Category: Economics
AGI Could Lower Interest Rates
Standard models predict that expectations of artificial general intelligence (AGI) should elevate long-term interest rates. I show that this prediction need not hold. I develop a heterogeneous-agent asset pricing model in which AGI, or more broadly, transformative AI (TAI) capable of automating most human labor, can lower interest rates even as it dramatically accelerates growth. Under baseline calibrations, the risk-free rate falls to near zero despite growth rising from 2% to 11%, and the equity premium expands from 6% to over 20%. The effect on yields is negative and muted for all maturities, even under aggressive assumptions about the speed of AI adoption. These results advise caution when interpreting long-term bond yields as a signal of market expectations of transformative AI.
That is from a new paper by Caleb Maresca of NYU. Via the excellent Kevin Lewis.
Justin Wolfers update
Wolfers’s moment of clarity ultimately sent him down a road less traveled by academic economists: creating his own media company.
On Wednesday, Wolfers, 53, announced that he had founded Platypus Economics, an independent media start-up that aims to reach a mainstream audience. The name is a nod to his Australian roots, cheekily referring to the odd-looking mammal native to his birthplace. He’s funding the business himself, using the income from his textbook sales.
…To get his content channels off the ground and build an audience, Wolfers is teaming up with Initial Digital, the digital media division of the Initial Group, an entertainment company that’s backed by the private equity firm TPG.
Here is the full NYT story.
ICE has not improved U.S. labor markets
We provide the first causal, national empirical analysis of the labor market impacts of heightened immigration enforcement during the second Trump administration. Enforcement increased everywhere, but, we take advantage of the fact that the increases have been uneven across geographic areas to classify areas as treated or control and then implement an event study and difference-in-differences design. Areas that experienced particularly large increases in the number of arrests also experienced a decrease in work among likely undocumented immigrants who remain in the U.S., compared to areas with smaller increases in arrests. We find no evidence of positive spillover effects to U.S.-born workers and U.S.-born workers who work in immigrant-heavy sectors are harmed.
That is from a new NBER working paper by Elizabeth Cox & Chloe N. East.
Rose Farts and the Invisible Hand
In Modern Principles, Tyler and I show the invisible hand by telling the story of how the increase in oil prices in the 1970s encouraged millions of adjustments in how goods were produced and allocated, everything from an increased use of brick for driveways to a movement of the flower market from the US, which relied on heating greenhouses, to warmer climes like Columbia and Kenya. See the I, Rose video!
The FT has an amusing update:
“When my sheep break wind, it smells of roses,” he said, recounting one of the more bizarre and far-flung consequences of the decision by US President Donald Trump and Israel’s Prime Minister Benjamin Netanyahu to bomb Iran in February.
Since Tehran hit back by firing drones and missiles at US allies in the Gulf — grounding cargo flights and closing off the Strait of Hormuz through which booming east African trade with the region used to flow — Mahihu has been forced to jettison millions of rose stems.
Trade and the End of Antiquity
What was the role of trade, and how did economic activity evolve at the End of Antiquity, when political power shifts away from the Mediterranean towards northern Europe and the Middle East? To answer those questions, we assemble a database of hundreds of thousands of ancient coins from the fourth to the tenth century, estimate a dynamic model of trade and money where coins gradually diffuse along trade routes, and recover granular regional trade and real consumption time series. Our estimates suggest that: Mediterranean trade was disrupted by the newly formed border between Islam and Christianity; economic activity shifts away from the Mediterranean starting in the fifth century; real consumption peaks in the Middle East in the eighth century; and by the end of the ninth century, Atlantic regions from Islamic Spain to Frankish northwestern Europe have become the wealthiest regions of the ancient western world.
That is from a new NBER working paper by .
Is there a recent growth in negative-sum assets?
That is the topic of my latest Free Press column, starting with that rebranding of the sneaker company to “an AI company.” Here is one excerpt:
As an economist, I find positive-sum gambles more appealing than negative-sum gambles. Positive-sum gambles might include buying blue-chip stocks, exercising more (even if there is always risk of injury), marrying, initiating a new friendship, or trying out a new idea at work.
We collectively, as Americans, are trying out more and more of these positive-sum gambles all the time. Contrary to common reports, younger generations are accumulating wealth at roughly the same pace as older ones, and each generation as a whole has been richer than the previous one. Real, inflation-adjusted wages in the United States are higher than ever before, even if we might feel the pinch of affordability relative to our expectations.
