Democrats are already looking beyond ObamaCare’s slow-motion failure, and Colorado is showing where many want to go next: Premiums across the state are set to rise 20.4% on average next year, and some have concluded that the solution is more central planning and taxation. Voters will decide on Nov. 8 whether to try the single-payer scheme that blew up in Vermont.

Amendment 69 would alter the state’s constitution to create a single-payer health system known as ColoradoCare. The idea is to replace premiums with tax dollars, and coverage for residents will allegedly include prescription drugs, hospitalization and more. Paying for this entitlement requires a cool $25 billion tax increase, which is about equal to the state’s $27 billion budget. Colorado would introduce a 10% payroll tax and also hit investment income, and that’s for starters.

So far the ballot initiative is not popular, and it is also opposed by the state’s Democratic governor.  Still, it would write ColoradoCare into the state’s constitution, and if you run referenda enough times, etc.  The broader point is that single-payer plans, whatever their virtues and flaws in toto, cannot work at the state level in the United States.  The single state is not big enough to bargain down health care prices very much, and furthermore the state government has to run a balanced budget and, because of competition with other states, has only highly imperfect control over its own feasible level of taxation and expenditure.  A single state cannot simply decide to “go Denmark,” for instance.

Here are further details on ColoradoCare, eventually the link will become noisy.  Here is a Denver Post Op-Ed against ColoradoCare, again a noisy link.

Hat tip goes to Christopher Balding.

Narrow networks in Obamacare

by on October 18, 2016 at 1:33 pm in Economics, Law, Medicine | Permalink

That’s why the results of a recent study of new plans offered in California are especially troubling. Simon Haeder, a West Virginia University political scientist, and colleagues at the University of Wisconsin-Madison and the University of California, Irvine, found that access to primary care physicians was relatively poor for a sample of plans offered through California’s Affordable Care Act Marketplace in 2015. Most Obamacare marketplace plans in California, as well as in other states, are narrow network plans.

Using a “secret shopper” approach, the study found that only about 30 percent of attempts for appointments with specific primary care doctors were successful. In this approach, an individual pretending to be a patient seeking an appointment called the offices of over 700 primary care doctors listed in marketplace plan directories.

In about 15 percent of cases, the doctor did not accept the caller’s plan, despite being listed in its directory. In nearly 20 percent of cases, the directory included the wrong phone number or the number was busy in two calls on consecutive days. Ten percent of doctors called were not accepting new patients. And about 30 percent of doctors called were not primary care physicians, despite being listed as such in the directory.

When callers were able to make an appointment, the average waiting time for a physical exam was about three weeks. In cases for which the caller pretended to have acute symptoms, the average time until an appointment was about one and a half weeks.

That is from Austin Frakt (NYT).  It seems to be an example of the kind of rationing many of us predicted for Obamacare, although I would like to see the comparable numbers for the pre-ACA years.  The piece has other points of interest, mostly about cost savings, which seem to be real.

A large share of American men between the ages of 25 and 54 who aren’t in the labor force may suffer from serious health conditions that are “a barrier to work” and suffer physical pain, sadness, and stress in their daily lives, according to research being presented next week by Princeton University labor economist Alan Krueger.

“Nearly half of prime age NLF [not-in-the-labor-force] men take pain medication on a daily basis, and in two-thirds of cases, they take prescription pain medication,” according to Krueger’s paper, Where Have All the Workers Gone?

Here is more from Peter Coy.  Here is the paper.

The very beginning is a little slow, but I thought Ezra was one of the very best guests.  The topics include the nature and future of media, including virtual reality, the nature of leadership (including Ezra’s own), how running a project shapes your political views, a wee bit on health care, what he thinks are the Obama and Clinton models of the world, Robert Putnam’s research on the costs of diversity, the proper role of shame in society, animal welfare, and of course Ezra’s underrated and overrated, with takes on Bob Dylan, The Matrix, William F. Buckley, Joe Biden, and more.  There is no video but here is the podcast and transcript.  Here is one excerpt:

COWEN: …Now Putman, let me ask you about Putnam, and how Putnam relates to Donald Trump. As you know, Robert Putnam at Harvard, he has some work showing that when ethnic diversity goes up that there’s less trust, less cooperation, less social capital.

If you think of yourself in the role of an editor, so you have an American society, diversity has gone up, and a lot of people have reacted to this I would say rather badly — and I think you would agree with me they’ve reacted rather badly — but there’s still a way in which the issue could be framed that while diversity is actually a problem, we can’t handle diversity.

Putnam almost says as such, and do you think there’s currently a language in the media where you have readers who are themselves diverse, where it’s possible not to just be blaming the bigots, but to actually present the positive view, “Look, people are imperfect. A society can only handle so much diversity, and we need to learn this.” What’s your take on that?

