us. Patient 1 (w/ InCo1): Doctor, I want to see you. How much do you charge

Provider: I cannot tell you. Depends. Speak with my biller

Patient 1 calls biller and they estimate $180

Patient 2 (w/ InCo2) has the same conversation and gets a $150 estimate

Patient 1 and 2 are friends and they compare notes.

Patient 1 complains to InCo1 that he paid too much money for the same visit that costs his friend, Patient 2, much less. Plus there's this website that shows the Provider accepts on the average, less than $120!

InCo 1 calls Provider: Hey! We heard you charged less for someone else! Trump has this website that says you accept on the average, less than $120! You better charge us less too or we will not renew our contract!

Medicare patient: Doctor, I would like to see you Cash patient: Doctor, I would like to see you

Scenario 1: \</comment><comment>----

Provider: InCo1, Fair enough. I guess I will absorb the cost of your paperwork, cumbersome claims process, 90+ days of payment delays and reduce my reimbursement amounts because I don't have student loans, rent, staff bills to pay. Medicare patient, I will see you even if I lose money because I'm in this business because I love it. Cash patient, I will honor my $100 rate but I will appreciate if you could tip me $20 because I just lost a few hundred

InCo1: No, you have to accept $100 now because you're a push over

InCo2: Yeah, what they said. It's not fair you charge us more! Cash patient: Do you want this money or not?

Scenario 2: \</comment><comment>----

Provider: InCo1, InCo2, not interested. There are few of me compared to the number of insureds you have and I will not absorb the cost of your paperwork, cumbersome claims process, 90+ days of payment delays. Infact, to renew our contract, my reimbursement amount is now $300 because dealing with you is too much of a hassle. Medicare patient, I will not see you because I am losing money on you. Go see someone else in a better position than I. Cash patient, I will honor my $100 rate because I don't have to deal with all the nonsense but only if you keep your mouth absolutely shut. If this $100 ever makes it to a Yelp review, our relationship is over. I almost considered charging you $200 instead because you don't have an insurance company bargaining for you but I have a weak spot for the unrepresented. President Trump, I charge everyone $300!

InCo1: Yeah, he charges $300. That's literally what it says in our paperwork. Here, see it!

InCo2: Yeah, he charges $300. That's literally what it says in our paperwork. Here, see it!

Cash patient: I have no clue what Provider charges. I am on a payment plan and paid $150 or $100. Maybe. I don't know, please keep me out of this I just want to get better OK?

Medicare patient: I have some cash but not enough to pay per visit. Maybe I should also go into business with InCo1 or InCo2 as supplements

Which is more likely you think?

As long as we have something like the EMTLA or similar where services have to be rendered regardless of ability to pay, the solution to sane pricing is to have King Kong fight with Godzilla and keep each other in check.

We just have to ensure we can control both King Kong fight and Godzilla - <USER2> so far - they both have been very selfish and barely controllable.

We must begin with killing employer sponsored health plans and put individual citizens in direct control of their care instead of whatever the distracted HR team puts together or the even more distracted brokerage company that the distracted HR team contracted after googling for "employee health benefits examples"

Individual citizens are not even in the game. They have no bargaining power.

Time to change that. Let them regain control of which network they want to work with regardless of where they happen to work or not even work at all.

The employer might be looking for the cheapest network but the employee might be looking for a network with good coverage or covers certain doctors of their choosing etc

Why complicate matters? Keep things simple.

Politics, employment and healthcare do not mix.

Healthcare is too important.

Keep them separate. Break the ties.

</comment><comment><USER76> The idea of requiring list prices of drugs to be displayed in commercials seems like it might be _very_ effective.

Imagine if you were able to do some quick mental math on your couch:

"Okay so ask my doctor about Poopathome for my rectal bashfulness... Well let's see first. It says $890/month average dose. My insurance covers 80% so that would cost me something like $180 a month. Yeah sorry Pfizer you'll have to do better."

<comment><USER77> >The idea of requiring list prices of drugs to be displayed in commercials

It's bizarre that prescription medication is advertised like that in the first place.

<comment><USER78> Exactly. In Canada you an only advertise either that a drug to treat a certain condition exists, or that a drug with a certain name exists, but not both in the same ad. Why advertise drugs to customers, they're not medical professionals - that's why we have GPs.

<comment><USER79> _Why advertise drugs to customers, they 're not medical professionals - that's why we have GPs._

Frankly (and maybe it's different in Canada), but I feel like people will have better health outcomes if they are aware of the options and consult, work with, and even challenge if need be, their GP.

