The Product vs. The Customer

A famous metafilter comment popularized the idea "If you don't pay for it, you are the product". It's commonly used to refer to advertising and free websites and so on. Curiously, there are a few other groups that I think it's far more applicable to than online advertising: education and healthcare.

Healthcare

It most applies to 3rd-party-paid healthcare, especially that variety where payment is provided by government for services provided to a patient. It is pretty trivial to see how per-service payment paid for by the government turns a patient population into a cash crop that is meant to be tended and harvested. Other civilizations lacking resources are more explicit about the fact that spending on people is not unlimited, but pro-healthcare American sensibilities are different:

Archive: Governor Andrew Cuomo @NYGovCuomo

My mother is not expendable. Your mother is not expendable.

We will not put a dollar figure on human life.

We can have a public health strategy that is consistent with an economic one.

No one should be talking about social darwinism for the sake of the stock market.

Mar 24, 2020

This isn't just rhetoric during the COVID-19 era

The Patient-Centered Outcomes Research Institute established under section 1320e(b)(1) of this title shall not develop or employ a dollars-per-quality adjusted life year (or similar measure that discounts the value of a life because of an individual’s disability) as a threshold to establish what type of health care is cost effective or recommended. The Secretary shall not utilize such an adjusted life year (or such a similar measure) as a threshold to determine coverage, reimbursement, or incentive programs under subchapter XVIII.

— Affordable Care Act, now US Code

Because arbitrary sums of money must be spent in the pursuit of health and because these Americans "will not put a dollar figure on human life", one finds that the patient (not paying for the healthcare) gets transformed into a form of livestock. I know of the existence of nephrologists associated with dialysis clinics who would find a way to transport patients from their care into perennial crops for clinics that they are given direct kickbacks from or have a family interest in. But there's no reason to believe me about that specific thing. It may be that we are spending 1% of the federal budget on dialysis entirely coincidentally.

Rather, one only needs to look at the scale of fraud where substance-abuse treatment facility operators and medical professionals colluded to retain a reliable source of valuable ARR.

To keep patients cycling through their facilities, the Youngs directed that patients be drugged with medication – “to knock the client out” – if they tried to leave. The Youngs also offered drugs to patients, cut them off from communication with family members, prevented them from accessing their belongings, and physically blocked them from leaving the facilities to continue billing their insurance policies. For example, when he was informed that a premium patient wanted to leave detox so he could smoke weed, Nathan “Pablo” Young instructed that the patient should be given what he wanted, off-site from the detox, to keep him there. The conspirators further instructed employees to coach patients to fabricate symptoms so they would be eligible for detoxification services. In some instances, as a result of policies instituted by the Youngs, patients were encouraged to use drugs or alcohol to become eligible for “treatment.”

— DoJ

That's just a sample of what's going on there. Other examples include unnecessary arterial procedures, enrolling non-terminal patients in terminal palliative care (which wasn't even provided), taking kickbacks for genetic testing orders billed to Medicare, taking kickbacks to send addicts to a specific rehab that had minimum stay conditions, submitting fraudulent prescriptions to Medi-Cal, and a (seemingly comparatively minor) operation to sell sample drugs to pharmacies who then packaged them up for normal sale.

Now, this sort of thing is probably not why more than a third of Stanford students are mentally disabled. Presumably those people have just overcome the difficulties they naturally face, and who better than someone who has faced such adversity to be the best students. But the DoJ did find that doctors have pulled off this hospice scheme before and the DoJ did find that people have pulled off this kickback scheme against Medicare and Medicaid before to over a billion dollars. In fact, one must imagine that since we "will not put a dollar figure on human life" the real crime here isn't spending other people's money but that it didn't actually extend anyone's life.

Education

Modern-day educational institutions have a wide array of degrees - many of which are a bad idea to participate in.

Around 23 percent of four-year degree programs have a negative return on investment, along with 43 percent of two-year degree programs. (These figures, along with all others in the report unless otherwise indicated, are weighted by enrollment.)

— The Foundation for Research on Equal Opportunity

Notably, going to university for fine arts is going to leave you worse off financially than if you'd never gone at all. For many others like English, Education, or Psychology only ignoring opportunity cost leaves you positive. Interestingly, I couldn't easily find surveys that broke out support for loan forgiveness based on major. There's a strong link to loan forgiveness based on political affiliation and one from major to political affiliation, so there's weak evidence that this is just self-interest. Elsewhere, one might find that STEM students are in favor of student loan forgiveness, but what is STEM?

CCA is home to six undergraduate STEM-designated degrees across a wide range of disciplines: Animation, Architecture, Communication Design, Interior Design, Interaction Design, and even Comics.

— Five reasons to consider a STEM-designated degree at an art school, California College of the Arts

A degree in Comics is slightly different from a degree in Electrical Engineering but they are both STEM-designated programs, so sometimes the results you see are skewed by a false conflation of category. This is particularly broad, but other such things leak into the category as well, and the incentive to qualify students as STEM so that one might be able to give immigrant F-1 students the STEM OPT Extension as a mechanism to give them access to the United States is quite high.

In any case, one fairly parsimonious reason for the expansion of college programs that yield poor results for students, and the attendant need to expand college enrollment by allowing academically weaker students to attend university is that universities treat students as cash crops.

The ability for students to pay for degrees is not in question. The federal government will give students money to pay for university. This is, of course, just a legal fiction about whom the money is being given to. Direct redistribution of tax funds to private parties is considered corruption in the United States, so a large amount of legal work goes into inventing elaborate schemes involving constrained intermediaries. If you want to give money to doctors and hospital CEOs, you first invent a scheme by which doctors and hospital CEOs can charge for patients and then give the patients the money.

The technique involved is not much more involved than giving a mule some drugs to transport across the border so that they are then paid on the other side, but Sufficient Indirection Is Innocence. This was not an unforeseen approach. The reason accreditation and so on exists is that some mechanism for the control of disbursement of federal funds needs to exist in order to ensure that we don't have a utility monster consume it all.

But predictably, regulatory capture has ensured that courses like Puppet Arts, eSports Coaching, and Comics are worthy of a four-year undergraduate program - the mechanism being that one accredits institutions, not their programs. These narrowly specialized courses rarely yield a positive outcome for students, but the delay between payment and return is sufficient for universities to rotate into the next crop. Since students usually do not go back to university, this is different from the perennial crop that a Medicare patient is, but is nonetheless similar in that the prime objective is to use the human for the purpose of extracting government money.

Conclusion

"If you're not paying, you're the product" is probably true, but the places where it applies most strongly are 3rd-party-paid healthcare or 3rd-party-paid education. If it has to be used, it should be used most strongly in those contexts.