Today, I learned that reading, understanding, and writing about it is a lot more complicated than I thought...

Table of Contents

• 1. Third-Party Voting: Remove Anti-Fusion Laws?
  • 1.1 Why does fusion voting matter today?
  • 1.2 El-Haj's Arguments Brief Flow
  • 1.3 How do Anti-Fusion Laws Impose a Burden on Associational Rights?
  • 1.4 Thoughts
• 2. Who Controls Your Dentist?
  • 2.1 DSOs
  • 2.2 Private Equity's Business Model
  • 2.3 Dental Insurance Consolidation
  • 2.4 Specific Problems Mentioned
  • 2.5 Strain on Dentists
  • 2.6 Remedies
  • 2.7 Thoughts

1. Third-Party Voting: Remove Anti-Fusion Laws?

I don't know much about law, politics, or even how the voting system works in the United States. I decided to change that by pursuing a line of questioning: What challenges do third-parties face in American politics to be relevant? This led me to this erudite paper by Tabatha Abu El-Haj: Fusion and the Freedom to Associate to a Better Politics.

The two-party system has neutered dissent. Most voters are choosing to be unaffiliated. El-Haj quotes the following statistics:

• A 2023 Gallup survey that found that 43% of adults identify as independent — not identifying with any major party.
• A 2024 Pew survey where only around 50% of voters under 25 are willing to affiliate with either major party.

These unaffiliated voters have no mechanisms in most jurisdictions to register their disapproval: alternative parties (aka third parties) are systemically suppressed. El-Haj says this is because electoral fusion voting is banned in 43 states (legal only in Connecticut and New York; partial in California, Pennsylvania, Vermont, and Oregon). She argues that fusion voting would help fix America's broken two-party system by giving minor parties a meaningful role in elections.

But what is fusion voting? Fusion voting is essentially a cross nomination, i.e., multiple political parties can nominate the same candidate. In the ballot, the candidate will appear multiple times — one for each party that nominated them — and their total vote count is the sum of votes received on all party lines.

Consider the following example:

In this example, Candidate X will win because the minor party's cross-nomination pushed them to the top. Thus, minor parties can play a decisive role in the election.

1.1 Why does fusion voting matter today?

El-Haj gives the following reasons:

1. Breaking the "Doom Loop" of Polarization: The two-party system makes every issue binary. Fellow voters see opponents as enemies, not fellow citizens. Fusion voting will create space for cross-ideological collaboration. It will allow voters to signal a nuanced perspective (vote for a particular candidate on a more moderate line) and give the candidate incentive to appeal to the center (take into account the minor party's position).
2. Giving "Politically Homeless" Voters a Home: Unaffiliated voters can channel their vote to a minor party; the minor party can cross-nominate the more moderate major-party candidate. This allows such voters to signal their preference without wasting their vote.
3. Preventing Spoiler Effects: A third-party candidate often "spoil" elections by splitting vote. This not only discourages serious minor party efforts, but also discourages voters from supporting minor parties. Fusion voting will not split the vote as multiple votes for the same candidate are combined.
4. Defending Against Authoritarianism: Authoritarian movements often win by facing a fractured opposition. Fusion voting can allow diverse groups to unite (form a coalition) behind a single candidate against the authoritarian group.

1.2 El-Haj's Arguments: Brief Flow

El-Haj makes her stand for fusion voting:

1. By demonstrating third-party politics has precedence in American politics (especially, in the 19th century).
2. By pointing that at the turn of 20th century, numerous state legislations instituted rules for minor parties that:
   • required them to demonstrate a threshold of electoral strength before gaining access to the ballot; and
   • limited their capacity to associate with others
3. This led to state entrenchment. For example, Kansas secured a one-party Republican rule for a century; New Jersey has not had a minor party quality for the ballot for the last 100 years.
4. Thus, state laws infringe and violate the First Amendment's freedom of association of both the voters and minor parties.
5. Assert and explain how the Supreme Court got it wrong in Timmons v. Twin Cities Area New Party (1997) which the state courts take as precedent to now allow fusion voting.

