Check out this Vox article on the impact of Black Lives Matter (BLM) protests on police homicides, other homicides, and property crime within the communities where protests occurred. It cites a study by Travis Campbell, a Ph.D. candidate in economics at UMass-Amherst with the following major findings for the period 2014-2019:
1) Police homicides in census areas where BLM protests took place were 10% – 15% less than if those deaths had followed the trend where BLM protests did not take place, after controlling for confounding factors like the local unemployment rate. That’s about 300 fewer uses of lethal force by police, or one less for every 4,000 BLM protestors. So far, so good, one might guess.
2) Other homicides increased by roughly 10% using the same basis of comparison, or somewhere between 1,000 and 6,000. This estimate is less precise for a number of reasons, and it was not the main focus of Campbell’s research. Still, using a value near the mid-point, say 3,000, yields one extra murder for every 400 BLM protestors! The effect seems to taper off after about four years.
3) Reported property crimes decreased by 8.4% in areas that had BLM protests, but the share of those crimes solved declined by 5.5%. Campbell interprets the latter as an indication of reduced policing intensity. Reports of crime might decline if confidence in the police declines post protest, but reduced effort by the police is also consistent with less reported property crime, less police engagement, and more homicide.
“The explanation is consistent with what happened in Baltimore after the Freddie Gray protests and riots, namely arrests went down and murders went up.”
The research did not include data on the 2020 protests and riots following the death of George Floyd due to lags in reporting homicides and crime.
One of BLM’s primary objectives is to end “systemic racism” in policing, a problem that has no real empirical basis. Nevertheless, a reduction in deadly confrontations between police and blacks would seem to be a win (though the study doesn’t address the racial makeup of police homicides). But if that means less police engagement and a substantial increase in homicides in the community, the cost is obviously too high. Areas suffering from high homicide rates need more policing, not less. But yes, it must be good policing in partnership with citizens, and there are real reforms that could help.
BLM’s continued calls to “defund the police” are more about signaling lofty intent than about solving real problems. After all, that’s the perverse charm of the Marxism espoused by BLM, Antifa, and gentry leftists having class immunity to unintended (but predictable) consequences. You don’t really have to solve problems. You can just make them for others and take credit for trying!
The pandemic outlook remains mixed, primarily due to the slow rollout of the vaccines and the appearance of new strains of the virus. Nationwide, cases and COVID deaths rose through December. Now, however, there are several good reasons for optimism.
The fall wave of the coronavirus receded in many states beginning in November, but the wave started a bit later in the eastern states, in the southern tier of states, and in California. It appears to have crested in many of those states in January, even after a post-holiday bump in new diagnoses. As of today, Johns Hopkins reports only two states with increasing trends of new cases over the past two weeks: NH and VA, while CT and WY were flat. States shaded darker green have had larger declines in new cases.
A more detailed look at WY shows something like a blip in January after the large decline that began in November. Trends in new cases have clearly improved across the nation, though somewhat later than hoped.
While the fall wave has taken many lives, we can take some solace in the continuing decline in the case fatality rate. (This is not the same as the infection mortality rate (IFR), which has also declined. The IFR is much lower, but more difficult to measure). The CFR fell by more than half from its level in the late summer. In other words, without that decline, deaths today would be running twice as high.
Some of the CFR’s decline was surely due to higher testing levels. However, better treatments are reducing the length of hospital stays for many patients, as well as ICU admittance and deaths relative to cases. Monoclonal antibodies and convalescent plasma have been effective for many patients, and now Ivermectin is showing great promise as a treatment, with a 75% reduction in mortality according to the meta-analysis at the link.
Reported or “announced” deaths remain high, but those reports are not an accurate guide to the level or trend in actual deaths as they occur. The CDC’s provisional death reports give the count of deaths by date of death (DOD), shown below. The most recent three to four weeks are very incomplete, but it appears that actual deaths by DOD may have peaked as early as mid-December, as I speculated they might last month. Another noteworthy point: by the totals we have thus far, actual deaths peaked at about 17,000 a week, or just over 2,400 a day. This is substantially less than the “announced” deaths of 4,000 or more a day we keep hearing. The key distinction is that those announced deaths were actually spread out over many prior weeks.
A useful leading indicator of actual deaths has been the percentage of ER patients presenting COVID-like illness (CLI). The purple dots in the next CDC chart show a pronounced decline in CLI over the past three weeks. This series has been subject to revisions, which makes it much less trustworthy. A less striking decline in late November subsequently disappeared. At the time, however, it seemed to foretell a decline in actual deaths by mid-December. That might actually have been the case. We shall see, but if so, it’s possible that better therapeutics are causing the apparent CLI-deaths linkage to break down.
A more recent concern is the appearance of several new virus strains around the world, particularly in the UK and South Africa. The UK strain has reached other countries and is now said to have made appearances in the U.S. The bad news is that these strains seem to be more highly transmissible. In fact, there are some predictions that they’ll account for 30% of new cases by the beginning of March. The South African strain is said to be fairly resistant to antibodies from prior infections. Thus, there is a strong possibility that these cases will be additive, and they might or might not speedily replace the established strains. The good news is that the new strains do not appear to be more lethal. The vaccines are expected to be effective against the UK strain. It’s not yet clear whether new versions of the vaccines will be required against the South African strain by next fall.