And there’s the rub: It seems to be a feature of human nature that as good things happen we have a desire to. . . piss some parts of those gains away. Entrepreneurs will step into those slots and create new, exotic, and appealing ways for us to do so. Sports gambling can be destructive and addictive, but for a lot of people it is mostly harmless fun. Yes, you’re more likely to end up losing, but a bet on how many points LeBron James will score might make the game more exciting.
So if NewBird AI is your idea of a modest thrill, who am I to stop you? Most people who trade in such stocks are spending discretionary funds rather than their lunch money. They may be making mistakes, but they are unlikely to end up in the breadlines.
The intertwining of successive ups and downs reminds me of how many people use GLP-1 drugs. They help you lose weight, and if they work for you, they ensure your weight will not rise above a certain level. So why not eat more chocolate ice cream? The penalty for overeating is smaller, just as in an economy of generally greater affluence and security, the consequences of losing some of your money on fun but highly speculative wagers diminish.
Unfortunately, the picture is not that smooth and safe for everyone.
I expect the policy issues here will only rise in importance.
Words of wisdom, on China shock 2.0
Michael Pettis frequently claims that, by running large surpluses, China is forcing “the demand-suppressing cost of their policies onto their trading partners.” The idea here is relatively straightforward: by disincentivizing consumption within China, China’s policies are reducing domestic demand, which, ceteris paribus, reduces global demand.
The problem with this logic should be fairly obvious: ceteris is not in fact paribus. It assumes other countries passively hold their own demand fixed in response to suppressed Chinese demand. But if that were the case, we should expect to see excess unemployment in the rest of the world in response to rising Chinese surpluses.
The empirical record decisively rejects this prediction: both US and EU unemployment was falling during China Shock 1.0 (2000-08), and post-2021 we’ve seen falling unemployment in the EU and stable full-employment in the US.
Monetary policy in other countries adjusts, preventing any shortfall of demand. The more sophisticated version of this argument recognizes that it only bites if other countries are constrained by the zero lower bound (ZLB). In that case, monetary policy cannot lower interest rates to offset a fall in demand elsewhere in the world.
But reports of the death of domestic demand levers at the ZLB have been greatly exaggerated. The monetary authority can raise the inflation target, implement (NGDP or price) level targeting, use forward guidance, and open up the spigots on QE. Furthermore, fiscal policy remains an adequate tool for boosting demand.
That is from J. Zachary Mazlish, the rest of the post has separate interesting points about China shock 2.0
Do Market Reforms Cause Growth?
Do market-oriented reforms cause economic growth? This paper revisits this question using a cross-country panel of reform episodes identified from various changes in well-known economic freedom and structural reform indices. We exploit the timing of reforms using distributed-lag and event-study frameworks that trace the dynamic response of per-capita GDP. We find little evidence of immediate growth gains and some short-run adjustment costs following reform. However, growth rises gradually and persistently over time, with economically meaningful effects emerging after several years. These patterns are robust across alternative measures of reform and specifications. The results reconcile conflicting findings in the literature by showing that market reforms generate long-run growth gains despite short-run disruptions. Overall, the evidence supports the view that institutional liberalization operates through slow-moving channels that accumulate into sustained improvements in economic performance.
That is from a recent paper by Jon Hartley and Brian Wheaton.
Pro-Development Environmentalists
The Breakthrough Institute (BTI) found that “just 10 organizations initiated 35% of the total NEPA cases brought by NGOs.” The Sierra Club and its local chapters alone were responsible for more than 14% of these lawsuits. The dominance of a small number of groups is more pronounced in forest management and energy cases; only 10 groups filed 67% and 48% of these cases, respectively. In BTI’s “The Procedural Hangover: How NEPA Litigation Obstructs Critical Projects” follow-up, which expanded the analysis to district and circuit court NEPA cases, Alliance for the Wild Rockies and the Center for Biological Diversity were responsible for 24% of all litigation against public lands management decisions.
To paraphrase Alex Tabarrok, federal environmental agencies seem to exist to manage the obsessions of a tiny number of neurotic—and possibly malicious—environmental NGOs.
Grant Mulligan’s excellent post shows in detail how environmental groups use the courts to block projects—including environmental projects. But Mulligan finds that a disproportionate share of the lawsuits come from a handful of relatively small organizations. A textbook case of the tyranny of the complainers.
The lawsuits give environmentalists a bad name but the key point is that many environmental groups are not reflexively anti-development.