GPs (or Primary Care Physicians, PCPs in the U.S.) share some goals with their patients, but many goals are not shared:

* Spending less money / good drug success / less side effects vs. using only tests/drugs they GP is comfortable with * Avoiding lawsuits vs. candid discussion * Taking time to research medical hypotheses vs. needing to get to the next patient

Come to think of it, if one is willing to invest the time, have an inquisitive mind, and demand a partnership relationship with most service providers, perhaps that person will generally have better outcomes in many areas (home repairs, dental, car service, etc.).

<comment><USER78> The only thing drug companies are incentivized to do is make money and you're giving them a side channel to an uninformed audience, then they go and whack the trained professionals over the head with this data and risk they don't understand because TV told them.

</comment></comment></comment></comment></comment><comment><USER80> Even though this is one step in the direction of 'free markets' ... they need to go further.

With healthcare, we fall into an entirely different domain of economics, especially because the leverage of those who have 'life saving' services over those who don't is basically existential.

A better solution would be: 'one price for everyone'.

The entire gambit of 'negotiated prices' is a fallacy in the end, it's just a matter of groups having collective power over another, it's not really economically efficient.

Either A) all Americans form a 'super powerful buying conglomerate' which is 10x more powerful than any healthcare provider, thereby forcing 'amazingly low prices' (which basically socialized medicine) - or B) we let the 'aggregate market demand' determine price, which is basically 'one price for all'.

America should probably follow one of the European examples where they have a public/private mix. I respect that some people just want full control and want to pay for that, it's fine, but there needs to be a socialized component more efficient than Medicare.

I'm not sure if Canada or UK are the best examples for America. Germany, Netherlands or Switzerland might be better.

</comment><comment><USER81> This may make pricing more transparent but it isn't going to help anyone unless action comes from regulation or something. Martha may check which local hospital has the best pricing for an anticipated upcoming medical need but in the moment the ambulance will take her to the closest and she'll be charged bankruptcy levels for care because the system itself is broken.

It'll help further see how broken the system is, but this does nothing to actually change it. It'll be held up by lawsuits for a while then either dropped when politically viable or used to prop up a 2020 plank without anything to actually stand on.

If Trump wanted to do something positive he'd bring back the individual mandate and try to reverse the loss of insurance and cost spikes since he signed the 2017 tax bill and other legislation aimed at destabilizing the Us healthcare system. He won't, because the GOP won't, because their goal isn't to help Americans, just the wealthy and corporations like the for profit groups running the detention centers at the border for $750/kid per day sans soap and toothbrushes.

</comment><comment><USER82> The headline "Trump Signs Executive Order Compelling Disclosure of Prices in Health Care" is a lie [0] and unsupported by the body of the article. Trump did not sign an executive order compelling disclosure of prices in healthcare (nor is that even possible, that's not how EOs work), and the body of the article does not support the claim that he did. He signed an executive order directing various government agencies to propose regulations consistent with existing law which would do that (which seems unlikely to be possible; to be both possible and necessary that would require a federal law to exist _permitting_ the executive to require such disclosure without itself _mandating_ it; if such a law did exist, you'd expect the EO to have cited it, which it didn't presumably because it doesn't) and also directs agencies to do some other, more likely to be possible, things (e.g., write reports identifying who the agencies think we should blame for the absence of price transparency.)

It's perhaps worth noting that this EO explicitly described itself as a follow-up of the report produced by the Administration as an outcome of the last EO Trump issued on this issue.

Actual EO text appears to be here: [https://www.whitehouse.gov/presidential- actions/executive-or...](https://www.whitehouse.gov/presidential- actions/executive-order-improving-price-quality-transparency-american- healthcare-put-patients-first/)

Though the official text will be whatever is published in th Federal Register, not what is on White House public info pages. When it is published, it should show up here: [https://www.federalregister.gov/presidential- documents/execu...](https://www.federalregister.gov/presidential- documents/executive-orders/donald-trump/2019)

[0] propaganda rather than clickbait, I suspect—its a lie to shape opinion of the large number of people who will only see the headline rather than one to get people to click through to read the article.

<comment><USER83> Exactly this. Forcing companies to show pricing is not something a EO can do. It could direct Medicare to indicate the prices it is willing to pay for example, but not to require corporations to do the same. That would require actual legislation.

That said it's a good topic to wish for.