KLEIN: I strongly agree. We do not have a language for demographic anxiety that is not a language that is about racism. And we need one. I really believe this, and I believe it’s been a problem, particularly this year. It is clear, the evidence is clear. Donald Trump is not about “economic anxiety.”

COWEN: A bit, but not mainly, I agree.

KLEIN: That said, I think that the way it’s presented is a choice between economic anxiety and racism. And one I don’t think that’s quite right, and two I don’t think that’s a productive way of having that conversation.

COWEN: Why don’t we have that language? Where did it go, or did we ever have it?


COWEN: You see this with Medicaid. A lot of people don’t sign up. They don’t have addresses. You can’t even get them, whatever.

KLEIN: They don’t like doctors. They’re afraid of doctors.

COWEN: This is me.

KLEIN: You’re afraid of doctors?

COWEN: “Afraid” isn’t the word.

KLEIN: Averse. [laughs]

COWEN: Maybe dislike. Averse. [laughs] They should be afraid of me, perhaps.

Definitely recommended.  The same dialogue, with a different introduction, is included in The Ezra Klein Show podcast.

That is the title of the new NBER paper by Liran Einav, Amy Finkelstein, and Atul Gupta, here is the abstract:

We document four similarities between American human healthcare and American pet care: (i) rapid growth in spending as a share of GDP over the last two decades; (ii) strong income-spending gradient; (iii) rapid growth in the employment of healthcare providers; and (iv) similar propensity for high spending at the end of life. We speculate about possible implications of these similar patterns in two sectors that share many common features but differ markedly in institutional features, such as the prevalence of insurance and of public sector involvement.

Note that the number of veterinarians doubled from 1996 to 2013.  The authors do not seem to have data on whether cats and dogs live longer in the United States, but I have a surmise…

Here are ungated copies of the paper.

Anti-mind, anti-man, anti-life

by on September 24, 2016 at 7:30 am in Medicine, Religion, Science | Permalink

Curing disease is good, right? No. Jemima Lewis, writing in the Telegraph, says curing disease is a sickeningly bad idea:

…the Zuckerberg-Chans have the most ambitious vision yet: developing new technologies and medicines to tackle every disease ever invented.

We’d better hope they don’t succeed. What would it do to the human race if we were granted eternal health, and therefore life? Without any deaths to offset all the births, we would have to make room on earth for an extra 208,400 people a day, or 76,066,000 a year – and that’s before those babies grow old enough to reproduce themselves.

Within a month of Mr Zuckerberg curing mortality, the first wars over water resources would break out. Within a year, the World Health Organisation would be embarking on an emergency sterilisation programme. Give it a decade and we’d all be dead from starvation, apart from a handful of straggle-bearded tech billionaires, living in well-stocked bunkers under San Francisco.

I’m shocked that anyone can write such depraved things in a major newspaper. In a decent culture this kind of thing would be relegated to some sick corner of the dark web. I suppose I shouldn’t be surprised, however. Ayn Rand villains exist. Look around.

…just as the bulk of the growth in employment can be attributed to a few sectors where productivity is either low or unmeasurable, a whopping 88 per cent of the total rise in the price level boils down to four sectors of the US economy…

How did you guess it was health care, higher education, real estate, and prescription drugs?

…In January 1990, those four product categories only accounted for 30 per cent of the money spent on consumption by the average American. (Housing was about half that.) Even after more than a quarter-century in which prices of these goods and services rose significantly faster than everything else, these four sectors still account for less than 40 per cent of total consumer spending.

Within health care, dentistry has seen the highest rate of price inflation.  Televisions, however, have been falling in price at the rate of about 12 percent a year since 1990.  Luggage, “dishes and flatware,” and household linens are all down in price dramatically, as are telephone and communication services.  Durable goods are down in price by about a third.

That is from Matthew C. Klein at FT Alphaville.

A miniature donkey can change your life. Ten of them can change it a lot.


Five years ago, Mr. Stiert was a software engineer at IBM. A bunch of things happened — divorce, a layoff, a sort of reckoning. Now, at 57, he says, “Every day is donkey day.”


Ms. Hill, 26, said she kept returning because donkeys “don’t judge.”

“They understand, even though they don’t talk,” she said.

And the dreaded regulatory state raises its feared hand:

(Before you run out to shop for donkeys yourself, make sure they’re legal in your town. They are not in New York City, for instance, where the Health Code bans “all odd-toed ungulates” — hoofed animals — other than domesticated horses, “including, but not limited to, zebra, rhinoceros and tapir.”)

Those are not the only good sentences about miniature donkey therapy meet-ups, Andy Newman at the NYT has more.  Here is a final winner:

For all their surprising virtues, donkeys can be a little stubborn.