What are the largest environmental groups doing with their money if not suing to stop development? Two of the three biggest, the Wildlife Conservation Society and San Diego Zoo Wildlife Alliance, primarily operate zoos. Land trusts like TNC, The Conservation Fund, and Ducks Unlimited protect land directly. Many also work on research and policy to varying degrees. Contrary to the typical narrative, many operate pro-market, abundance-style projects.
TNC has several programs that align with the abundance agenda. TNC’s Power of Place research and policy work is aimed at facilitating the build-out of renewable energy and transmission infrastructure. The idea behind the research is to identify and speed the permitting and development of renewable energy projects that won’t interfere with important conservation areas. The Bureau of Land Management (BLM) used the research as part of its Western Solar Plan, which aims to promote solar development on public land. TNC also wants permitting reform, and their mapping efforts are an example of what environmentalism that builds could look like — identify critical habitats that need protecting and guard them closely while unleashing building everywhere else.4
While the tyrannical minority has held up forest management projects, TNC has been an advocate and practitioner of forest thinning and prescribed burns to prevent catastrophic wildfires for more than 60 years. In California, they’re part of a coalition working to thin millions of acres of overgrown forests.
TNC isn’t alone. Audubon’s renewables siting work, Ducks Unlimited’s water infrastructure projects, and the Conservation Fund’s Working Lands programs all follow the same pattern of balancing environmental protections with economic imperatives. Plenty of green groups agree, as Larry Selzer, Conservation Fund’s President and CEO, says in Abundance by Ezra Klein and Derek Thompson, “we have to build, and build, and build.”
I’m not trying to defend all the choices of TNC or suggest that the big environmental NGOs don’t promote their share of bad policies. I had plenty of discussions with degrowthers when I worked at TNC that made me want to pull my hair out. I’ve also written about the need for environmentalism to be more positive-sum in frustration over zero-sum environmental positions. But on the whole, environmentalists have been made too convenient a villain by abundance advocates. Environmentalists aren’t as uniformly obstructionist, degrowth, and misanthropic as commonly believed.5
Understanding that only a vocal minority of environmentalists are anti-progress, procedural complainers is important because abundance advocates and environmentalists aren’t natural enemies—and assuming they are serves neither side.
Capitalism and Modernity
Jesús Fernández-Villaverde, one of the few economists in the world equally at home solving stochastic dynamic optimization problems as with sociological theory and history, has an excellent series of twitter posts on capitalism and modernity.
JFV: I have been reading (and re-reading) a lot of social theory.
What strikes me is that most critics of “capitalism” (whatever “capitalism” might mean, and regardless of the value of those critiques) are really critics of modernity, understood as the organization of society around technology, formal institutions, and rational criteria.
I teach the economic history of the Soviet Union and socialist China, and all the pathologies (pollution, reliance on fossil fuels, inequality, depersonalization, consumerism, alienation, you name it) that you can find in a poor neighborhood of 2026 Philadelphia appeared in the same way, or even more, in a factory in Leningrad in 1970 or on a collective farm in Jiangsu in 1978.
Critics seem to lack a vocabulary (or, if you prefer, a cognitive framework) for distinguishing “capitalism” from modernity. For example, people everywhere tend to link personal relationships to displays of consumption. There are likely deep evolutionary reasons for this. De Beers did not invent spending a lot of money on a useless engagement ring: it rode a pre-existing disposition into a particular form of consumption. Couples in Leipzig in 1982 were as interested in conspicuous consumption as those in Chicago in 2026. Talking about “Love and the Cultural Contradictions of Capitalism” misses the point completely.
Of course, you can try, as some of the more perceptive Trotskyists did, to argue that the Soviet Union or China were not truly socialist countries, but this is just a lazy application of the “no true Scotsman” fallacy, and, consequently, their complaints failed to gain much traction outside some departments of cultural studies.
But this is not just a matter of poor analytic skills, as bad as those are. More importantly, it means that 99% of the policy proposals activists put on the table to correct the problems of “capitalism” are doomed to fail because they do not understand where the root cause of the phenomena they complain about lies.
I see this at the university. Do you think the corporation you deal with is self-serving and incompetent? Wait until you need to deal with the Graduate School at a private Ivy League university. The incentive problems (asymmetric information, career concerns, lack of timely feedback, pressure toward conformity) that cause dysfunction in the former are even more pronounced in the latter because of the absence of a profit motive, the sharpest disciplinary mechanism.