Vaccinations have been underway now for just over a month. I had hoped that by now they’d start to make a dent in the death counts, and maybe they have, but the truth is the rollout has been frustratingly slow. The first two weeks were awful, but as of today, the number of doses administered was over 14 million, or almost 46% of the doses that have been delivered. Believe it or not, that’s an huge improvement!
About 4.3% of the population had received at least one dose as of today, according to the CDC. I have no doubt that heavier reliance on the private sector will speed the “jab rate”, but rollouts in many states have been a study in ineptitude. Even worse, now a month after vaccinations began, the most vulnerable segment of the population, the elderly, has received far less than half of the doses in most states. The following table is from Phil Kerpen. Not all states are reporting vaccinations by age group, which might indicate a failure to prioritize those at the greatest risk.
It might not be fair to draw strong conclusions, but it appears WV, FL, IN, AK, and MS are performing well relative to other states in getting doses to those most at risk.
Even with the recent increase in volume, the U.S. is running far behind the usual pace of annual flu vaccinations. Each fall, those average about 50 million doses administered per month, according to Alex Tabarrok. He quotes Youyang Gu, an AI forecaster with a pretty good track record thus far, on the prospects for herd immunity and an end to the pandemic. However, he uses the term “herd immunity” as the ending share of post-infected plus vaccinated individuals in the population, which is different than the herd immunity threshold at which new cases begin to decline. Nevertheless, in Tabarrok’s words:
“… the United States will have reached herd immunity by July, with about half of the immunity coming from vaccinations and half from infections. Long before we reach herd immunity, however, the infection and death rates will fall. Gu is projecting that by March infections will be half what they are now and by May about one-tenth the current rate. The drop will catch people by surprise just like the increase. We are not good at exponentials. The economy will boom in Q2 as infections decline.”
That sounds good, but Tabarrok also quotes a CDC projection of another 100,000 deaths by February. That’s on top of the provisional death count of 340,000 thus far, which runs 3-4 weeks behind. If we have six weeks of provisionals to go before February, with actual deaths at their peak of about 17,000 per week, we’ll get to 100,000 more actual deaths by then. For what it’s worth, I think that’s pessimistic. The favorable turns already seen in cases and actual deaths, which I believe are likely to persist, should hold fatalities below that level, and the vaccinations we’ve seen thus far will help somewhat.
Both the Pfizer and the Moderna COVID vaccines require two doses, with an effectiveness of about 95%. But a single dose may have an efficacy of about 80% that is likely to last over a number of weeks without a second dose. There are varying estimates of short-term efficacy, and but see here, here, and here. The chart above is for the Pfizer vaccine (red line) relative to a control group over days since the first dose, and the efficacy grows over time relative to the control before a presumed decay ever sets in.
Unfortunately, doses are in short supply, and getting doses administered has proven to be much more difficult than expected. “First Doses First” (FDF) is a name for a vaccination strategy focusing on delivering only first doses until a sufficient number of the highly vulnerable receive one. After that, second doses can be administered, perhaps within some maximum time internal such as 8 – 12 weeks. FDF doubles the number of individuals who can be vaccinated in the short-term with a given supply of vaccine. Today, Phil Kerpen posted this update on doses delivered and administered thus far:
Dosing has caught up a little, but it’s still lagging way behind deliveries.
As Alex Tabbarok points out, FDF is superior strategy because every two doses create an average of 1.6 immune individuals (2 x 0.8) instead of just 0.95 immune individuals. His example involves a population of 300 million, a required herd immunity level of two-thirds (higher than a herd immunity threshold), and an ability to administer 100 million doses per month. Under a FDF regime, you’ve reached Tabarrok’s “herd immunity” level in two months. (This is not to imply that vaccination is the only contributor to herd immunity… far from it!) Under the two-dose regime, you only get halfway there in that time. So FDF means fewer cases, fewer deaths, shorter suspensions of individual liberty, and a faster economic recovery.
An alternative that doubles the number of doses available is Moderna’s half-dose plan. Apparently, their tests indicate that half doses are just as effective as full doses, and they are said to be in discussions with the FDA and Operation Warp Speed to implement the half-dose plan. But the disadvantage of the half-dose plan relative to FDF is that the former does not help to overcome the slow speed with which doses are being administered.
Vaccine supplies are bound to increase dramatically in coming months, and the process of dosing will no doubt accelerate as well. However, for the next month or two, FDF is too sensible to ignore. While I am not a fan of all British COVID policies, their vaccination authorities have recommended an FDF approach as well as allowing different vaccines for first and second doses.
There are currently two vaccines in limited distribution across the U.S. from Pfizer and Moderna, but the number and variety of different vaccines will grow as we move through the winter. For now, the vaccine is in short supply, but that’s even more a matter of administering doses in a timely way as it is the quantity on hand. There are competing theories about how best to allocate the available doses, which is the subject of this post. I won’t debate the merits of refusing to take a vaccine except to say that I support anyone’s right to refuse it without coercion by public authorities. I also note that certain forms of discrimination on that basis are not necessarily unreasonable.
The vaccines in play all seem to be highly effective (> 90%, which is incredible by existing standards). There have been a few reports of side effects — certainly not in large numbers — but it remains to be seen whether the vaccines will have any long-term side effects. I’m optimistic, but I won’t dismiss the possibility.