</comment></comment><comment><USER84> We saw what happened to airlines when they allowed 'comparison shopping' and internet search engines did that for us. Ugh. I'd much rather not have the same thing happen with hospitals. For that matter, i'd much rather remove it back for airlines too, as would every middle class passenger (someone who isn't bothered by extra $30 in ticket price, but can't yet afford a private jet).

I already see people thrown out of ER room handcuffed because someone with a loyalty card of a higher priority level called in :)

<comment><USER26> Extra $30? Prices were a _lot_ more expensive than that. Ticket prices are about half what they were in 1979.

<comment><USER84> If you guarantee me 32'' pitch on all flights, 50lb of check in luggage, ability to change and return any ticket, any time, and good food and wine on every flight in economy, i sign to pay 2x.

After all, we have more or less this in premium economy when you have it on the flight (unfortunately it's on just a few, and business is, too drying up), and it's MORE than 2x more expensive.

What airlines have become is just an insult to the human dignity. No industry should operate that way. If you are concerned with what comparison shopping, price optimized on the Internet, and free competition done to the taxi drivers, turning them into precarious, powerless and poor Uberists, why aren't you concerned with the 'demand side' of the same problem? Much less healthcare. I'd absolutely hate to get any treatment in a system which is 'optimized' in the similar manner.

</comment></comment></comment><comment><USER85> This will do exactly jack squat to control prices, but it MIGHT make enough people that are not paying attention to start thinking about what's going on with healthcare in this country and why it's so expensive.

Every time I go to the doctor in the US I wonder WHY they are doing what they are doing, WHY they want to see me two weeks from now even if I have a chronic condition that's perfectly managed already and hasn't changed in years...

I never met so many unethical individuals like since I moved to the US and started going to the doctor.</comment>


DockerHub introduces download limits starting Nov 1st - <AUTHOR> https://docs.docker.com/docker-hub/download-rate-limit/ <comment><USER2> Knew about the rate limiting, but didn't know they planned retention limits now too. Not sure how I feel like about... I guess less stuff to search through, but wonder about rarer things if trying to find an example for. I guess if you use more popular stuff, not really a problem though.

</comment><comment><USER3> A similar discussion was had a week ago: [https://news.ycombinator.com/item?id=24262757](https://news.ycombinator.com/item?id=24262757)

<comment><AUTHOR> Thanks, missed that :-(</comment></comment>


The Three Economic Eras of Bitcoin - <AUTHOR> https://medium.com/@rusty_lightning/the-three-economic-eras-of-bitcoin-d43bf0cf058a <comment><USER2> If anyone wants the "old" bitcoin back, there are plenty of altcoins that are still worthless! If you want a less popular coin you can even fork btc or anything else, that's the beauty of software. Nothing has changed. Bitcoin is totally replaceable.</comment>


Deldo – a sex toy control and teledildonics mode for Emacs - <AUTHOR> https://github.com/qdot/deldo <comment><USER2> Now mastery of emacs can stroke more than your ego. I just hope it's not in a minor mode or the author may end up in jail...

I'll show myself out.

</comment><comment><USER3> "Every program attempts to expand until it can read mail. Those programs which cannot so expand are replaced by ones which can." -jwz

emacs is now well beyond that.

</comment><comment><USER4> Something tells me the market overlap here isn't quite right.

...They should've made it for Vim.

<comment><USER5> hue hue

</comment></comment><comment><USER6> This is my new argument for "Emacs > Vim" war.

</comment><comment><USER7> "Issues: 1"

</comment><comment><USER8> Deldo author here. AMA.

</comment><comment><USER9> > Fixed trailing parens so #emacs will stop laughing at me.

Yup, avoiding things trailing is a must in sextoylogy.

For some reason is not a surprise to find than the program calls a python here. Looks the right tool for the job in both senses of the phrase.</comment>


Computational Modeling in Algebra, Physics and Data Science, for All Students - <AUTHOR> https://www.bootstrapworld.org/ <comment> a-saleh I have heard a lot about the direct-instruction teaching methodology lately, and as far as I know, Bootstrap subscribes to that. Felliene Hermans has a good talk about direct instruction in programming: [https://www.youtube.com/watch?v=pUBAUI5Tal0](https://www.youtube.com/watch?v=pUBAUI5Tal0)

I would like to get to one of their workshops, where they teach the methodology to the perspective teachers, but it seems it is all US-based?

</comment><comment><USER2> Has anyone had experience with Bootstrap's education program?</comment>