At a very fundamental level, Marx got modernity wrong; Weber got it right. Time to spend much less time with Marx and much, much more time with Weber.
Here’s the second post:
Many readers yesterday asked for more concrete examples of what I have in mind regarding the distinctions between features inherent to modernity and those inherent to “capitalism.”
Imagine we have a functioning socialist commonwealth. For simplicity, I will call it the SC.
Imagine also that this SC aims to provide state-of-the-art medical care to its citizens. This is not about superfluous consumption. It is about the desire to provide good preventive care, adequate treatment, palliative care, and so on.
Soon, you realize that you need the scientific-technological complex that develops advanced mRNA vaccines and, even more importantly, the industrial capacity to produce tens of millions of doses at short notice when a new virus arrives or an old one mutates. These are sophisticated processes that involve coordinating millions of individuals with diverse knowledge, skills, and personalities.
But it does not stop there. You will need to produce thousands of MRIs, scanners, FLASH radiotherapy machines, and all the bewildering array of equipment you find in a top hospital.
And I insist: wanting to be treated with the latest oncological equipment if you get cancer is not frivolity. It is a deep human desire that a good society (any society, really) should attempt to provide.
How are you going to accomplish all this? An SC does not want to use private property, so it relies on some form of public property. But public ownership is not the main issue. The real issue is that the SC would need to organize large bureaucratic organizations. Without them, it cannot develop and deploy vaccines, MRIs, scanners, and the rest. The need to scale is the key mechanism at play, not who owns the property.
And, because of their scale, these large bureaucratic organizations will suffer the type of problems that critics of “capitalism” attribute to “capitalism.” The organization will be impersonal and alienating, and inefficient due to career concerns, asymmetric information, conformity effects, and internal politics.
Moreover, because resource constraints hold in every human endeavor, some claims for medical treatment will be denied. The SC will not have enough resources to satisfy every medical demand (and medical demands are, for all practical purposes, unlimited), every demand for education, every demand for the environment, and every demand for this or that worthwhile cause. Sorry, yes, scarcity will always be with us, with or without AI.
Patients whose requests for medical treatment are denied will be particularly annoyed because the SC is built on the idea that such events cannot happen. At least in a “capitalist” society there is someone to blame (the “capitalist”).
Those who deny the need for large bureaucratic organizations are living in a fantasy world. I am pretty sure the day they are told they have prostate cancer, they will run to their closest large bureaucratic organization for treatment.
Those who deny the problems of large bureaucratic organizations, and how deeply irresoluble those problems are, have not seen how not-for-profits work. I have never seen more acrimonious fights than within not-for-profit organizations, where some shared sense of the common good unites members. The fights are fierce precisely because profits play no role.
I have been reading about these issues for nearly 40 years, and I have seen plenty of proposals to address the problems of large bureaucratic organizations. A favorite among many is “participation” or “more democracy” within the organization. No, sorry, more “participation” or “more democracy” only makes things worse. Yugoslavia taught us that you cannot run a large bureaucratic organization based on democratic participation (well, you only need to know some basic economics; Arrow’s impossibility theorem, anyone?).
Large bureaucratic organizations are essential to modern life, and they are full of problems, with or without “capitalism.”
This is what Weber understood and what Marx, who had an incredibly naïve view of the future, never grasped. Weber saw that bureaucracy is not a feature of “capitalism” but the institutional form modern society uses to coordinate large-scale tasks under rational, impersonal rules. Hospitals, ministries, armies, universities, and, yes, corporations all converge on the same form because it works at scale. The iron cage is not capitalist. It is modernity.
The third excellent post on whether capitalism created modernity which criticizes Quine and the analytic-synthetic distinction (!) is here.
The economic rise of Latin America?
When the world goes looking for shelter during an oil war, the destinations are predictable: the dollar, gold, short-term Treasuries. Nobody puts Latin American sovereign bonds on that list.
Yet as the dollar surged in March, the region’s average sovereign spread didn’t move. There was no contagion. The reason is structural, not lucky: as net commodity exporters borrowing in their own currencies, these governments earned more dollars from the crisis than they owed. This reflects, too, the shift in borrowing profile. Brazil issues 96 per cent of its sovereign debt in reals, for example. Mexico, more than 80 per cent in pesos.
And in the first quarter, with the Iran war already under way, Brazilian local bonds returned 7.3 per cent in dollar terms. Colombia, 4.2. Even Mexico, the regional laggard, eked out 0.3. All three carry the same “emerging market” label as Thailand, which fell 7.2 per cent, and India, which lost 5.9. Between the Brazilian and Thai bonds, there was a difference of nearly 15 percentage points in performance.