As loyal readers know, I’ve long been in favor of a system where a drug approved in another major, developed country is also approved here. For a long time it seemed as if I was shouting in the wilderness but in the last few years support for the idea has grown, as the Cruz-Lee Reciprocity bill indicates. In A Cure for Swelling Drug Prices: Competition, Greg Ip at the WSJ notes another new development:

Mr. Tabarrok says the FDA should also offer reciprocal approval of drugs that regulators in other advanced countries have already cleared. Imports of generics from countries with government-negotiated prices ought not to be as controversial as patent-protected drugs because they involve far less expensive and risky research. Indeed, the Generic Pharmaceutical Association and its European equivalent, Medicines for Europe, have proposed a “single development pathway” under which approval in one jurisdiction would automatically confer approval in the other.

The proposed plan is for generics only where the issues are simpler but Greg is right to conclude more generally:

The FDA has long insisted, for safety reasons, that it approve all drugs regardless of whether they have been approved overseas. But if the FDA was once a better regulator than its overseas peers, it isn’t now. Ken Kaitin, a professor of medicine at Tufts University who has studied drug regulation around the world, says there is “absolutely no evidence” the U.S. drug supply is safer than in Britain, Canada or Europe.

Thus, the FDA wouldn’t be compromising safety by harmonizing its approvals with foreign regulators. Indeed, by making more drugs available at lower cost, it could ultimately make Americans healthier.

Conatus Pharmaceuticals Inc. has several patents for emricasan. Some don’t expire until 2028. A third party wanting to sell the molecule would need to license it from Conatus, according to Joseph O’Malley, global chair for intellectual property at Paul Hastings LLP.

“Assuming that drug were to be found to treat Zika,” Mr. O’Malley said, “it would be bad news for the company. It would be under tremendous pressure to license it for little or no money.”

Alfred Spada, Conatus’s chief scientific officer, said if emricasan “were effective in the treatment of such a devastating disease, I think we would be ecstatic.”

Here is the full WSJ story, via the excellent Kevin Lewis.

The FDA and the EpiPen Shock

by on August 30, 2016 at 8:20 am in Economics, Medicine | Permalink

I haven’t written much about the massive increase in the price of the EpiPen because I’ve said it all before–mostly this about FDA costs and delay and some bending of various laws to favor cronies and, as with the infamous Shkreli and Daraprim case, one solution would be a reciprocity system that allowed importation of epipen-like devices approved abroad.

I’m glad, however, that I didn’t go into this in detail because SlateStarCodex has knocked one out of the park on this issue:

…when was the last time that America’s chair industry hiked the price of chairs 400% and suddenly nobody in the country could afford to sit down? When was the last time that the mug industry decided to charge $300 per cup, and everyone had to drink coffee straight from the pot or face bankruptcy? When was the last time greedy shoe executives forced most Americans to go barefoot?

…[lots of stuff about FDA and EpiPen specifically]…

Imagine that the government creates the Furniture and Desk Association, an agency which declares that only IKEA is allowed to sell chairs. IKEA responds by charging $300 per chair. Other companies try to sell stools or sofas, but get bogged down for years in litigation over whether these technically count as “chairs”. When a few of them win their court cases, the FDA shoots them down anyway for vague reasons it refuses to share, or because they haven’t done studies showing that their chairs will not break, or because the studies that showed their chairs will not break didn’t include a high enough number of morbidly obese people so we can’t be sure they won’t break. Finally, Target spends tens of millions of dollars on lawyers and gets the okay to compete with IKEA, but people can only get Target chairs if they have a note signed by a professional interior designer saying that their room needs a “comfort-producing seating implement” and which absolutely definitely does not mention “chairs” anywhere, because otherwise a child who was used to sitting on IKEA chairs might sit down on a Target chair the wrong way, get confused, fall off, and break her head.

(You’re going to say this is an unfair comparison because drugs are potentially dangerous and chairs aren’t – but 50 people die each year from falling off chairs in Britain alone and as far as I know nobody has ever died from an EpiPen malfunction.)

Imagine that this whole system is going on at the same time that IKEA donates millions of dollars lobbying senators about chair-related issues, and that these same senators vote down a bill preventing IKEA from paying off other companies to stay out of the chair industry. Also, suppose that a bunch of people are dying each year of exhaustion from having to stand up all the time because chairs are too expensive unless you have really good furniture insurance, which is totally a thing and which everybody is legally required to have.

And now imagine that a news site responds with an article saying the government doesn’t regulate chairs enough.

Read the whole thing.

Addendum: Steve in the comments reminds me that there is a case of a big increase in the price of chairs. Of course, it proves the rule.

The rest of the story” stories have a punch line that twists everything that came before into an entirely new and deeper perspective. My favorite such story is about John Nestor.

Nestor became a minor if hated celebrity in the mid-1980s in Washington, DC for his policy of driving on the beltway in the left hand lane at 55 mph, not a mile faster, the rest of the traffic be damned. Nestor believed that the 55 mph speed limit saved lives and he was going to help other people by slowing them down regardless of the exasperation, raised fingers, or honking. He knew better than other people.