Despite competing doctrines about how the available supplies of vaccine should be allocated, there is widespread acceptance that health care workers should go first. I have some reservations about this because, like Emma Woodhouse, I believe staff and residents at long-term care facilities should have at least equal priority. Yet they do not in the City of Chicago and probably in other areas. I have to wonder whether unionized health care workers there are the beneficiaries of political favoritism.
Beyond that question, we have the following competing priorities: 1) the vulnerable in care homes and other elderly individuals (75+, while younger individuals with co-morbidities come later); 2) “essential” workers of all ages (from police to grocery store clerks — decidedly arbitrary); and 3) basically the same as #2 with priority given to groups who have suffered historical inequities.
#1 is clearly the way to save the most lives, at least in the short-run. Over 40% of the deaths in the U.S. have been in elder-care settings, and COVID infection fatality ratesmount exponentially with age:
To derive the implications of #1 and #2, it’s more convenient to look at the share of deaths within each age cohort, since it incorporates the differences in infection rates and fatality rates across age groups (the number of “other” deaths is much larger than COVID deaths, of course, despite similar death shares):
The 75+ age group has accounted for about 58% of all COVID deaths in the U.S., and ages 25 – 64 accounted for about 20% (an approximate age range for essential workers). This implies that nearly three times as many lives can be saved by prioritizing the elderly, at least if deaths among so-called essential workers mimic deaths in the 25 – 64 age cohorts. However, the gap would be smaller and perhaps reversed in terms of life-years saved.
Furthermore, this is a short-run calculation. Over a longer time frame, if essential workers are responsible for more transmission across all ages than the elderly, then it might throw the advantage to prioritizing essential workers over the elderly, but it would take a number of transmission cycles for the differential to play out. Yes, essential workers are more likely to be “super-spreaders” than work-at-home, corporate employees, or even the unemployed, but identifying true super-spreaders would require considerable luck. Moreover, care homes generally house a substantial number of elderly individuals and staff in a confined environment, where spread is likely to be rampant. So the transmission argument for #2 over #1 is questionable.
The over-riding problem is that of available supply. Suppose enough vaccine is available for all elderly individuals within a particular time frame. That’s about 6.6% of the total U.S. population. The same supply would cover only about 13% of the younger age group identified above. Essential workers are a subset of that group, but the same supply would fall far short of vaccinating all of them; lives saved under #2 would then fall far short of the lives saved under #1. Quantities of the vaccine are likely to increase over the course of a few months, but limited supplies at the outset force us to focus the allocation decision on the short-term, making #1 the clear winner.
Now let’s talk about #3, minority populations, historical inequities, and the logic of allocating vaccine on that basis. Minority populations have suffered disproportionately from COVID, so this is really a matter of objective risk, not historical inequities… unless the idea is to treat vaccine allocations as a form of reparation. Don’t laugh — that might not be far from the intent, and it won’t count as a credit toward the next demand for “justice”.
For the sake of argument, let’s assume that minorities have 3x the fatality rate of whites from COVID (a little high). Roughly 40% of the U.S. population is non-white or Hispanic. That’s more than six times the size of the full 75+ population. If all of the available doses were delivered to essential workers in that group, it would cover less than half of them and save perhaps 30% of minority COVID deaths over a few months. In contrast, minorities might account for up to two-thirds of the deaths among the elderly. Therefore, vaccinating all of the elderly would save 58% of elderly COVID deaths and about 39% of minority deaths overall!
The COVID mortality risk to the average white individual in the elderly population is far greater than that faced by the average minority individual in the working age population. Therefore, no part of #3 is sensible from a purely mathematical perspective. Race/ethnicity overlaps significantly with various co-morbiditiesand the number of co-morbidities with which individuals are afflicted. Further analysis might reveal whether there is more to be gained by prioritizing by co-morbidities rather than race/ethnicity.
Megan McArdle has an interesting column on the CDC’s vaccination guidelines issued in November, which emphasized equity, like #3 above. But the CDC walked back that decision in December. The initial November decision was merely the latest of the the agency’s fumbles on COVID policy. In her column, McArdle notes that the public has understood that the priority was to save lives since the very start of the pandemic. Ideally, if objective measures show that identifiable characteristics are associated with greater vulnerability, then those should be considered in prioritizing individuals who desire vaccinations. This includes age, co-morbidities, race/ethnicity, and elements of occupational risk. But lesser associations with risk should not take precedence over greater associations with risk unless an advantage can be demonstrated in terms of lives saved, historical inequities or otherwise.
The priorities for the early rounds of vaccinationsmay differ by state or jurisdiction, but they are all heavily influenced by the CDC’s guidelines. Some states pay lip service to equity considerations (if they simply said race/ethnicity, they’d be forced to operationalize it), while others might actually prioritize doses by race/ethnicity to some degree. Once the initial phase of vaccinations is complete, there are likely to be more granular prioritizations based on different co-morbidities, for example, as well as race/ethnicity. Thankfully, the most severe risk gradient, advanced age, will have been addressed by then.
One last point: the Pfizer and Moderna vaccines both require two doses. Alex Tabarrok points out that first doses appear to be highly effective on their own. In his opinion, while supplies are short, the second dose should be delayed until all groups at substantially elevated risk can be vaccinated…. doubling the supply of initial doses! The idea has merit, but it is unlikely to receive much consideration in the U.S. except to the extent that supply chain problems make it unavoidable, and they might.