1.3 How do anti-fusion laws impose a burden on associational rights?

This is how, by:

1. Barring minor parties from nominating their first-choice candidate.
   • This undermines the essence of the freedom of association as it forces the minor party to run their second-best candidate. This affects who joins, volunteers, donates, or runs with the minor party. Parties built membership by linking voters to particular candidate. Minor parties risk "spoiling" (by nominating second-best candidate) or undermining themselves (by endorsing their true best candidate but who is on another party's ballot).
2. Undermining coalition building by preventing minor parties from forming political alliances with a major political party around a candidate.
   • This undercuts their only path to political responsiveness (by alliance).
   • Coalition building would allow a candidate to take the policies of the minor party seriously and deliver on them.
3. Preventing voters who want to associate with a viable major-party candidate without associating with a party they despise.
   • For example, unaffiliated voters or voters who fear wasting their vote on a third candidate.
4. Artificially limit the minor party's appeal and suppress growth
   • Minor party cannot expand because anti-fusion laws mask their electoral strength. Voters avoid "wasting" or "spoiling" vote on a minor party candidate (who was forced to choose second-best candidate).
   • Support for minor party — recruitment, fundraising, volunteerism, bargaining power — is affected because anti-fusion laws don't allow separate party-line tally. Disaggregated tallies on a separate party line signal who a party’s voters are, where they live, and how many votes the minor party can reliably deliver. Without this information, it will be harder to establish evidence that a minor party contributed to the election. Even the elected candidate won't know, and thus, they will be harder to hold accountable to policy commitments promised.
5. Undermining a minor party's post election bargaining over policy.
   • anti-fusion laws obscure information and renders associations invisible. Without the disaggregated tallies discussed above, it is harder to build leverage, as endorsements without a ballot line generate no auditable measure of support. The number of votes that were cast based on the minor party's endorsement are folded into the major party’s support, masking their political strength.

To learn more about how El-Haj argues against the Supreme Court verdict in Timmons v. Twin Cities Area New Party (1997), I urge you to read the full paper.

1.4 Thoughts

El-Haj's arguments make a lot of sense to me. But, I am no law expert to understand how persuasive her case is for fusion law or have enough political acumen to understand how it will actually play out in real practice. El-Haj states in the paper that third-parties in Kansas (United Kansas), New Jersey (New Jersey Moderate Party), and Wisconsin (United Wisconsin) are appealing for fusion law to their respective state courts. I wonder how the appeal is going on and if it will spread to other states.

I need to keep expanding my understanding of how the political system functions here in the United States at both the state and federal level.

2. Who Controls Your Dentist?

This is a question that Matt Stoller — author of the book, "Goliath: The 100-Year War Between Monopoly Power and Democracy"— asks in his podcast by inviting Dr. Jill Tanzi, a dentist and founder of the Alliance of Independent Dentists: Who Controls Your Dentist?.

I tried watching the full video, but couldn't get into it. Fortunately, Matt also shared a transcript of the video: Transcript. By combining this transcript with Opus 4.5, I was able to plough ahead with the content.

The core problem is that the dental industry, which has traditionally been made up of independent dentist-owned practices, is being taken over by financial investors and large corporation (Surprise, Surprise!). This mirrors what already happened to medicine (which I need to investigate), and the concern is that it's bad for patients.

Back in the good old days, a dentist was both the healthcare provider AND the business owner. This gave an incentive for the dentist to keep the patient healthy so that the patient keeps coming and refer their friends. They'd generally own the practice for 20-30 years, build relationships, and eventually sell to another dentist when retiring.

But now, there are several players trying to extract money from this system:

1. Dental Service Organizations (DSOs);
2. Private Equity's Business Model; and
3. Dental Insurance Consolidation

2.1 DSOs

DSOs are companies (often backed by private equity) that buy up dental practices. Many states have "corporate practice of medicine/dentistry laws" that say only licensed dentists can own dental practices. This exists to prevent business people from making medical decisions. DSOs get around this by saying: "We don't own the practice, we just manage it".

What actually happen is that the dentist is reduced to being just a "straw dentist" — a licensed dentist on paper as the nominal director, but with no power. This is how:

• The dentist can't fire the management company;
• The dentist can't sell the practice independently; and
• The DSO controls pricing, treatment plans, staffing, and supplies.

There is also no transparency to the patient; a patient will never know if the dentist is independent or managed by a DSO.

This is all highly simplified; I urge you to read this article for the details: The DSO Down-Low.

2.2 Private Equity's Business Model

A private equity is a firm who buys companies, try to make them more "profitable" (often by cutting costs or raising prices), then sells them in 5-7 years for a profit. According to David Dayen, a recent study states that there were 161 private equity deals in dental healthcare in 2024 alone — 10% more than last year and more than any other healthcare sector.

The problem is that their timeline is 5-7 years, not 30 years. They are not building relationships with patients; they're building something to flip. This video by Wendy's Production goes into detail in how Private Equity firms flip, strip, and make a profit: How Private Equity Consumed America.

2.3 Dental Insurance Consolidation

Dental insurance works differently than medical insurance. For example:

• If you need a $200,000 surgery, medical insurance might cover most of it.
• A dental insurance will typically have a $1000-$2000 annual maximum. If you have a $5000 procedure, you are paying most of it yourself.

Dr. Jill actually calls the dental insurance "basically a coupon" or "discount card" — it is not really insurance in the traditional sense. She also talks about Delta Dental — the most dominant dental insurer in many states. She says that they've become so powerful that they can:

• Set arbitrary reimbursement rates (not based on actual market prices): If a filling costs $200 but insurance only reimburses $80, the dentist either eats the loss or charges the patient the difference.
• Keep dropping what they pay dentists
• Dictate which dentists you can see
• Buy dental practices directly (like "Cherry Tree Dental" in Wisconsin): This creates massive conflict of interest. The company deciding what treatment you need is the same company that has to pay for it.

2.4 Specific Problems Mentioned

Some specific problems mentioned in the podcast:

1. Padding bills: Adding small $50-100 fees for things like "liners" or antimicrobial rinses that may not be necessary
2. Over-treatment: some DSOs recommending extensive (and expensive) work on baby teeth that children will lose anyway—sometimes requiring sedation, which carries risks.
3. Under-treatment: When an insurer owns the practice, they might deny necessary treatment because they'd have to pay for it.
4. Inexperienced dentists: DSOs hire new graduates (cheaper) who lack mentorship and may not stay long, so you don't build a relationship.
5. Lack of transparency: DSOs often keep the original practice name, so you don't know it's been bought. There's no legal requirement to disclose ownership.

2.5 Strain on Dentists

Independent dentists are also squeezed from multiple directions:

2.6 Remedies

The podcast mentions some remedies:

1. Enforce existing corporate practice of dentistry laws: Many states have these laws but they're not enforced because of the "management" loophole
2. Give dental directors real power: If the nominal dentist-director could actually fire the management company, the loophole wouldn't work
3. Public service loan forgiveness for dentists: Incentivize dentists to work in underserved areas by forgiving student loans (similar to programs for doctors)
4. Government dental clinics: Provide affordable care while giving new dentists experience without working for DSOs

According to Dr. Jill, 80% of dentists are still independent (compared to medicine), which is good news. She says that the dental industry is seeing what happened to medicine and trying to organize before it's too late. The Alliance of Independent Dentists (dentistalliance.org) maintains a directory so patients can verify if their dentist is truly independent.

2.7 Thoughts

I had no idea about the existence of DSO; so this is good information. Matt also brought a good point in the podcast that separate insurances for medical and dental should not exist in the first place: it is like asking one small part of your body to be insured separately, which only happens to be a small discount/coupon. I know many people who prefer to fly to Turkey or India to get any serious dental operation done; the entire trip+cost is apparently cheaper than the cost in the United States. The baby teeth part dropped my jaw: that is insanely cruel. I hope that doesn't happen much. I wish private equity firms didn't exist; their entire business model is financializing without providing any tangible value to either employees, businesses, or patients: only to a tiny number of investors.