The truth, of course, is that it’s actually variance in speed that kills so by driving more slowly than everyone else Nestor was increasing risk not lowering it. But that’s not the punch line. The punch line? John Nestor was an FDA bureaucrat so obstinate that even the overly cautious FDA thought he was a menace and they pulled him from his job in the renal section for not approving a single new drug in more than four years. On the roads or at the FDA, John Nestor illustrated why I say caution can be deadly.

My second favorite story like this comes from a recent article on land use policy by Mark Gimein at the New Yorker:

In 1948, a federal housing bureaucrat named Paul Oppermann, trying to come to terms with the perils of the nuclear age, proposed a solution to the problem of protecting America’s cities from the bomb: empty them out preëmptively by encouraging the population to move to suburbs and small towns of fifty thousand or fewer. “No power in the world could afford to drop an atomic bomb on a city of 50,000 or less” is how the San Francisco Chronicle summarized the talk that Oppermann gave to a local planning organization. Plus, Oppermann explained, you get slum clearance into the bargain.

The punch line? “The next year, Oppermann assumed office as San Francisco’s planning director.” As Gimein notes Oppermann wasn’t able to move people out of San Francisco but he was able to “[cripple] growth with arcane lot-size rules and off-street-parking-space minimums.”

So now you know the rest of the stories.

No, this is not a repeat of the post from yesterday, there is another twist:

Doctors in Belgium have rejected an imprisoned murderer and rapist’s request for medically assisted suicide, the Justice Ministry said on Tuesday, less than a week before he was due to receive a lethal injection.

…Van Den Bleeken, 51, and in prison for nearly 30 years, had complained of a lack of therapy provided for his condition in Belgium. He argued he had no prospect of release since he could not overcome his violent sexual impulses, and wanted to die in order to end his mental anguish.

Belgium has pioneered the legalization of euthanasia beyond terminal illness to include those suffering unbearable mental pain.

But others have received euthanasia:

Cases which attracted international attention included the euthanasia of two deaf twins who were in the process of losing their sight, and of a transgender person left in torment by an unsuccessful sex change operation.

In February, Belgium became the first country to allow euthanasia for terminally ill children at any age, a move which drew criticism from religious groups both at home and abroad, though application for minors is limited to those about to die.

It is perhaps the wrong mood affiliation to apply the euthanasia process to an actual criminal:

Belgium, like the rest of the European Union, does not have the death penalty.

Here is the full article, and for the pointer I thank A. Le Roy.

Demand curves do slope downwards:

Euthanasia tourists are flocking to Brussels to get a lethal dose. Doctors at hospitals and clinics at Belgium’s capital are seeing an increase in number of euthanasia tourists who are travelling from across the world to their accident and emergency rooms.

As elective medical killings are illegal in France, French patients are often arriving with suitcases. They believe that their request to die will be carried out within a week.

In 2015, a whopping 2,023 people were medically killed in Belgium. The number has more than doubled in five years. According to Olivier Vermylen, an emergency doctor at Brugmann University hospital, seven out of 15 euthanasia cases involved French people.

“It’s a phenomenon that did not exist five or six years ago. Nowadays I get phone calls about French people who arrive in the emergency room announcing that they want euthanasia,” Vermylen told Belgium’s Sudpresse newspaper, reports The Times.

Even at the Jules Bordet institute in Brussels, almost a third of euthanasia consultations, that is 40 out of 130 cases, are by French people. One of the primary reasons why people choose to get euthanized in Belgium is the cost.

Euthanasia in Switzerland costs €4,000 (AU$5,935), writes The Australian. However, euthanasia in Belgium is usually free as the treatment is covered by the European Union’s health insurance card. The bills are sent to French healthcare providers.

And here is a person who needs that extra dose of media training:

“Of course, Belgium is not here to euthanize half the planet. I can understand those who say that France should look after its own patients. But this is easy to say in the office. When you have a patient who is suffering in front of you, you don’t think of that. You help – whether they are French or not,” said Brugmann University hospital’s Michele Morret-Rauis.

I am sorry people, but in light of that state-dependent utility function known as “life or death,” if it ever came to such a point I would opt for Switzerland.

Here is the article, via the excellent T. Hynes.

Very good sentences

by on August 19, 2016 at 2:21 pm in Current Affairs, Law, Medicine | Permalink

There are two unavoidable realities of making the American health-care system less costly: Americans must use less care, and our nation’s legion of well-paying, stable jobs in the health-care sector need to be both less numerous and less well paid. What no one can figure out is how to generate the political will to make this happen. The public option doesn’t fix that political problem.

That is from Megan McArdle, mostly on why the public option is no longer a viable…option.