Most of the news about COVID vaccine development is positive, but there are still huge doubts about 1) whether an effective vaccine(s) will ever be available; 2) when it will be available; 3) in what quantities (supply chains for vaccines present issues that most lay persons would never imagine) ; 4) the best approaches to allocation across young/healthy vs. old/vulnerable; 5) how long it will provide protection (the news is good on lasting immunity as well); and 6) whether people will actually take it. Given all these uncertainties, it’s worth considering an approach to stanching the coronavirus that won’t require a vaccine while still allowing a return to normalcy: cheap, rapid tests available to consumers on a daily basis in their homes or in businesses.
The full benefits of cheap, rapid tests can take people a while to wrap their heads around. In fact, there are skeptics who’s views on any and all testing are colored by suspicions that increased testing is some sort of conspiracy to spread fear and keep the economy hobbled. It’s true that increased testing drove much of the increase in COVID cases this summer, which caused the mainstream media to delight in spinning alarmist narratives. Fair enough, but that misses the point, which I’ll try to elucidate below. I credit a John Cochrane post for bringing this to my attention.
A successful vaccine breaks the so-called “transmission chain”, but so does frequent testing to identify infectious individuals on an ongoing basis so they can self-quarantine. As Alex Tabarrok has emphasized, we should worry about identifying infectious individuals, as opposed to infected individuals. They are not the same. Cheap, rapid, and easy-to-administer tests have already proven to be fairly accurate during the infectious stage. The idea is for individuals to self-test every day and stay home if they are positive. Or, employers can test workers every day and send them home if they are positive. Frequent testing also makes it simpler to trace the source of an infection and may reduce the importance of tracing.
To those who say this represents an affront to personal liberty, and I’m very touchy on that subject myself, recall that even now people are being screened in their workplaces using thermometers, questionnaires, or on the basis of any frogginess perceived by supervisors and co-workers. Those “tests” are far less accurate in identifying COVID-19 contagiousness than the kinds of cheap tests at issue here, and they are certainly no less intrusive. Then there are the many businesses facing restrictions on their operations: how “accurate” is it to keep everyone at home by locking down places of business? How intrusive is that? Those restrictions are indefensible, and especially with the advent and diffusion of cheap, rapid tests.
Of course, people might cheat and not report positives. Tests could be administered at workplaces to avoid that possibility, or at points of admission to businesses and facilities, but a few minutes of delay would be necessary. I would not support a centralized database of daily test results. If nothing else, relying on the good faith of individuals in reporting their results would be a giant leap forward in breaking the transmission chain now, rather than counting on the possibility of a successful virus in the indefinite future. And we might then avoid the whole pro-vax/anti-vax imbroglio that already foments, which raises major questions bearing on individual liberty.
Then there is the question of positive tests within multi-person households. Should the entire family or household self-quarantine? I say no, not if the others are negative, but then the others should test twice before going out, which dramatically reduces the probability of a false negative, and they should probably test more frequently, perhaps several times a day.
There are other important details to address: Who will pay for the tests? Will workers be paid to stay home if they test positive? How long will they be required to stay home? How will repeated tests be treated? I don’t want to get into detail on all of these points, but cheap, fast tests can help overcome many of these difficulties, and I believe many of the details can and should be worked out privately.
Unfortunately, the FDA has approved only two rapid tests, and they are not very rapid and not cheap enough. Only one had been approved up until last weekend because the FDA found the accuracy to be lacking … compared to PCR tests! But the FDA finally issued an Emergency Use Authorization for a saliva-based test (SalivaDirect) developed at Yale, partly funded by the NBA and the Players Association. The test still requires processing at a lab, so it’s really not convenient enough and not fast enough. Here is Zach Lowe on the cost:
“The cost per sample could be as low as about $4, though the cost to consumers will likely be higher than that — perhaps around $15 or $20 in some cases, according to expert sources.”
The benefits of tests that are rough, ready, and cheap will be huge. Such tests will also enable retesting, which helps to overcome the dilemmas of false positives and negatives. False negatives might be of greater concern to the FDA, but again, false negatives are less likely during the contagious stage of an infection, and the tests will be accurate enough that transmission risk will be drastically reduced.
The FDA needs to move beyond its stodgy insistence on achieving laboratory levels of accuracy. It’s unlikely that a single test source will be adequate to stanch the transmission chain, so the agency should rush to approve as many cheap, rapid tests as possible, with as many advisories and patient warnings regarding test results and follow-up instructions as it deems necessary. Remember, these tests are much better than thermometers!
When the federal government intervenes to stimulate the economy, it generally means a big spending program or tax reduction and an increase in the federal deficit. This year we’ve witnessed the largest single-year fiscal policy effort in U.S. history, an effort to aid individuals whose jobs were lost and to stimulate the suddenly depressed economy. The coronavirus lockdowns in most states brought federal legislation enhancing unemployment compensation, one-time support payments to most adults, emergency business “loans” that are largely to be forgiven, and many other elements. The cost of these packages is expected to be about $2.4 trillion. And there will be more legislation this summer intended to stimulate hiring, including a probable infrastructure bill. President Trump still supports what the Administration calls a “hiring subsidy”, which is in fact a payroll tax holiday. As described, it would not explicitly target new hires, but would grant the holiday to all workers regardless of employment status. All these programs will ultimately be quite costly to taxpayers.