The first explanation for the disparities is geography. Asia takes 84 per cent of the crude that flows through Hormuz; Latin America takes virtually none…
Every oil shock in modern history has broken Latin American bonds — 1973, 1979, 1990, 2008. The sequence was always the same: a crisis drove the dollar up, commodity revenues collapsed and governments that had borrowed in dollars they could not print were left holding the bill. That was the original sin. And now it is mostly gone.
Here is more from Erika Mouynes at the FT.
HUD Says Realtors Can Now Speak the Truth
HUD: The U.S. Department of Housing and Urban Development (HUD) sent a “Dear Colleague” letter to real estate professionals clarifying they are not violating the Fair Housing Act when they share information with prospective homebuyers about neighborhood crime rates and school quality data.
“Buying a home is one on the most significant decisions a family will ever make,” said Secretary Scott Turner. “Americans should not be left in the dark about vital facts like neighborhood safety or school quality. HUD is making clear that real estate professionals can openly and lawfully provide this information in an equal and consistent manner to American families.”
The background is that The Fair Housing Act of 1968 prohibits discrimination in housing based on race, color, religion, sex, national origin (and via later amendments) familial status, and disability. Discrimination included “steering” buyers toward or away from neighborhoods based on protected characteristics. The Biden administration ramped this up with a directive and Executive Order that essentially said the Fair Housing Act must be interpreted not just to prohibit discrimination but to redress and undo past discrimination:
This is not only a mandate to refrain from discrimination but a mandate to take actions that undo historic patterns of segregation and other types of discrimination and that afford access to long-denied opportunities.
…the [HUD] Secretary shall take any necessary steps,…to implement the Fair Housing Act’s requirements that HUD administer its programs in a manner that affirmatively furthers fair housing and HUD’s overall duty to administer the Act (42 U.S.C. 3608(a)) including by preventing practices with an unjustified discriminatory effect.
The “discriminatory effect” language reinforced that so-called disparate impact, not just intentional discrimination counted as discriminatory—and it contributed to a legal and reputational environment in which platforms and agents had strong incentives to avoid anything that could be characterized as steering. As a result, by the end of the year, Realtor.com had removed its crime map from all search results, as did Trulia, Redfin announced it would not add crime data to its platform and since Zillow already didn’t include such data, by early 2022 all the major portals had dropped crime information. Similarly, the National Association of Realtors published material instructing agents not to directly answer client questions about neighborhood safety. One article in “The Safety Series” was titled “‘Is This a Safe Neighborhood?’ Don’t Answer That” and by “Safety Series” they meant safety for the realtor not the client.
So without explicitly making such information illegal, the government created a legal and reputational climate that chilled its provision. Portals removed crime maps and realtors became reluctant to answer ordinary buyer questions about neighborhood safety and school quality. That is a degradation of service, not a civil-rights victory. The pretext was that crime information might not be accurate but the real fear was that it would accurately suggest neighborhoods with high percentages of black residents had more crime. Withholding information about crime and schools, however, does not change the facts; it just shifts the informational advantage toward buyers who are wealthy, well-connected, or sophisticated enough to find the data themselves. Moreover, it should go without saying that black homebuyers also want information about neighborhood crime rates–don’t these buyers count? Suppressing truthful information is rarely a good way to improve outcomes. As with Ban the Box, blocking direct access to relevant information encourages worse proxy-based decision-making.
Trump’s HUD is correct: fair housing law should prohibit discrimination, not prevent realtors from telling the truth.
Dwarkesh!
It’s been great to see Dwarkesh Patel rise to the top ranks of podcasters. The profile in the NYTimes is excellent. Dwarkesh’s success is his own but I couldn’t help but smile at the early, wacky GMU influences—all of which I can attest are true:
Mr. Patel recorded the first episode of “The Lunar Society,” his original name for the podcast, from his dorm room at the University of Texas at Austin in 2020, during the early months of the Covid pandemic, when he was 19. He was taking online classes, bored, and thirsty for intellectual engagement. So he did what any normal college sophomore might do and cold-emailed Bryan Caplan, a member of George Mason University’s famously libertarian economics department. In the email, he described how three Caplan books had shifted his perspective on immigration, education and how many children to have. Mr. Caplan responded encouragingly, and after a further friendly exchange, Mr. