Hypochondria isn’t what people think it is, and the U.S. medical system makes it worse.

Trigger warning: discusses panic attacks and health problems. Use caution if you’re sensitive to health anxiety or panic.  

I suffer from health anxiety, often called hypochondria. In addition to cyclothymia (a milder variant of bipolar disorder) and panic attacks, I suffer from an intense fear of health problems. In fact, almost all of my panic attacks are related to obsessive health-related anxieties.

Oddly, despite my extreme phobia of sickness, I fear death very little. I’m a Buddhist and believe in reincarnation, so I believe that I have died millions of times (although I don’t remember them) and am therefore “dead” already, and it ain’t so bad. Death doesn’t scare me. I hope that it won’t be painful (the period leading up to it probably will be; I’m realistic) and I look forward to the event itself. Getting sick scares the shit out of me, not because of the pain or risk of death or inconvenience, but just due to the sheer humiliation of it.

Most people use “hypochondriac” to describe a person who is overly dramatic, needy, or attention-seeking when it comes to matters of health. That’s not me. When a panic attack starts throwing bizarre symptoms and I start belching, smacking my stomach to prevent (a completely imagined and probably medically impossible) diaphragmatic spasm that I fear might stop my breathing and kill me, ineffectively massaging my neck and shoulder muscles, or pacing the room, I really wish others wouldn’t take notice. It’s fucking embarrassing. It’s stupid. The stereotypical hypochondriac constantly believes that he is sick. Not so, at least not in my case. Cognitively, I know that (with high probability) I am not sick. I eat well, don’t drink or use drugs, and I exercise regularly. I have also (unfortunately) had enough people close to me die that I realize that bodies usually break down slowly– House be damned– and never for no reason– House gets that right– so I can ratiocinate that the slight pain at my ribcage isn’t actual angina, which I am almost certainly not having because I am a 31-year-old in good shape and no family history of early heart disease. I know that, cognitively. But the thing about obsession is that it trumps cognition. You can know that you’re OK and that the panic attack will end once the meds kick in, and you are basically lucid, but intrusive thoughts about ambulances and hospitals and uncaring medical professionals and life-wrecking bills and losing jobs and relationships can’t be stopped. They build up until you have detached from reality and your body (or, at least, the signals you are getting from it, with probable neurological wire-crossings turning mild discomfort into more dreadful sensations) begins to go haywire.

Panic disorder is the ultimate troll. It is almost hallucinatory in its ability to throw bizarre physical symptoms at a person. I won’t list them, because I don’t want to give panic fuel to someone else who might be reading this, but to name one of the more bizarre ones: phantom smells. (I name it because it’s actually pretty funny, moreso than thinking today is the day you discover that you have adult-onset diabetes because of a dry throat.) What the fuck is up with that phantom smell shit? If God or “the Universe” is testing me or sending a message, what the hell does the smell of fucking relish have to do with it? I think the only other disease (than panic disorder) that causes phantom smells is brain tumor, and I’ve had the problem for 7 years and I’m still alive, so I’m pretty sure it’s not the latter. Fucking relish. Anyway…

One TV character who is shaping up, for the record, to be my favorite mentally ill character is Chuck McGill on Better Call Saul. It’s a compassionate depiction, but a realistic one. He’s not a drooling mental patient or an invalid or a psychotic murderer. He has a crippling anxiety disorder (far more intrusive than mine) which is a fear of electricity, and has had to leave his high-paying job as a law partner because of it, but (as of Episode 2) he’s lucid, smart, morally decent, and likable on all counts. In the mentally ill population, he’s a “silent majority” example: one who has a stigmatized illness, but with full intelligence and moral decency intact. Admittedly, “full intelligence and moral decency intact” is not how most people view mental illness; that is, largely, because most people associate mental illness with the most visible and extreme examples: (1) people who are so far gone that they can’t function in society at all, and (2) substance abusers, who are an atypical set for a number of reasons. I’d actually guess that the “silent majority”, even with stigmatized illnesses like bipolar disorder, is well over 90 percent. The stereotypical Hollywood manic-depressive goes on spending sprees, becomes sexually promiscuous, does a bunch of drugs, or gets into fistfights. When I go hypomanic I can be found at 1:00 am… reading. Or writing. Or coding. I call this the “cerebral subtype” and while it has its dangers (sleep deprivation can exacerbate hypomania) it does not make a person like me morally dissolute. It makes me… slightly groggy the next day.

The general population, in my view, doesn’t like to accept the reality about “mental illness”, which is the term we use for neurological diseases whose symptoms involve cognition. First, these are mostly “boring” health problems like all the other ones, which present challenges and can be extremely painful and disruptive, but rarely change the moral character of a person. People wouldn’t deign to ask whether a person with migraines or diabetes “can handle” a difficult job, but that’s a common question asked of people who’ve dealt with anxiety. These “mental” illnesses don’t send a person on a one-way journey into insane lal-a tinfoil land. They don’t, in general, make a person “crazy” in the sense of being impulsive, delusional, or dangerous. They are malfunctions in an organ that, while extremely powerful and resilient, exists in a stew of complex organic chemicals and operates according to an electrical protocol that we just barely understand. Most mentally ill people (whether we’re talking about bipolar disorder, depression, or anxiety) are surprisingly “normal”: again, the silent majority. Why is there a resistance to this idea, in the mainstream? Because, in general, people don’t want to believe that painful things won’t happen to them. “If I don’t smoke, I won’t get lung cancer.” “If I take 27 vitamin pills per day, I’ll die at age 109 in my sleep.” “If I’m not a crazy person, I’ll never have a life-altering depressive episode.” Sorry, but all of those beliefs are false. Healthy choices alter the probabilities quite favorably, and most people who reach age 25 without a mental health issue are in the clear… but there are no guarantees.

This is why (as of Episode 2) I find Chuck McGill so interesting. He’s not “crazy”. Everything he says has value. He’s an intelligent and good man. He also happens to suffer from a severe psychiatric illness. It seems paradoxical in light of our expectation that mentally ill people be “crazy” (in the drooling, “mental patient” sort of way) but it’s actually pretty normal. I don’t know how Better Call Saul intends to develop him, but this is one of the more honest portrayals of mental illness that I’ve encountered. The tragedy of these diseases (in their most severe forms; mine is relatively mild) is that they afflict normal people, not “crazy” ones. There is such a thing as “crazy”, but it’s mostly orthogonal to mental illness. Religiously motivated suicide bombers are crazy, but I would wager the guess that quite a large number of them suffer from no biological mental illness and that, at the top of terrorist organizations, people with mental illness (except psychopathy) are very uncommon. Evil is real and not the same thing as mental illness.

Back to panic: a true panic attack– and I’m not talking about the low-level yuppie anxiety attacks that come from a deadline and too much caffeine– is a venture into something like “crazy”, but paradoxical in that the panicking person is, in fact, terrifyingly lucid. A person with that much adrenaline is, in some ways, in peak physical function (despite mental distress). Facing off against a smilodon, one would want that “fight-or-flight” response. It’s when it’s triggered without cause that we call it “a panic attack”, because it’s so pathological against the backdrop of modern life, in which mortal danger is rare but social protocols must be followed. Acute panic tends to last no more than three minutes, although the fatigue and anxiety that can exist afterward can spawn another wave of panic, leading into an episode that can last (at worst) two or more hours. Panic is almost hallucinatory; it wouldn’t be inaccurate to describe it as a (short-lived) bad trip on a drug that one didn’t voluntarily take, and never really wanted. It is almost admirably creative in its ability to take mild discomfort (which is inevitable with any anxiety disorder) and transform it, wholly in the mind, into acute danger. A tight shoulder muscle becomes “chest pain”, and cold extremities become “imminent hypothermia”, and the fatigue that sets in after 20 minutes of panic (if the attack hasn’t abated by then, which it usually has) becomes a threat of fainting (which any proper hypochondriac knows by the medical term, “syncope”.) I know that this sounds fucking ridiculous. Sufferers of the disease would agree; it is. But the nature of a panic attack is that baseless and undefined fear reaches such a crescendo that it will (for a minute or two) override sensible cognition. That extreme, biologically-induced fear needs to crystallize around something and it is usually something in the body– that machine that (usually) works so well running on its own, for billion-year-old reasons that science is just starting to understand, and that it is impossible for us, on a second-by-second basis, to consciously manage.

The popular image of a hypochondriac is of someone who either convinces himself that he is sick, or feigns illness because he enjoys attention and sympathy. An actual hypochondriac is the opposite. First, we have no incentive to pretend and, if anything, we downplay our suffering. It’s fucking humiliating, and it would depress the shit out of most people, and my desire with regard to negative moods is anti-reproductive; I combat them by making efforts not to spread them. It’s the one thing I can do. Depression and anxiety are not physically contagious and my job is to prevent social contagion. If there’s any danger of error in a hypochondriac, it’s that we may (later in life, when life-threatening physical illnesses are more common) misinterpret dangerous health problems as just panic attacks and not seek care. Second, we generally do not frequent ERs when we have health-anxiety-induced panic attacks. Contrary to the image of a hypochondriac as someone who is stupidly or delusionally convinced of an illness he doesn’t have, we know cognitively that we are probably fine, but are overwhelmed by the intense physical symptoms and racing, uncontrollable negative thoughts. When you misinterpret (due to crossed neurological wires, not stupidity) neck tension as the throat closing up, you will fucking panic. (In fact, your breathing is fine. But you feel like you are choking and it is going to freak you out.) Going to an ER during a panic attack doesn’t help: you’ll spend four hours surrounded by hospital staff who resent you (“another one of these rich white pieces of shit ‘freaking out’ after a hard day at work”) and you’ll see people who are suffering from painful and more severe health issues (panic fuel) than the one you’re having… only not to get the medical attention you need because (a) ERs are intended for life-threatening conditions rather than subjectively terrifying ones and (b) ER doctors can’t be sure that you’re not a drug-seeker and are therefore conservative (for understandable reasons) when it comes to dispensing medicine. I’ve been to an ER twice for a panic attack (more on that, later) and it turned one of the worst experiences of my life into… an even worster experience. And yes, I made up the word “worster” because some things are so shitty that they entitle a person who has experienced them to make up words. Third and most importantly, we do not “freak out” because we want to get out of work, win sympathy, or otherwise gain favor from other people. First of all, that doesn’t work, especially not with stigmatized conditions. Most of us hypochondriacs are type-A control freaks (after all, hypochondria derives in part from our inability to know or control the operation of our own bodies) who, if anything, love to work a little bit too much. Trust me on this: I enjoy my job, I’m good at it, and I would absolutely love to be able to work 80 hours per week (not to say that I would work that much, but I’d like to have the ability) and not lose a single minute, ever, to anxiety or panic.

That’s enough of this shit, but this rant wouldn’t be complete without an indictment. One of the most important things to understand about mental illness is that, in terms of origin, it’s usually “no one’s fault”. My parents didn’t cause this; they were great. Nor is it my fault, really. I didn’t ask to have it. Nor is the fault of society or past relationships and jobs or present ones… for the most part. Based on genetics, it’s almost a guarantee that a person of my makeup would have struggles no matter what circumstances he landed in. It’s an interesting trade: 4 standard deviations of this fetishized quantity called “intelligence” in exchange for losing 5% of your time to painful mood and anxiety disorders. I’m not bitter about the deal, even though I didn’t make it voluntarily. To be honest, I’d probably make it again. I’m glad I’m me. It really sucks some of the time, but isn’t that true for everyone?

No one’s at fault for the fact that I’ve had panic attacks, but I’m going to throw some stones at those who’ve made the condition worse. The U.S. medical system, to put it bluntly, can die in a fucking taint fire. I’ve had good doctors and bad ones, and I continue to see the good ones despite my acquired doctor-phobia because I’m rational, but the system itself is a moral disaster.

My first panic attack came in 2008. It was scary, bizarre, and confusing. Though many come with warning and a build-up, this one hid immediately. This sudden and absolutely terrifying “mystery” health problem involved vomiting, tunnel vision, apprehension and shaking. It came on at 2:37 pm. I tried to drink water and it was physically impossible to swallow. At 2:41 pm, I was white as a ghost but lucid. At 2:46 I began vomiting and screaming (in front of work colleagues). At 2:50 I was fine. Around 3:00 an ambulance was called and I arrived at an ER at 3:15. I saw a lot of people who were suffering, and worried about that being my immediate future, so I had a couple of anxiety waves (none reaching the level of the original one). Around 7:15, I got about 72 seconds of contact with a doctor who diagnosed it as a panic attack. So, that is what a fucking panic attack is. See, I’d thought I’d had “panic attacks” before but, in retrospect, those were mild anxiety attacks. The difference is in degree. If anxiety is sugar, panic is coke.

The second one was worse. The first panic attack is scary but might just be a one-off. The second comes with the “yep, I’m now going to be a psychiatric cripple for a while” realization. It came a week later. Most of my panic attacks come in the late afternoon, but this one came around 1:00 in the morning. It made sleep impossible (exacerbating the illness) and rolled along for about 22 hours. A typical panic episode has 3-4 peaks spread out over 15-30 minutes. This one must’ve had 100 peaks. I was exhausted, dry-heaving, unable to keep food down. At random times during that day, my vision would suddenly go blurry, or I’d have an intense whole-body tingling, or I’d feel weightless (not in a good way, but like one is leaving the planet forever but will never die). Finally, at 6:00pm that evening, the girl I was living with forced me to go to the ER. I arrived at 6:38pm.

I was living in Williamsburg. I like Brooklyn but dislike Williamsburg: there is an intense negative energy there. It was full of young people who were arrogant, flaky, and full of bullshit Burning Man drug-wisdom that can combine with the “openness” of one’s mind upon acquiring a new disability to make you more scared of what’s going on than you should be. (“You’re entering a new spiritual plane!” vs. “You’ve developed a treatable condition and, if you take your meds and pursue cognitive-behavior therapy, you’ll be able to hold down a job and function normally within 6-12 months.”) I bring this up because, while Williamsburg is an affluent part of Brooklyn, the hospital that we chose to go to was… not. It was in the ghetto, and it was badly run.

I learned this later: when you present with a panic attack, physicians are supposed to run a battery of tests to rule out other conditions that can produce similar symptoms. This is good for two reasons. First, although they are rare in 24-year-old males, there are far more serious health conditions with similar symptoms that ought to be excluded. Second, it lets you (as patient) know that you are objectively healthy. Panic attacks are not nearly as scary when you are able to convince yourself, 100%, that “just panic” is what they are. If every panic attack felt like “just a panic attack” they wouldn’t be scary. It’s their weird-ass inventiveness at coming up with new symptoms that makes them terrifying. Anyway, that didn’t happen at my first ER visit, so I demanded it at my second. I went to triage and said, perhaps with some exhaustion due to 17 hours of mental anguish, “I know that I’m just having a panic attack but I want you to run all the requisite diagnostic tests and tell me what the fuck I have to do to fix my fucking brain.” I may have been a bit pushy, given the state that I was in. The staffer didn’t like this. He didn’t like me. I was a white kid living in Williamsburg with a $100+k-per-year job at age 24. He probably assumed that I had blitzed my brain on designer drugs (I hadn’t). He dumped me in a psychiatric ER. Now that is a place where I never again want to be.

You can leave a regular ER if the wait time is unreasonable, but not in the psychiatric section. Once you’re in, you can’t get out. They take your shoelaces, they take your money, and you can’t be discharged until you’ve seen a doctor (which may be, as it was in my case, more than 6 hours later). There was a loud television, and what struck me in the hypersensitivity of acute panic was how negative the content was: commercials designed to exploit envy and insecurity, some episode of some shit about teenagers being horrible to each other due to boredom. Most people (including myself, in normal moods) can be exposed to that low-level negativity and not be affected by it; it’s just crass entertainment. But it is fucking irresponsible to blast that shit, at full volume, into a crowded psychiatric ER with 14 people and 12 chairs. Most people in psychiatric ERs are recovering from panic attacks (and they are probably one of the worst places to recover from anything) and hypersensitive and should not jostled with the negativity of the world. I mean, for fuck’s sake… pretend you actually care about these people instead of just wanting to drown them out with TV noise.

During that six hours, I heard a number of screaming matches between staff and patients, and while one patient stood out as particularly loud and pugnacious, many of them did not deserve the harsh treatment they got. I, for my part, was treated well because I was able to gain the presence of mind to learn the rules and follow them. Sit down (on the floor, because there weren’t enough chairs) and don’t scream or piss anyone off. Be polite when you need to use the bathroom. Definitely don’t say, “I could get Xanax on the street instead of waiting for you assholes.” (The woman who screamed out that line must’ve added a few hours to her wait. Also, you’ll never get a benzo at an ER, even if you actually need one. Also, there’s a cop standing right there at the door, and while he does have better things to do than give a shit about such things being said, show some respect for the law.) I followed the rules, put up with my six-hour wait, tried to read although it was impossible to concentrate, and watched people with far more serious mental health issues suffer and (because of my own state) the most prominent thought was, and I’m ashamed of this now, “I hope that’s not my future.” Turned out, it wasn’t. But I’ll get there.

I got to see a doctor (the one doctor, on a Monday) around 1:00 in the morning. For all the horseshit of that ER and hospital, he was pretty good. He was surprised that I ended up in a psychiatric ER (and apologized for the fact) and he explained to me the physiology of panic attacks and, while he couldn’t prescribe, he gave me a referral.

There’s one more bit of the story that I have to tell. A month later, I went to a specialist for something else, and he discovered that it wasn’t a “phantom” health problem (or hypochondria) that was triggering the panic attacks. At least, it wasn’t then. I’m now at the point where just reading about a disease can give me a panic attack, but at that time, I had a real health issue. The difficulties I’d been having with breathing and swallowing were caused by a bacterial plaque that had formed in my throat after a bout of flu (that I, being stupid and macho and 24, tried to work through) from which I hadn’t properly recovered. The chest pains that I’d been having were LPRD/GERD (acid reflux) triggered by flakes of the plaque breaking off and fucking up my guts. The derealization and hallucination I’d been experiencing were not a brain tumor but typical of high-level panic attacks (thankfully, I rarely have them now.) Once discovered, that problem was easy enough to cure… but I spent a month with a giant bacterial plaque in my throat. I think that even normal people would get panic attacks after having a nasty motherfucker like that living inside them. But I digress.

So why do I indict the American medical system? From my two ER visits, I learned (perhaps in error, because I don’t think that all ERs are bad; I’ve just never met a good one) that emergency rooms will resent and ignore me. This is fine, because an ER is a terrible place to go during a panic attack, and if I ever have a real ER-worthy condition, the odds are that I won’t be conscious. I was eventually able to find good doctors (a psychiatrist for the panic, which persisted even after the throat condition was cured; and an ENT in Chinatown who managed to figure out what was actually wrong with me, physically speaking) but I had to seek out the specialists and hope that my insurance would cover the visits. I was my own Dr. House. The worst bit was the nightmare of insurance. Let me put it in no uncertain terms: U.S. health insurance is a fucking scam, and while “Obamacare” (PPACA) has improved the situation, the basic facts of it remain. In a way, health insurance is the most brilliant swindle there is. First, it picks a great target: sick people. When you rob sick people, they’re less likely to fight back or kick your ass or throw a year of life (when many of them have not so many years left) into a lawsuit. The problem with robbing sick people is that most of them don’t have any money, because they tend to be old and unemployed. So they’re soft targets, but with little meat to chew on. Health insurance is brilliant, as far as ignominious crimes go, because it collects premiums while people are well, cash-rich, and generally young… and then denies promised care when (in general) they are too old, sick, and poor to fight back. It’s like a robber with absolutely no sense of ethics discovered time travel! It’s fucking evil, but give credit where credit is due. Health insurance is an amazingly inventive form of theft.

If you’re not from the U.S., you cannot imagine how bad our health care system is. The quality of care when it is delivered is, I would say, spotty. We do have world-class researchers and there are many individual doctors and nurses who are excellent. I wouldn’t take that away from anyone. Our hospitals are depressing and dangerous places where super-bugs breed because our government doesn’t have the spine to disallow the (cruel and needless) abuse of antibiotics in fucking factory meat farms. Relevant to this topic, our billing/insurance system– even if you’re insured, you’re likely to face enormous out-of-pocket costs if you get seriously sick– compounds the stress of illness and has been a contributing factor to thousands of deaths every year. It’s terrible. I’d call it “Third World” but it’s honestly worse. It’s one thing not to have the resources, as the Third World medical systems often do not. It’s another to be rich in resources but to be a greedy fucking asshole. If there is a hell, I’m sure that the architects of the U.S. health insurance system are going to receive punishments that’d make Dante faint.

Health insurance may seem to be an orthogonal, after-the-fact issue when one is talking about panic. In fact, it taps into what, I think, is at the core of panic. What is it that one truly fears during a panic attack? I’ve said this before, and I’m not bullshitting: I don’t fear death. At least, I don’t fear it in the abstract. It will happen to me and, while I would prefer for it to take its time, I am at peace with it, and I think that most people (including most panic sufferers) are. This body will turn into a corpse, I will pass into another state of existence, and (if reincarnation is true) I will re-emerge as a person who will probably never hear the name “Michael O. Church”. To me, the one thing that is most comforting is that death and panic are opposites. Death is an end of this life; we don’t know what follows it, but we know that we ain’t here anymore. It’s impermanence. For a contrast; in panic, there is a fear of permanence or finality or stuckness. It’s not that the suffering (physical symptoms of health problems one does not have) is intolerable, but there is a sensation that they will never end. (Of course, they always end.) Sometimes, there is the fear, “I will die like this.” In fact, panic attacks are non-lethal. I am not a man of steadfast faith, but I feel comfortable in the belief that whatever being dead is like (and, of course, I don’t know what it is like) is quite different from a panic attack, and probably much nicer.

I don’t believe that panic is actually about death. I think that it’s about humiliation and disempowerment and finally abandonment. So let’s talk about those three fears. Are panic attacks humiliating? A little bit, but most people in the vicinity of a person having an attack are not going to have the intense focus on the event that the sufferer does. I’ve had panic attacks in public and I doubt most people remember them. Are they disempowering? They can be, and some people become shut-ins if they get really bad, but the truth is that a person who is  flooded with adrenaline is actually at the peak of his physical power (although he will be utterly exhausted when the adrenaline wears off). Panickers fear “losing control” but the adrenaline’s purpose is to make sure they have total control if any real danger that should present itself (this means there is a loss of non-essential control, and that produces many of panic’s trademark symptoms). As far as disabilities go, I think that panic attacks are one of the less disempowering, unless they become extremely frequent.

So then, let’s talk about abandonment. I think that it’s something that all of us, and even those who seem to be self-reliant badasses, fear. One can hold a cognitive belief that one is owed nothing by others in the world and not suffer for it. Many people, when they acquire disabilities (such as my relatively mild one) attempt to minimize the disability’s impact on others and be as self-supporting as possible. That’s all fine and good. However, I think that we, as humans, have an ancestral terror with regard to abandonment. We’ll be self-reliant as much as we can, but we need to believe that others will care for us if we are suddenly struck down. I think that most people are OK with the concept of eventual death, but the idea of being left to die, when they could be saved, strikes a primal chord. This, of course, gets to why there is, in many, a more bitter hatred toward health insurance companies (who murder by inaction) than there is toward cancer (which, though not a conscious organism, does the actual killing).

Now we have the U.S. medical system (and, most relevantly, these monstrosities that we call insurance companies) in our crosshairs, because abandoning people is what they do. Doctors don’t; if anything, they are eager to save lives whenever possible. But the rest of the system conspires to deny care, push people away, and let sick people die on someone else’s doorstep.

See, it was irritating that I spent 4 hours in an ER, having to wait to be told that my life wasn’t actually in danger. And spending 7 hours in a psychiatric ER (a prison, in essence) when I didn’t need to be there was a pretty miserable ordeal as well. That shit, though, is small potatoes. I’m OK. (It wasn’t that way for this woman, who died of deep vein thrombosis after a 24-hour (!!!) wait in a psychiatric ER’s waiting room). Then I had to deal with billing, and insurance, and insurance run-arounds, and denials of care that were explicitly contrary to law… for years. Having to leave my job, I had to shell out for COBRA only to have basic claims denied for arcane reasons that were clearly illegal. (“What are you going to do, unemployed, sick person? Sue us?”) That was 2008. Luckily, I had the good sense to find physicians who’d accept fair rates, and I ended up OK, but I also knew that if I did develop a life-threatening health problem, I’d be at the mercy of some absolutely horrible organizations.

It was probably 2010 before I recovered to the point of being traditionally employable (and a bit longer before I had the guts to leave the crappy startup I was at) and there is a large class of jobs that is probably out of the question forever. I’m 31 years old and quite functional (as a programmer, I’d say that I prefer to be “purely functional”) but being a hot-shot trader is pretty much out of the cards. Anyway, let’s talk about 2008 and 2009. I took a job at a pre-A startup, knowing that I still wasn’t well enough to deal with an 8-hour day in a typical tech office. (Actually, I’m surprised that normal people can withstand 8 hours in an open-plan office. Noise is one thing, but being visible to so many other people is horrendous. Every worker ought to be entitled to a barrier at his back.) At this startup, I had no health insurance. You know what’s worse than having a hypochondriacal panic attack? Having a hypochondriacal panic attack and knowing that you have no health insurance, which means that all these health problems the mind is inventing could actually lead to disaster. To put it bluntly, the US healthcare system took a period of my life that should have been one of recovery, and made it one of continuing stress and unraveling. It would not surprise me if I were diagnosed with PTSD based both on the period during which I was underinsured and received poor care, and during the panic-onset recovery period (late 2008-2009) during which I was uninsured.

I recovered. The panic attacks are pretty rare now. I have a good job, I’m married, I have two beautiful cats, and I even have decent health insurance– well, I think so; of course, the only way to actually test your health insurance is to become seriously ill– and can access decent doctors for my continuing medical needs, which are relatively low in expense and volatility. I have, for the most part, beaten this motherfucker. That said, I still have the attacks on occasion. Maybe it’ll be a benign heart palpitation or stomach pain that sets it off. Maybe it will be a bad memory pertaining to the dangerously inept medical treatment I received in the past, that spills over into a flashback. These are things that I shouldn’t have to deal with. I am fucking sick of the fucking panic attacks, and I am fucking sick of living in a society that thinks that it is OK for hospitals and insurance companies to take sick people and, out of a level of greed that even the robber barons would consider abhorrent, stress them out and fuck up their lives even further.

I am, and this should be obvious, disappointed by the progress achieved by President Obama on the healthcare front. Did he improve the system, incrementally? Absolutely, but not by enough. Getting rid of “life caps” and shooting down the scam plans was a good thing, no question. That said, health insurers will invent new ways to fuck people over and in 5 years we’ll be back at the same old shit. The system is too rotten to be improved by any incremental means. You can’t transplant new organs into a patient whose body is 85% cancer. At that point, it’s well past over. We need a single-payer or public-option system, and the existing private insurance companies need to die. Right now we have a system in which the doctors work overtime to heal and fix people, but the hospital billing departments and the insurance companies work overtime to stress them out and re-sicken them. It’s ludicrous. It’s like paying one person to dig holes and another to fill them up, but with more severe ethical ramifications because peoples’ health is at stake.

I write this not as a victim of a rather boring (to tell the truth about it) condition, because I am no victim. At my worst, I was no sicker than most people will be at their worst. Instead, I am a courier, and the message is clear: destroy the current, failing, morally execrable system, and build something new.

Why high-deductible medical insurance often doesn’t do what it’s supposed to.

“There was a friend of mine growing up, call him Tom, whose father was a health insurance executive. Once a month or so, he’d come for dinner and sleep over because his Dad was just in a foul mood, would go upstairs, not be able to cook, and not want to talk to anyone. I asked Tom why his dad had so many bad nights, and he’d explain that his father was a health insurance executive. I didn’t get it at first. Finally, when Tom was about 16, I asked him to explain this matter further. What causes his father’s bad nights? Tom laid it out straight: ‘Those are the days when Dad saves a man at work.’ “ — Unknown American origin.

As the medical insurance and healthcare picture in the U.S., despite the best intentions of at least a few left-leaning policymakers, continually gets worse over the decades, it’s becoming common that health insurance plans have high deductibles, sometimes as high as $10,000 for a family if one needs to go “out of network”. Moreover, given that health insurers will just decide not to cover things because some college dropout or failed-into-the-dark-side doctor decides that a treatment is “not medically necessary” (against the word of an actual fucking doctor) or a “lifestyle” treatment, even “out-of-pocket maximums” can’t always be trusted. Being “insured” means less by the day.

All of this said, for young and relatively well-off people, these high-deductible plans with HSAs seem like a good deal. On paper, taking one can be a reasonable bet, and if there were a way guarantee that they covered all medical expenses, I might agree. If you have a few thousand dollars or more in the bank, and you’re not likely to get sick, then you’re probably only giving up a few hundred dollars in expectancy by taking the high-deductible plan. So what goes wrong? What is the unexpected and systemic issue with high-deductible plans?

Libertarians like the idea of high-deductible plans insofar as they encourage patients to respond to economic signals when choosing treatments. While this appears to be a fine idea (on its own terms, that is) on paper, there are a number of issues with it. Free markets work well at solving a large number of pricing problems, but healthcare has extreme time behavior that other markets don’t. An issue that costs $500 to treat now might cost the patient, or society, $100,000 in a year if untreated. Markets work best when short-term signals reflect long-term conditions, and poorly when there’s a severe discrepancy between the two. Second, there’s a huge information asymmetry for patients, who simply don’t know enough to make informed decisions. Most patients would do better to trust their doctors than to try to make every single medical decision for themselves. This means that exposing patients to “price signals” is at best pointless and, at worst, dangerous. Due to the already-mentioned time behavior of most medical problems, by “dangerous” I also mean “expensive”.

What goes wrong with high-deductible plans? It’s not that deductibles are inherently a bad concept. They apply to auto insurance policies and are generally pretty harmless. The problem with high-deductible plans is this: while insurance companies are trypophobia-inducing clusters of assholes, the “good” news is that they’re assholes to hospitals and medical billing departments as much as to patients, and they have leverage, and they twist arms, and they get prices down. The result of this is that medical bills assessed to fully insured people are about a third as high as those assigned to the uninsured. The medical industry has high fixed costs, and no one knows what a service “should” cost, and uninsured or underinsured patients are so unlikely to pay (and, quite often, unable to pay) that billing departments will just plain price gouge. It’s ridiculous and perverse, and it’s questionable whether it should even be legal to set fees after a service is rendered. Hotels, restaurants, and transportation agencies have to set a price before the consumer makes a decision, but hospitals get to make up numbers after the service is rendered, resulting in absurdities like $250 charges for “mucus collection system” (in non-asshole language, a Kleenex). The only check against this are the health insurance bureaucrats. While they’re clearly motivated by corporate greed rather than good intentions, this class of people indirectly benefits policyholders by knocking prices down reducing premiums.

If we accept that insured patients pay medical bills indirectly, then at least the insured patient has an asshole on his side in negotiation with medical billing departments. The insurer will say, “accept this price or you’re ‘out of network’ and will get fewer patients”. As an individual, though, no patient can say “reduce the damn bill or I’ll never get appendicitis in your ER again”.

The problem with high-deductible plans is that, when a young person insured under one gets sick and incurs a mid-sized bill (say, $1500) the insurer has no incentive to engage in the arm-twisting (arm-twisting that is directly responsible for slashing insured patients’ bills by 60 to 80%, and that you will miss dearly, should you have to pay a medical bill directly) that they absolutely would do if they, as insurer, were paying the bill. (This is different if the insured person is frequently sick and likely to overflow the deductible on a regular basis; but until recently, people like that couldn’t even get insurance.) Don’t get me wrong: I’m not pro-arm-twisting in general. I’d like to see doctors and nurses and medical technicians fairly compensated, not driven to the bottom. In fact, I’d much prefer to re-join the First World and replace our rotten system with a public-option or single-payer system. I’m only saying that, as an individual, I’d prefer to have an asshole arm-twister negotiating my bills down rather than not have one.

High deductible health insurance would be a reasonable idea, and appealing to high-income young people like me, if there were some way to guarantee that the insurer would negotiate just as aggressively as if the deductible were zero and the insurer were paying the bill in its entirety. Unfortunately, I am not aware of any way to enforce that.

There is no “next Silicon Valley”, and that’s a good thing.

I recently moved to Chicago and, a couple weeks later, found myself reading this article: Why Chicago Needs to Stop Playing by Silicon Valley’s rules. I agree with it. I also want to speak more generally on “the next Silicon Valley”. It doesn’t exist. The current Silicon Valley is succeeding in some ways ($$$) and failing in others (everything else) but the truth of it is that it’s an aberration. It has as much staying power as the boomtowns surrounding North Dakota oil. Trying to replicate it is like attempting to create one of those ultraheavy chemical elements that lasts for 50 nanoseconds, but less interesting and far less cool.

I’m 31 years old, which is about 96 in Silicon Valley years, and I’ve seen a lot of the country and world, and I’ve come to the conclusion that “the next Silicon Valley” is a doomed ambition because it’s a pretty fucking lame one.

Rather than explain this, I think that a picture really is worth a thousand years here. So let’s look at some inspiring, creatively energetic, cities. These are the sorts of places that bring ordinary people to reach for the extraordinary, instead of the reverse.

Budapest:

Chicago:

New York:

London:

Paris:

Okay, so now let’s take a look at Silicon Valley.

I think my point is made by these pictures. There is a sense of place in the world’s great cities that just isn’t found at 5700 Technology Park, Suite #3-107, Nimbyvale, CA 94369.

Why no location can electively become “the next Silicon Valley”

I think the pictures above tell the story well. Becoming the next New York or Budapest or Paris or Chicago is a worthy vision, although any city will develop its own identity more quickly and more successfully than it can replicate another. Becoming the next Palo Alto is fucking lame. Now that the cherry orchards are gone, the only thing that the Valley has is money, and “I just want more money” is a pathetic ambition that leads to failure. Money has to come from somewhere, so it’s worthwhile to understand the source of the money and whether a region’s success is replicable (and desirable). Silicon Valley is rich because it’s a focal point for passive capital. This capital, drawn from teachers’ pension funds and university endowments, gets funneled through a machine called “venture capital” that is supposed to throw its money behind the most promising new businesses. Yet for reasons that most would find unclear, those funds tend to be directed toward a small geographic area. Now, the passive capitalists don’t especially care where their money is sent, so long as they get good returns. If the best business decision were to put that most of that money into Northern California, that would be easily accepted by the passive capitalists, even if they live in other places. While an Ohio State Police pension fund might ideally prefer that some of the jobs created by their passive capital be created in Ohio, they’ll gladly see their money deployed whereever it gets the best returns. That means that the extreme concentration of deployment in California would be completely OK– if it were justified by returns on investment. However, venture capital has been an underperforming asset class for years, and there’s no sign that this will change, because VCs are incentivized to optimize for their personal reputations and careers rather than their portfolios, and that favors the behavior we see. With the returns being abysmal, however, perhaps the Palo Alto strategy ain’t working. Perhaps this extreme concentration of passive capital, creating jobs in already-congested places where ever owning a house is extremely improbable for people who do actual work, is pathological.

My sense on the matter is that Silicon Valley is pathological, hypertrophic, and innately dysfunctional. Talent and capital like to concentrate, but not necessarily in that specific way, and not in such heated competition for resources with the existing economic elite (whose values are at odds with those of the most talented people). While it starves the rest of the country of attention and capital, Silicon Valley is past congestion and suffering for it, in terms of traffic and land prices. On paper, it’s set in a beautiful geographic area, and if you can get away from everything created by humans, California actually is quite pretty. That said, 22-year-olds without cars aren’t going to be impressed by Mountain View’s 200-mile radius when everything they actually see on a daily basis is an ugly, suburban shithole that they pay far too much to look at. Talented people do want to be around other talented people, but they prefer diversity in talent, not rows and rows of tech bros (who often aren’t very talented, but that’s another story). Because of talent’s natural draw toward concentration, and given the U.S.’s tendency toward high geographic mobility, I don’t think that this country will ever have more than 15 or 20 serious technology “hubs”– and even that would be a stretch, given that we currently have about five– but I do think that it’s possible to have a distribution that’s better for everyone involved. The current arrangement is bad for “winning” locations like Northern California, bad for the losing geographic areas, and bad for pretty much everyone individually except for extremely wealthy venture capitalists (who benefit from a reduced need to travel) and well-placed landlords.

As it exists, Silicon Valley probably shouldn’t. It’s a boomtown with ugly (and expensive) housing that wasn’t built to last. It has what could be a decent (if sleepy) almost-city in San Francisco, recently destroyed by the unintentional conspiracy of NIMBY natives (who create housing supply problems) and VC-funded new money. It is rich, on paper, and will be for some time. But replicating accident and pathology is a pretty lame strategy when directing the fate of a new place. The causes of Silicon Valley’s richness and (mostly former) excellence are more worthy of study than the superficial factors, like weather or workplace perks or representation in the entertainment industry.

What, then?

While “next Silicon Valley” is a lame ambition, there is something to that geographic region that makes it attractive to talented entrepreneurs. It provides a path to corporate hegemony that, at least by appearance, combines the “cool factor” of starting a business with the low risk of an investment banking or management consulting track. It encourages risk-taking and a superficially cavalier attitude toward failure, which appeals to a certain type of young person who has never failed and who hasn’t learned yet that life has stakes. The Valley has also done a great job of rebranding the corporate experience as something that left-leaning, upper-middle-class young people can swallow. Silicon Valley excelled in technology in the late 20th century; in the early 21st, it has proven itself world-class at marketing. Since brand-making is crucial to success in the sorts of first-mover, red-ocean gambits that VC (increasingly oriented toward attempting to sit inside the natural monopolies that technology sometimes creates, rather than actually building technology) now favors, that’s not surprising.

In business, there seems to be a continuum between low-risk, slow-growing businesses and “rocket ships” that burn up in orbit 95% of the time. There’s also a misperception, that I want to combat, that utter failure of new businesses is the norm. The risk exists, but 90% failure rates (while not uncommon in the Valley) are actually pathological. The actual failure rate is somewhere around 50 percent. In fact, compared to corporate jobs, the failure rate of typical small businesses (as opposed to VC-funded red-ocean gambits) isn’t much worse. Between firings, layoffs, political messes and damaged reputations relegating a person to second-class status, non-promotability, and less-desirable projects, it seems to be a constant that about 50 percent of jobs fail within 5 years. Of course, the range of outcomes is different; starting a business has more personal downside, and more potential gain. If there’s something that ought to be fixed in the process of new-business formation, it’s the amount of financial risk borne by those who don’t use venture capital.

For low-risk businesses that are unlikely to fail, bank loans are available. However, bank funding is a non-starter in launching even the least risky (“lifestyle”) technology companies, because bank loans those tend to require personal liability, which means that you can’t use them for something that might actually fail. Bank loans are great if one wants to capitalize a franchise restaurant or a parking garage, but not suitable for anything that involves making a new product. At the other extreme, there’s VC. The mid-risk, mid-growth range is, however, overlooked. For a business carrying, say, a 20-30% chance of failure and targeting 40% annual growth, there’s no one out there. Why is that?

Venture capital could be just as profitable by investing in mid-risk businesses as it is by throwing into the extreme high-risk pool. After all, if valuations are fair, then there’s just as much profit to be made investing in large companies as small ones. We’re probably not going to see a change in VCs’ behavior, though. The truth about that industry is that it’s celebrity-driven, and the VCs have a lot to gain and lose by playing the reputation gain. No one cares about the difference between a 7% and an 12% annual return on investment, but there’s a lot of credibility that comes from having “been in on” a Facebook or a Google. This also explains the (justly) hated tendency of venture capitalists toward collusion, co-funding, and reliance on social proof. One might want for VCs to compete with each other (i.e. do their jobs) and avoid this sort of mediocritizing collusion, but with the career benefit of being in on the once-per-decade whale deals being what it is, the incentive to spread information (even at the expense of entrepreneurs, and of ethical decency) around is obvious.

A successful business could easily be built by focusing on the mid-growth / mid-risk space, and delivering an option that removes personal financial risk while avoiding the ugliness and the aggressive risk-seeking (even at the expense of the ecosystem’s health) of traditional venture capital. That would also reduce reliance, for businesses, on the geographical advantage of Silicon Valley, which is access to ongoing capital and the perception of a liquid market for talent. It could be very profitable. It could be this mentality that builds the next ten thousand great companies. It won’t be done in Silicon Valley, however; and when it happens, it won’t come from anyone attempting to, or even cognizant of such a concept, create “the next Silicon Valley”. It will be driven by people creating the first something.

2015

I haven’t written much lately, in large part because I am trying to change course in terms of what I write about.

A change of focus?

Over the next year, I’d like to steer my focus toward more technical topics. CS 666 (software politics) is a subject that I’ve had to learn and use, the knowledge is important, and I’m glad to have shared it, and will continue to do so if I think that it’s good for the world. All that said, my heart’s not as much in it as it could be in other fields (like machine learning, language design, and even board game design, all of which are more dear to me than the MacLeod organizational model as it applies to software). It’s easy to focus on the intricacies of CS 666 and forget about the stuff that inspired us to get into technology in the first place. I swear that I didn’t join Google, back in 2011, hoping to become an expert in office politics. (Alternate summary: “I joined a Leading AI Company, and all I got was this lousy MBA’s Worth of CS 666 Knowledge.”) I wanted to level up on machine learning and software engineering… but a working knowledge of software politics is what I actually got from Google (and many other companies where I worked). At any rate, I think that I’ve put that to good use since then. I do what I can. But I’d rather focus on other stuff now.

The road to technical excellence (on which I am still a journeyman, not yet a seasoned ranger) is hard: you have to get high-quality work (which, in most companies, involves CS 666 in order to hack the project-allocation system) and be able to deploy it into the organization (ditto). Most programmers ditch the individual-contributor path in the manage-or-be-managed world of the closed-allocation mainstream, knowing that the only way to sustain sufficient advantage in the division of labor to grow and protect expertise and excellence is to gain direct control of it (“it” meaning the division of labor). They learn the political game, become managers easily once that is done, rise into the executive ranks because managerial tracks in supposedly “dual-track” organizations are always easier to climb than the technical ladders, and are lost to the field as individual contributors. It’s good for them, but not always for the world. A cynic might say that what begins as a diversion into CS 666 becomes, for many, a permanent state of distraction.

At the same time, we have this epidemic of criminally underqualified, well-connected individuals getting funded and acquired. In this frothy state, tech seems to be all about fucking distractions. I don’t like that it’s happening, and I’ve said more than my piece on it. The question I have to ask myself, continually, is whether I am making real progress, or just contributing to that state of distraction that I dislike. And then I have to ask what is best for me. Looking at the next 12, 24, and 48 months… I’ll be honest, I’d like to learn more computer science and spend less time on CS 666. There’s just a lot out there that I don’t know, and should, not only in computer science but in mathematics, the sciences, and the arts.

In truth, my status as some sort of emerging “conscience” of Silicon Valley must be considered temporary, since I don’t even live there, and have no interest in ever doing so. (What does it mean when the conscience of a place lives thousands of miles away from it?) On all that political stuff, the best thing that could happen to me would be for me to meet someone with the right vision, but who’s better than I am at pushing it through, and who doesn’t (like me) secretly wish he could study machine learning and leave the CS 666 to someone else. Ten years from now, I don’t want to be dumping execration on the moral failures of the technology industry, the way I do now. I want to see that we have grown the fuck up and solved our own problems. That will require people who are like me, but even better in battle, to take charge and start fighting.

The good news, for me individually, is that I think I just might be reaching the level of capability where the politics starts to get less intense. When you’re 22 and unproven, you’re going to have fight political battles just to get the good projects, and to get recognized for what you’ve done. It’s an ugly process of trial and error that I’d like never to repeat. Now I’m 31, more eminent in terms of talent, and would like to see myself protecting the good, in the future, rather than needing protection. Time will tell how that goes, but I’d like to finish next year with more technical articles and fewer political ones on the blog.

Chicago

In other news, I’m moving to Chicago in early January. I’m quite excited about the move. Anyone who wants to get together over pizza (either kind!) and beer and talk about functional programming, machine learning, board games, or why the world would be better if it was run by cats, should reach out.

On the supposed aversion of software engineers to “the business”.

There’s a claim that’s often made about software engineers, which is that we “don’t want anything to do with the business”. To hear the typical story told, we just want to put our heads down and work on engineering problems, and have little respect for the business problems that are of direct importance to the companies where we work. There’s a certain mythology that has grown up around that little concept.

Taking a superficial view, this perception is accurate. The most talented software engineers seem to have minimal interest in the commercial viability of their work, and a rather low level of respect for the flavor-of-the-month power-holders who direct and supervise their work. It’s easy to conclude that software engineers want to live in an ivory tower far away from business concerns. It’s also, in my experience, completely incorrect. Business can be intellectually fascinating. As I’ve learned with age, new product development, microeconomics and game theory, and interpersonal interactions are just as rich in cognitive nutrition as compiler design or random matrix theory. I might prefer to study hard technical topics in my free time, in order to keep up a specialty, but I’m a generalist at heart and I don’t view business problems or interpersonal challenges as inferior or “dirty”. More to this, I think that most software engineers agree with me on that. We’re not ivory tower theoreticians. We’re builders, and as we age, we begin to respect the challenges involved in large projects that present interpersonal as well as technical challenges.

So why are so many talented software engineers seemingly averse to the business? Why do most talented programmers fly away from line-of-business work, leaving it to the less capable and credible? It’s this: we don’t want to deal with the business as subordinates. That, stated so, is the truth of it.

There are a few who protect their specialties with such intensity that any business-related work is viewed as an unwanted distraction, and I’m glad that they exist, because the hardest technical problems require a single-minded focus. I’m not speaking (not here and now, anyway) for them. Instead, I’m talking about a more typical technologist, with an attraction to problem-solving in general. Is she willing to work for “the business”? Of course, but not as a subordinate. If she’s going to be called in to mix business concerns with her work, she’s going to want the authority and autonomy necessary to actually solve the problems put in front of her. It’s when working with the business doesn’t come with these requisite resources and permissions that she’d rather slink away and build interpreters for esoteric languages.

The stereotype is that software engineers and technologists “don’t care” about business problems. The reality is that they avoid working on line-of-business software because the position is inherently subordinate. Give them the authority to set requirements, instead of coding to them, and they’ll care. Make them partners and drivers instead of “resources”, and they’ll actually give a damn. But expect them to interact with the business in a purely subordinate role, as in a typical business-driven “tech” company, and the talented ones (who are invariably smarter than the executives shouting orders, but have chosen not to participate in the political contest necessary to get to that level) will hide from the front lines.

If a company views software engineering as a cost center, and programming as a fundamentally subordinate activity, it will find that talented programmers avoid direct interaction with the business (which will, by design, happen on subordinate terms) and software it builds will either be of low quality or irrelevant to its business needs– because those who have the ability to write high-quality software won’t even bother to make their work relevant. However, this pattern of degeneracy (although common) should not be taken as a foregone conclusion. There are more similarities than differences between business problems and engineering problems, and it’s quite possible to give people with programming and engineering talent the incentive to learn about the business. While technical talent flies away from “business-driven programming” like a bat out of hell, there’s no intrinsic animosity between programming talent and “the business”. To the contrary, I think that people with experience solving these two classes of problems could have a natural affinity, and have a lot to learn from each other. Any such meeting has to come on terms of equality, however. If working with the business means doing so as a subordinate, then no one with technical talent will do so in earnest.

This comment was censored by Y Combinator’s Hacker News.

The news topic was Alan Eustace’s recent skydiving record.

The Hacker News comment thread is here.

My comment is here. The link may not work.

Here is the text of it.

Maybe this is cynical but I dislike stories like this. I’m glad he got back safely, but it sounds a bit Everest-y. Felix Baumgartner was an experienced jumper. Every time a corporate executive pulls the “throw money at something hard for mere mortals” card I cringe. Again, Everest. The number of rich businessmen who die because Mother Nature does not give a fuck about job titles is immense.

The comment itself isn’t that interesting. What is interesting is that such a vanilla remark (profanity isn’t taken to be an issue on Hacker News) could be censored. I wonder why? What libertarian nerve did I tweak?

I’m not going to speculate. But enjoy the above, an average, ordinary comment rendered unusual by the mere fact of it being censored.

It might be time for software engineers, especially in Silicon Valley, to unionize.

Should software engineers unionize? Two years ago, I would have said “no”. In fact, I did say “no” two years ago. At the time, I was unduly influenced by the negative reputation of unions in this country, and drawing a rather artificial distinction between “unions” (blue-collar) and professional “guilds” (white-collar, often prestigious). I saw the need to draw together and collectively seek our common interest, but I gave it the language of a “profession”.

Two years ago, I argued that we needed structure of a constitutional nature, and I still agree with that. Software, right now, is an every-man-for-himself, “Wild West” industry. There are no unions, talent agents for programmers are rare to nonexistent, talented engineers are fired quickly and without apologies (or severance), and the engineer is wholly responsible for his own career advancement. (Some companies are so backward that they deduct conference attendance from vacation days!) A small number of companies (e.g. Valve, with its open allocation system that allows employees, within reason, to define their own work and pick projects) offer constitutional guarantees regarding internal mobility and social justice, but that is far from the norm. In most companies, the fundamental idea is that employee lives entirely at the whim of a manager, “and you should be thanking [him] every morning, along with Jesus, for giving you another day.” Constitutional protections of employees would be anathema to most organizations, whose internal models of social justice are akin to Elizabethan England’s “great chain of being” concept, in which the monarchy ruled by divine right and was unaccountable to anyone.

The Wild West employment climate was tolerable to most Silicon Valley software engineers when they shared in the upside (i.e. stood a serious chance of getting rich, or at least comfortable, through hard work). Twenty years ago, programmers from middle-class origins could actually raise venture funding without relying on (upper-class, connected) “advisors” and extraneous business co-founders who’d charge several percent, and want to manage, just for introductions to investors. Twenty years ago, housing was affordable in the Bay Area, and living on a low salary to pursue a dream was legitimately possible. Twenty years ago, startups fired good employees as often as they do now, but they offered genuinely positive references and introductions to investors when they did so. The attitude was, “We need a different skill set than what you have, but we’ll make sure you land on your feet.” It was more like a rock band breaking up over genuine creative differences than a person being singled out and humilated. Twenty years ago, while it was rare that a startup would explicitly pay for an engineer’s career advancement (2-4 conferences per year was standard, but tuition reimbursement was rare) engineers had the authority to define and self-allocate their own work, so they actually could advance their careers without above-normal assistance. Twenty years ago, there was just as much volatility in day-to-day employment as there is now, but the Valley was still run by lifelong technologists who identified themselves as engineers, not talentless hacks self-identified as future rich people who had ethical license to do whatever they wanted because they were “changing the world”. More often than not, the engineers in that time looked out for each other. It was a different time, and a better one for the Valley.

Second phase

Silicon Valley has devolved in a number of ways. Housing has become inordinately expensive, with California NIMBYists opposing high-density housing at every turn. (“California: where the future is built by people living in the past.”) The result of this is that a typical software engineer, making about $120,000 per year, an amount that would still be considered high in most of the U.S., can end up living paycheck-to-paycheck. What made Northern California great in the 1960s to ’80s has become its downfall: its openness to the new. As a region, it was too trusting. It allowed non-resident third-world despots and corrupt officials to buy real estate that they’d rarely or never use, pricing Americans out of their own housing. Worse, when smooth-talking East Coast financiers took an interest in the region in the 1990s, it welcomed them, unaware that they’d eventually take the place over and out-compete the lifelong technologists for venture capital. The Battle of Palo Alto has been lost.

No one can reverse the arrow of time. We shouldn’t look to restore the Silicon Valley of 1975, because it doesn’t exist anymore, and it never will again. We should be focused on creating something better in 2025. At that, we have a chance. Of course, we need for a substantial number of lifelong technologists to regain money and power. With the U.S. middle-class falling to pieces, this is not going to happen without opposition. There is not a rising tide, and all boats are not being lifted. We, the lifelong technologists and engineers, have to wrest power from the existing elite. We have to do something that engineers (and middle-class Americans, overly steeped in outdated concepts of meritocracy and fair play) generally hate to do: we have to get political. After all, an unreasonable aversion to political activity supports the status quo and is, therefore, political already.

‘Cause the takers gonna take, take, take, take, take, and the makers gonna make, make, make, make, make…

Ayn Rand’s fan club loves to use the rhetoric of “takers” and “makers”. I generally dislike this distinction as it is commonly used, since the “taker” label is usually applied to the poor and uneducated who, through no fault of their own, have little to offer society. Yet it’s illuminating, specifically because it shows Rand’s view of corporate capitalism to be fundamentally incorrect. To Rand, the entrepreneurs were the “makers”, while she assigned the “taker” label to the poor, disenfranchised, and disliked lower classes as well as to government bureaucrats. In reality, the takers are the private-sector social-climbers who, being better at social and political machination than those doing the actual work, capture most of the value generated by the productive but politically disorganized makers. In most companies, the high-status positions are owned by blue-blooded, 100x takers (well-positioned, unaccountable executive bureaucrats) and the all of the work is done by underpaid makers who “just want to do good work” and (to their detriment) refuse to “get political”.

As the takers move in to technology, and out-compete makers for attention and resources due to their single-minded focus on political victory above creation, they destroy its innovative capacity, replacing creativity with mean-spirited, zero-sum slagging. They’ve introduced stack ranking, which is the epitome of zero-sum squabbling. They’ve created an age-discrimination culture that values deference to authority over experience. They’ve replaced a mindset of exploration and value creation with the anti-intellectualism of the enterprise Java shop. They’ve done so much damage that anything that reduces or challenges their power deserves serious consideration.

At this point, there is probably nothing that could be lost in bringing the unions into Silicon Valley.

Objections to unionization

There are four main objections to unionization of Silicon Valley engineers. I’ll address each of these.

1. Unions pit management and labor against each other. 

This is the easiest of the four to destroy. With stack ranking in place in companies like Amazon and Google, and with 0.02% slices of 100-person startups qualifying for “ownership” (as in, “you should work 90-hour weeks and carry a pager because you’re an owner“, which is a bald-faced lie) in the Valley, labor and management are against each other. “Class war” is already happening, but it’s one-sided as the working class refuses to defend itself (yet). An engineer is far less likely to advance to the investor ranks in the Valley than an associate in an investment bank or law firm is to “make partner”. Ruses and phony promises, instead of career investment, are deployed to encourage young engineers to work 90-hour weeks on other peoples’ ideas. Management started the fight, and it’s winning hand-over-fist. Equalizing, in this fight that’s already underway, just makes our position better. Collective bargaining may not be the only tool that might allow us to equalize, but it’s a historically proven one.

Improving software engineer wages will also transfer future income away from socially well-connected takers and back to makers. This will give us the capital to fund whatever happens after the ossification of the VC-funded world in Silicon Valley is complete. Oddly enough, even if unions diminish innovation in the companies where they’re implemented (and I don’t see a good reason to believe that they will) they wound enhance innovation in the broader economy by reviving the middle class, and making it possible again for people of average means to capitalize new companies.

2. Wage normalization/mediocrity.

Some unions regulate wages to a degree that most software engineers (including me) find unreasonable. Public school teachers’ unions, for example, make it difficult to fire incompetents and often impossible to pay great teachers what they’re really worth. Though unions improve the aggregate wage, their reputation is for pulling compensation to the middle. This is a genuine problem that we’ll have to deal with. How do we prevent across-the-board mediocrity in compensation? Whatever collective bargaining structure we create for engineers, it shouldn’t prevent one who is genuinely worth millions per year from making that much. I’d like to see a salary floor set, but there shouldn’t be a ceiling.

There is, oddly enough, good news on this item. To tell the truth, wage normalization has already happened in the Valley. An entry-level software engineer at a large tech company will make about $120,000 per year, all-in. If she works her ass off for ten years and becomes 5 to 25 times as valuable, she’ll be lucky to make more than 1.5 times that. With ten more years, she’ll be lucky if she’s not starting to face age discrimination. Employers know that becoming and staying a “10x” engineer requires continuing access to high-quality work, which they make artificially rare (closed allocation). This makes it awkward and difficult for a Staff Engineer to ask for appropriate pay: sure, she’s adding tens of millions per year of value to the company, but that’s because the company is “generously” giving her decent projects!

In other words, we don’t have to worry about unions introducing wage normalization. It’s already there. Most “10x” engineers get mediocre wages, relative to the value of their contribution, already. Sure, there are engineers who make $750,000 per year plus stock options, but (a) that’s extremely rare, and, (b) it often has more to do with managerial favoritism than merit. Software engineers’ salaries aren’t abnormally high, and they are certainly not “inflated”, for 99 percent of us. For most of us, downward wage normalization has already occurred. If collective bargaining can deliver upward normalization, we should take it.

3. Seniority.

Airline pilots’ unions are notorious for the toxic culture existing around seniority. That is certainly a thing we should not replicate. The pilots who’ve been with the airline get the best routes and make large sums of money ($200,000 per year and up) while the junior pilots make the worst routes and make very little, and this is by contract. These sorts of seniority systems are immensely damaging, both to the airline’s ability to sustain itself as well as to the quality of service, and undesirable even for most pilots. First, they make it a disaster for a pilot to be laid off, because it means starting again at the bottom of the queue. Second and relatedly, they make it nearly impossible for pilots to change airlines without damaging their careers. Third, this sort of overvaluation of seniority leads to mediocrity, because it allows the most experienced people to rest on their laurels. Fourth, while it seems to protect old hands, it also discourages people from moving into that career later in life, because they know they’ll never be able to get the good jobs. In truth, these sorts of seniority systems are a form of aggressive age discrimination, because they lock out mid-life career-switchers who might bring in new blood and knowledge from other domains.

Silicon Valley’s startup culture, with its age discrimination culture and worship of youth, seems to be at the opposite extreme. However, I think this is a false dichotomy. This attraction of employers to the young exists because they can be abused. The seniority system and rate-limiting of promotions still exist. It’s just that the employee’s upside has been eliminated, because companies can renege on the benefits that come with seniority. The seniority system itself is still very much in place. It’s just a broken one.

A few years ago, in a job search process, I submitted to a company’s pre-interview code test a solution that, I was told, was one of the three best submissions they’d seen, and this was a pretty prestigious company, so I’d guess that they’d received a lot of code samples. I interviewed and got an offer, which was… for a junior position. Blowing away the code challenge didn’t matter. This ties into a general dislike I’ve developed for code tests and “brainteasers” on interviews. I’m very good at them, but there’s an error rate for anyone, because sometimes a candidate is rejected because the reviewer dislikes the language he chose. If there’s a chance that performing extremely well can bump a person up a rank or two, then I’d be all for these tests. It’d be to my advantage. If they’re just another hurdle to pass, bringing only downside (and that seems, often, to be the case) then I’d prefer to avoid them. Why would I waste time on a code test just to get a junior position?

In the VC-funded world, we see an amalgam of two systems on the topic of seniority. (This is a common theme of corporate capitalism, which exists to deliver the best of two systems– capitalism and socialism– for a well-connected elite and the worst of both to the rest.) If you don’t have the social connections to get funded and acqui-hired, you still have to get into the queue at the back, pay dues, and watch mediocrities get better projects and more opportunities to succeed. So it shares that in common with the decrepit seniority systems: excluding “the 1%”, the young get shafted. On the other hand, the lack of internal promotion (thus, mandatory job hopping) and aggressive performance appraisal (creating noise in the system, because when stack-ranking comes out, no one is safe; it’s like “The Purge”) make it so that everyone has to be prepared to be on the job market at any time. Thus, later in one’s career, the promises of seniority can be reneged upon. Young programmers (except for well-connected– and, increasingly, parentally connected– ones who can become founders) have to contend with seniority systems that become excuses for why they don’t get good projects or to make meaningful decisions and learn a thing or two. But twenty years later, there is no safety net for them and the “Wild West” rules dominate.

4. Lack of innovation and mediocrity.

Unions, in the interest of advancing their workers’ interests, will sometimes generate regulations that can hamper innovation. Is this a concern? It depends. If you aggressively unionized an open-allocation, engineer-driven software company like Valve, it would probably be a change for the worse. If it’s a closed-allocation software company, you lose… nothing.

Some unions cause mediocrity in wages, while some provide general protection and a wage floor but allow market wages. I think it’s obvious that software requires the second type. Sometimes, unions protect incompetent employees. A software union ought to negotiate a guaranteed severance, but not prevent bad engineers from being fired. With regard to the three issues raised above, I think we’ll be able to engineer a collective-bargaining arrangement that prevents those problems. This one, the fourth, is the biggest. Sometimes, in the interest of protecting members’ jobs, unions introduce a lot of regulations that slow down work, and we don’t want that.

If the company uses closed allocation, the “good news” is that there’s absolutely nothing to worry about when introducing a union. Companies formalize closed allocation (with internal headcount limits, official performance reviews, and a prevailing distrust of employees) when they’ve reached a stage at which innovation is (a) de-prioritized, and (b) considered to be a job for executives alone. Once a firm is rate-limiting and restricting innovation like that, it has already decided that it doesn’t need most of its people to be creative. Fair enough, one might say, as there’s a lot of important work that doesn’t need to be innovative. That’s the kind of work over which unions unambiguously succeed. At that point, let’s bring in the unions to make sure that the workers are fairly treated and compensated. If they’re actually paid appropriately and can save money (imagine that!) they might be founders in the future.

Closed-allocation management is such an innovation killer, already, that any loss that might be inflicted by collective bargaining is just a rounding error. If a company has already decided to implement closed allocation, it’s shown that it no longer believes that it needs innovation. It’s probably right. So there’s nothing to lose.

In sum, the feared culture of mediocrity and distributive squabbling won’t be introduced by programmers’ unions. It’s already there, thanks to Silicon Valley’s management.

In fact, a properly structured professional guild is the only way that I can come up with for defeating that mediocrity. If we put a floor on how programmers can be treated and compensated, we can drive the unqualified and desperate out of our industry, which is the first step toward proper professionalization, and we can cancel the projects that aren’t worth a properly compensated engineer’s time. The main reason that so many software engineers are assigned bogus projects is that our salaries are too low. If it cost more to waste our time, we wouldn’t be assigned to the useless work that a closed-allocation shop generates.

Other benefits

I can’t predict the effect that labor unions would have on software engineer compensation. There are too many variables. My best guess is that they wouldn’t increase salaries by very much (possibly 10 to 20 percent, with more improvement at the high end) but that they’d remain at 2014 levels, even after the current tech bubble bursts. Unions might seem unnecessary in a time when mediocre engineers can earn $140,000 per year, but there’s no reason to be sure that salaries will stay at that level, even for the strong engineers who are worth several times that in any economic climate. We ought to start organizing now, rather than waiting until we ostensibly need to.

Moreover, there are other gains that would improve software workplace cultures immensely. The fact is that, since most of us will never experience the one-in-a-thousand upside outcomes of “fuck you money” or direct promotion to partnership ranks at Sequoia, we’re better off to abolish the Wild West employment culture that exists now. It would be tolerable if it delivered real upside and autonomy to us, but it doesn’t.

Here are some specific protections we could get through a union:

  • We could destroy stack ranking and mandate that performance review histories not be part of a company’s internal transfer process, eliminating a large class of professional extortions and bringing companies closer to the open-allocation ideal.
  • We could put an end to exploitative terms in employment contracts such as binding mandatory arbitration, employer ownership of side projects, and one-way non-disparagement clauses that exist only software engineers are too trusting and many don’t read their offer letters beyond the salary and title. (Yes, I agree that it’s “their fault” when they get shafted because they didn’t read their contracts. But it’s unfair that the wiser among us have to compete with these clueless fuck-ups in a race to the bottom.)
  • We could require employers to allow employees to have representation (legal and career-coaching) in the room when negotiating with management regarding performance appraisal, terminations, references and introduction clauses.
  • We could reduce the incidence of back-channel references, blacklists, and “no poach” agreements by setting up a union tip line, and by providing legal assistance to victimized employees.
  • We could have matters of negotiation that are embarrassing for the individual, such as those surrounding disability accommodation, workplace privacy, severance and performance appraisal, managed ex ante, for all of us, by experienced professional negotiators.
  • We could eliminate (or, at least, curtail) the sharing of HR data, such as salaries, titles and performance reviews, across companies (typically, into third-party “data collection” services), a probably-illegal practice deployed to reduce salaries and to blacklist suspected unionists.
  • For freelancers and entrepreneurs, we could eliminate the “we’ll call other clients/investors and turn off unrelated interest” class of professional extortion that is often used against them.

Only an insane person would see the above protections as undesirable. They’re necessary for economic and cultural reasons. It’s astonishing and barbaric, for example, that a software engineer can be put on a PIP without the right to have a representative (including, if he wishes, an attorney) in the room with him when that notice is given. We ought to fix that. It’s not just an issue of finding the right price point for our labor; it’s a critical moral issue that we ignore at our peril.

Where to look next

Professional athletes have unions, and have not experienced wage normalization. Their work and rewards have not been drawn to mediocrity. They still compete incredibly hard against each other. The same, I would argue, applies to Hollywood. It’s heavily unionized, and yet, the product is far from mediocre. (Some might dislike much of what Hollywood produces, but in terms of success on the global market, the U.S. entertainment industry excels. On its own measurable terms, the product isn’t mediocre.) Rather than producing mediocrity and stifling innovation, these unions serve to protect workers (and their careers, and their reputations) in a complex, hit-driven business where talented individuals can add immense value, but in a way that’s hard to measure. Software is also a complex, hit-driven business of the same kind, and we deserve the same protections. We have a need to protect our reputations and health, and to avoid being “type-cast” and losing our personal brand, and we have the right to representation that enables us to do so.

I don’t know the inner details of Hollywood’s unions and I can’t say, with any real confidence, that their model is perfect or right for us. I’m not sure. I will say this much: that would be a place to start looking. We have several counterexamples to the “unions produce mediocrity and kill innovation” argument that is made every time someone discusses collective bargaining for software engineers. These give us starting points for this exploration.

Is there an alternative?

I’ve established that nothing is lost in unionizing a typical, closed-allocation software company. The failings and corruption risks of unions are minuscule in comparison to the proven failure and corruption of typical corporate management. If your company uses stack ranking (to my knowledge, Google still does and Amazon does) then you should unionize it. Just killing off stack ranking will show the men upstairs enough momentum to properly scare them. That would be a heroic start.

With regard to open-allocation, innovation-friendly technology companies, I’m less convinced that unions are necessary. Some of the protections I’ve described are owed to software engineers in any context, but a company that commits to open allocation is already offering many of those. The few companies that offer constitutional protection against misguided management– and I’m not talking about vague platitudes about not being evil (directed at Microsoft, which abolished stack-ranking, while Google still has it) or “20 percent time” policies with no teeth– may not be in need of unions. The most progressive ~1 percent of technology firms are already providing much of what unions are there to deliver.

If you’re a technology manager or small business owner and you don’t want the need for unions to exist, the best strategy is to adopt a transparent and constitutional style of management. I’ve studied open allocation a fair bit, and for technical innovation, it is the only solution within current knowledge. The fear I have with regard to the concept is that, in the future, it might be bastardized like “agile” or “object-oriented programming”. After all, “open allocation” is, itself, just two words. It’s the spirit behind the concept that is important. A more general, infrastructural ideal with much broader applicability is constitutional management. Some companies have an “Employee Bill of Rights” that can only be modified by a secret-ballot majority vote. That’s the kind of thinking that a technology company needs if it wants to avoid the need for a union.

However, expecting progressive management to take back the Valley is not, sadly, realistic. It’s time to give up the dream of a return to the 1970s-era middle-class, union-free Silicon Valley, because that’s not going to come back; and to disabuse ourselves individually of the notion that an engineering position at a VC-funded startup is 3 years’ distance from being a well-funded CEO, because it doesn’t work that way either. Collective bargaining may be just a starting point, and maybe it’s not the final right answer, but it’s time to explore the concept.