But what if there is a way to stimulate hiring without adding a dime to the federal deficit? (And I’m not talking about monetary policy, which inflicts costs of its own.) One inventive idea would create hiring incentives on a contingent basis, but with the beautiful feature that the program itself eliminates the contingency. Alex Tabarrok recently devoted a post to this idea, for which credit goes to Robertas Zubrickas. Here’s how it works, in Zubrickas’ words:
“… we propose a policy that offers firms wage subsidies for new hires payable only if the total number of new hires made in the economy does not exceed a prespecified threshold. An example would be a promise to cover all new labor costs contingent on that less than, say, 100,000 new jobs are created in total. From a firm’s perspective two outcomes can occur from this policy. One outcome is when the number of new jobs is less than the threshold, in which case the firm has its additional labor costs covered while keeping all the additional revenue. The second outcome is when the threshold is met and no subsidies are paid.”
If enough firms hire in order to reap the subsidies, then aggregate hiring exceeds the threshold and no wage subsidies are paid, but the additional employment boosts demand sufficiently to justify the hiring. Fiscal stimulus without any budget impact! Incredible, right?
There are problems, of course. The simple program described would carry big risks for many businesses. Just because aggregate hiring exceeds the threshold doesn’t mean demand for your firm’s offerings will increase. To take an obvious example, can a rural employer count on an increase in demand? The program could be designed to hinge on different regional hiring thresholds, or different industry hiring thresholds, but that quickly gets complicated.
Moreover, firms will have an incentive to free ride on other businesses who hire up-front. The timing of cash flows would also be critical. Are the subsidies to be paid upon proof of hiring, with repayment later if the aggregate hiring threshold is reached? If not, I suspect many employers would rather scramble to hire workers upon the realization of any increase in demand as might occur, but unwilling to risk hiring given the possibility that the subsidy will be lost and that their own sales will remain weak. That might be especially true for small firms. And if the subsidy is paid up front, good luck getting it back on behalf of taxpayers! So there are substantial fiscal risks, whether or not the aggregate hiring threshold is met. But perhaps those risks could be minimized with some limited tests of such a program.
Finally, this sort of plan would be much less likely to succeed with repetition. Then again, a one-time contingent hiring subsidy might be well suited to the so-called “low-employment equilibrium” that many believe we face today. The contingent subsidy is certainly a market distortion, but one hopes it would be a temporary distortion.
Zubrickas’ contingent wage subsidies are fascinating. The pandemic and the social distancing imperative have increased the cost of doing business, and the infection risk perceived by consumers is a potential drag on demand. Wage subsidies would reduce hiring costs, but if enough firms hire, those costs would be restored while demand would be stronger. But additional sales might not materialize for your firm! Designing a program of this type so as to minimize the risks faced by individual firms and taxpayers is tough, but it is an idea worth exploring in more detail. In concept, it’s certainly preferable to fiscal programs that carry huge costs and usually end in permanently larger government.
Ask anyone on the street about prescription drug prices, or ask anyone in the press, and you’ll probably hear they are out of control. That contention is false. The conventional wisdom is typified by this exaggerated BS about insulin pricing … actually, you can find a vial of the kind I used for many years for about $25 without much difficulty.
Individual experience differs, of course. Yes, there are new drugs on the market that are exorbitant; there are older drugs still under patent that are pricey too. Those represent a fairly small part of the total market, however, and one on which policymakers should tread lightly if they hope to foster the development of new, life-saving drugs. Newer insulin varieties are not in that class, and those varieties don’t always incorporate meaningful improvements for patients.
Getting Old Is Hell
In fact, prescription drug prices have been declining for a number of years. The real problem is we’re always getting older! In a report from the Progressive Policy Institute, Michael Mandel describes what he calls the prescription drug escalator. Alex Tabarrok has a good summary of the article. The chart at the top of this post, from Mandel, shows that the number of drugs prescribed rises steadily with one’s age. The total bill rises along with age, which may create the perception that you’re paying higher prices. Unsurprisingly, more of each health-care dollar spent out-of-pocket (OOP) goes to prescribed medications as you age, and more goes to prescription drugs as health declines. As Mandell says, the increases experienced by individuals are a matter of utilization as opposed to pricing..
“… direct-out-of-pocket CPI for generic prescription drugs decline[d] by about 50% between 2007 and 2016 …”
Average OOP prescription costs peaked in 2006, according to Mandel’s data. Tabarrok quotes Mandell:
“May 2019 research report from the Agency for Healthcare Research and Quality reported that average out-of-pocket spending for prescribed medications, among persons who obtained at least one prescribed medication, declined from $327 in 2009 to $238 by 2016, a decrease of 27 percent. Data from the Bureau of Labor Statistics Consumer Expenditure Survey shows that average household spending on prescription drugs fell by 11% between 2013 and 2018.
Moreover, OECD data shows that average out-of-pocket spending on prescribed medicines in the United States ($143 per capita in 2017) is actually lower than countries such as Canada ($144), Korea ($156), Norway ($178), and Switzerland ($215).”
The declines in OOP drug costs came despite a shift in health-care payment responsibilities from insurers to consumers in recent years — OOP costs would have declined much more had the shift not occurred, according to Mandel. As he says, consumers now have more “skin in the game”, and apparently they act on it.
Another basis of the misperception about escalating drug prices has to do with the way they are reported. Mandel says:
“List prices are the published prices that manufacturers charge to wholesalers. Net prices reflect the revenues that drug manufacturers receive, net of rebates and discounts to prescription benefit managers, insurance companies, and hospitals.
Studies of list prices invariably show very strong growth. For example the IQVIA Institute for Human Data Science found that the list price of the average brand rose from $364.92 to $657.08 since 2014, an 80% increase. Similarly, a widely cited recent study based on list prices found that from 2008–16, the costs of oral and injectable brand-name drugs increased annually by 9.2 percent and 15.1 percent, respectively. … By contrast, net prices and net pharma revenue have been growing much more slowly, once rebates and discounts are accounted for.”
The Pricey Segment
There area variety of circumstances that bear on the pricing of individual drugs. Clearly, non-generic drugs are subject to more upward price pressure and give rise to anecdotes that feed misperceptions about the overall trajectory of drug prices. These are either new drugs or older ones sold under extended patents, which are sometimes granted for even minor changes in a drug’s chemical makeup.
Some new drugs are life-saving breakthroughs targeting rare diseases. The unfortunate truth is that drug development is a very costly enterprise, often stretching well over a decade in the U.S. under the FDA’s approval process. Moreover, U.S. consumers actually subsidize the cost of drugs for European consumers, where drugs are typically subject to price ceilings or are directly negotiated by government. By the time drugs go to market, development is treated as a fixed cost; even the low prices in Europe cover the marginal cost of production, so pharmaceutical manufacturers don’t mind selling there as long as their development overhead is paid by someone. That’s the rub.
Drug development costs are heavily influenced by public policy, often to the detriment of consumers. The FDA’s drug approval process is in dire need of reform, and patent extensions should be severely curtailed. As an advocate of free trade, I also favor a lifting of restrictions on imports of drugs to the U.S.
Conclusion
You’re likely to see more physicians as you age, they’re likely to prescribe more drugs, and you’re likely to pay more for prescriptions OOP. That’s the escalator in action. You can minimize the slope of your personal prescription escalator by taking good care of yourself and using generics when possible, but the slope is often beyond a person’s control. Nevertheless, over the past 13 years in the U.S., most of those experiencing higher OOP costs have this escalator, i.e., aging, to thank… it’s drug utilization, not pricing.
A relatively small but important share of the market has experienced price escalation. Newer, highly specialized drugs can carry high price tags. Patents give drug manufacturers considerably more pricing power, and drug companies have sought to maintain “evergreen” patents by manipulating their formulations. U.S. import quotas and restrictive pricing abroad have left consumers in the U.S. holding the bag for a large share of drug development costs. These shortcomings can be addressed via streamlined drug approval, patent reform, and lifting import restrictions.
A critical policy prescription is to liberate market forces and foster competition in the pharmaceuticals industry. Price controls in the U.S. would eliminate all incentives for new breakthroughs, leading progress in many areas of treatment to a stand-still. Price controls merely substitute the arbitrary decisions of politicians and bureaucrats for the market’s ability to balance dynamic consumer needs, medical expertise, and the costs faced by sellers.
Lately I’ve heard people complain bitterly that their federal tax refunds will be smaller this year. It’s as if they expected the 2017 tax package to lead to a larger refund on taxes paid in 2018, rather than a lower tax liability. Yes, those are two different things. About 80% of U.S. taxpayers are expected to see a net reduction in their federal taxes for 2018, but they might or might not receive refunds. Was your withholding reduced by the new tax law? Then you might receive a smaller refund even if your taxes are lower. Likewise, if you reduced your withholding too much, you will receive a smaller refund. Did your income rise? Then maybe you’ll pay more taxes and see a smaller refund.
The withholding tables were adjusted by the IRS in early 2018 based on the changes dictated by the tax package. Lower withholding was applied to many taxpayers, but it is often possible to manage one’s withholding rate within certain limits. How many of those pining for a refund took action to preserve a higher level of withholding? Let’s hope it was zero, for their sake.
Don’t get me wrong: if you’re not sure whether you’ll owe taxes when you file, it’s always nice to hear that a refund is coming. Moreover, the withholding allowance calculation is a very imprecise guide to one’s tax liability. Clearly the tax package did not benefit every taxpayer, especially high earners and small business people. Those in high-tax states lost a chunk of their state and local tax deduction. And another thing was somewhat irritating: continuing high compliance costs. Even under this so-called tax simplification, it remains necessary for many taxpayers to collect information related to potential deductions. After all, how else would you know whether it makes more sense to itemize rather than take the larger standard deductions now available? Small business people have some other compelling reasons to complain about this “simplification”.
Jazz Shaw at Hot Air observed that thisWashington Post article about reduced tax refunds was crafted as if to inflame resentment among taxpayers:
“This is certainly a clever bit of ‘coverage’ of a story based primarily on people bitching on Twitter. Notice how the WaPo manages to promote a hashtag denigrating the tax cuts in the second paragraph. [#GOPTaxScam] The premise here is clearly that the tax cuts reduced some people’s refunds, only Republicans voted for the tax cuts, therefore the tax cuts must be bad and so are the Republicans.”
I don’t have the link now, but yesterday Alex Tabarrok had this sarcastic reaction to the WaPo article:
“Voters irate because the government didn’t force them to give it an interest-free loan…”
Perhaps no explanation is required, but the government has free use of your funds whenever too much is withheld from your regular paycheck — it pays you no interest on the “loan” as part of your ultimate refund. If getting that refund is the only way you can save, you’re doing it wrong.
The musical comedy Urinetown opened in 2001 and ran for 965 performances, not a bad run by Broadway standards. The show, which is still performed in theaters around the country, is a melodramatic farce: a town tries to deal with a water shortage by mandating that all townspeople use pay toilets controlled by a malevolent private utility. Despite the play’s premise, pay toilets are a solution to the very real problem of finding decent facilities, or any facility, in which to relieve oneself in public places. Anyone who has ever strolled the streets of a city has encountered this problem from time-to-time. But in the U.S., where local budgets are typically strapped, the choice is often between scarce and decrepit free toilets or no toilets at all. Otherwise, those seeking relief must rely on the kindness business owners or pass laws allowing non-patrons to commandeer businesses’ bathrooms at will. Toilets with user fees, however, are an alternative that should get more emphasis.
In part, the theme of Urinetown reflects a longstanding notion among anti-capitalists that pay toilets are a disgustingly unfair solution to these urgent needs. One can imagine the logic: everyone has a need and a right to make waste, so we should all have access to sparkling public toilets for free! There is also the presumed misogyny of charging at stalls but not urinals (which are cheaper to maintain, after all), but overcoming that problem should not present a great technical hurdle. And surely pay toilets could be made to accept EBT cards, or locally-issued pee-for-free cards for the homeless.
Yes, we all make waste. However, most of us are so modest and fastidious that we quite literally “internalize the externality” we’d otherwise impose on others were we to seek relief in the street or behind trees in the park. We hold it and sometimes incur high costs in search of a restroom. Those are costs many of us would willingly pay to avoid.
As Alex Tabarrok says in “Legalize Pay Toilets“, outrage over pay toilets, very much like the kind expressed in Urinetown, is what led to outright bans on pay toilets in America during the 1970s (also see Sophie House’s discussion of the need for pay toilets at Citylab). According to Tabarrok, “In 1970 there were some 50,000 pay toilets in America and by 1980 there were almost none.” Many travelers know, however, that pay toilets are fairly commonplace in Europe.
In the wake of pay-toilet bans in America, and without the flow of revenue, those one-time pay toilets were not well-maintained nor replaced. In that sense, hostility to the concept of pay toilets is responsible for the paucity and abysmal condition of most public restrooms today. Public restrooms are often plagued by a tragedy of the commons. And when you do see a “free” public restroom in relatively good condition (in an airport, on a turnpike, or elsewhere), it is usually because its costs are cross-subsidized by payments for other goods and services offered in those facilities. It’s not as if you don’t pay for the bathrooms.
There is no question of a willingness to pay, but legal obstacles to pay toilets remain. Pay toilets are still very uncommon. New York City actually decriminalized public urination a few years ago, an odd way to deal with the shortage of restrooms. Some cities, such as Philadelphia, have initiated efforts to bring back pay toilets, but they have made little headway. Just last year, the toilet paper producer Charmin ran a successful publicity campaign in New York City by testing a mobile toilet-sharing service (à la Uber ride-sharing) called Charmin Van-GO. The company described the test as a big success in terms of publicity, but apparently the service has not been offered on a continuing basis.
The economic problem posed by full bladders and bowels on the public square can be solved with relative efficiency using the price mechanism: pay toilets. The flow of revenue can defray the costs of restrooms and their maintenance, easing the strain on public budgets and covering the cost of keeping them clean. Pay toilets can be provided publicly or built and operated by private providers. Pricing the use of toilets, whether offered publicly or privately, helps focus resources at the point of need. Free public toilets, in contrast, are scarce and typically unsanitary. Funding public restrooms through taxation, rather than user fees, involves a loss of efficiency because taxpayers are often distinct from actual users. Forcing purveyors of food and drink (or anything of value) to offer bathroom access to “free riders” creates another obvious source of inefficiency. Allowing the use of EBT cards at pay toilets, while overcoming certain objections, would also involve inefficiencies, but at least they’d be limited to subsidies for a small proportion of the bathroom-going public. Given the alternatives under the status quo, our cities would be far more pleasant if they were flush with pay toilets.
“Incels” have received plenty of bad publicity since the horrifying van attack in Toronto two weeks ago. It was preceded in 2014 by a killing rampage in California perpetrated by an individual with a similar profile. In case you haven’t heard, an incel is an involuntary celibate, either male or female, though male incels have garnered nearly all of the recent attention. Whatever their other characteristics, incels share a loneliness and an unmet desire for intimacy with other human beings.
Lux Alptraum shares her views about the differences between male and female incels. She blames “angry, straight men” and “toxic masculinity” for both the violence that’s recently come to be associated with incels and the relative inattention paid to the plight of female incels. I value her perspective on the issue of female incels. There are obviously extreme misogynists among males in the incel “community”. Some are so enraged by their plight that they engage in on-line bullying, and a plainly deranged segment of incels, including the perpetrators of the crimes mentioned above, have advocated violent retribution against those they deem responsible for their low sexual status. That means just about anyone who can find a partner.
Alptraum paints male incels with a very broad brush, however. Similarly, various leftist writers have categorized incels as predominantly “right wing” and even racist, but involuntary celibacy and misogyny do not lie conveniently along a two-dimensional political spectrum. Incels are present in many groups, crossing racial, religious, and political lines. There are incels among the transgendered and undoubtedly in the gay community. Gay individuals can exist in relative isolation in towns across America. Physical disabilities may condemn individuals to involuntary celibacy. And not all incels are “ugly”; instead, they may suffer from severe social awkwardness. But there are bound to be incels who live quiet lives, unhappy, but adjusted to their circumstances, more or less.
The recent focus on incels has prompted some interesting questions. Ross Douthat’s opinion piece in The New York Times asks whether anyone has a “right to sex”, as some incels have asserted. Robin Hanson discusses the idea of a “redistribution of sex“, noting in a follow-up post that governments throughout history have influenced the distribution of sex through policies enforcing monogamy, for example, or banning prostitution. Voluntary agreements to exchange sex for remuneration are one way to alter the distribution. In fact, to demonstrate the lengths to which a government could go to redistribute sex and intervene against “sex inequality”, Hanson mentions policies of cash redistribution, funded by taxpayers, to compensate incels for the services of prostitutes. There are examples of such benefits for the disabled. Here is Alex Tabarrok on that subject:
Subsidies and charity aside, it’s easy to understand why prohibition of sexual services for hire would be seen as an injustice by those unable to find partners willing to grant sexual benefits. From a libertarian perspective, trade in sex should be regarded as a natural right, like the freedom to engage in any other mutually beneficial transaction, so long as it does no harm to third parties. One’s body is one’s own property, and it should not be for government — or others — to decide how it will be used.
Laws against prostitution do great harm to society and to the individuals involved in the sex business. Forget about ending prostitution. That will never happen. According to Abigail Hall, there are about 1 million prostitutes working in the U.S. They almost all work underground, with the exception of those operating in legal brothels in Nevada. Prohibition keeps the price up, but the workers capture a low share of those returns. Their bosses are harsh masters relative to those in legal businesses. These workers cannot report crimes against them, so they are often subject to the worst kinds of abuse. Illegality usually means they don’t have access to good health care, which places customers at greater risk. Legalizing (or decriminalizing) prostitution would reduce or eliminate these problems. From Hall:
“By legalizing the sex trade, we would allow those involved in the sex trade to come out from the shadows, use legitimate business practices and legal channels, and decrease the likelihood that women will be trafficked by violent groups of criminals. … As prostitution becomes a legitimate profession, it allows for prostitutes to be more open with their doctors about their sexual history and seek treatment for STIs and other problems.”
Many object that prostitution exploits women, legal or not, and that it exploits low-income women disproportionately. But there will be voluntary sellers as long as there is a market, again, legal or not. And there will be a market. As for a disparate impact on the poor, Hall says:
“The fact that those who select prostitution as a profession may be poor is inconsequential…. It may be true that some women who work as prostitutes would strongly prefer another profession. Even if this is the case, women who voluntarily choose prostitution as a means of income should be allowed to practice their profession in the safest environment possible.”
The ongoing development of “sex robots” offers an avenue through which incels might enjoy activity that approximates sex with a human being. These robots are becoming increasingly realistic, and their costs are likely to decline dramatically in coming years. For incels with a congenital inability to interact with other human beings, this option might be far preferable to hiring the services of a prostitute. And the introduction of both male and female sex robots into senior care facilities might reduce the likelihood that sexually aggressive residents will abuse others. It happens.
Free markets are amazing in their ability to maximize the well being of both consumers and producers of a good or service. Trades are mutually beneficial and therefore are voluntary, and price signals redirect resources to their most valued uses. The prohibition on prostitution, however, has made it a very dangerous business for practitioners and customers alike. Prohibition has led to dominance by organized crime interests and local strong-men and -women. It has also thickened the intersection of prostitution with other prohibited activities, such as the drug trade. This creates a toxic criminal environment within which women are trapped and abused. Legalizing prostitution would liberate these individuals and create safer conditions for them and their customers. Private solutions would still be available to those who wish to keep prostitution out of their buildings or neighborhoods. And legalization is one way that sex could be made safely and voluntarily accessible to incels. Perhaps, one day soon, the availability of sex robots will help incels satisfy their desires as well. Some incels will still harbor strong resentment toward those for whom sex is not out of reach. Nevertheless, it is reasonable to ask whether such a “voluntary redistribution of sex” would not produce unambiguous social benefits. To deny these benefits to groups like the disabled, or really to anyone with a physical or emotional inability to find a willing partner, and to insist that sex workers be exposed to danger and abuse, is not just priggish, but cruel.
In advanced civilizations the period loosely called Alexandrian is usually associated with flexible morals, perfunctory religion, populist standards and cosmopolitan tastes, feminism, exotic cults, and the rapid turnover of high and low fads---in short, a falling away (which is all that decadence means) from the strictness of traditional rules, embodied in character and inforced from within. -- Jacques Barzun
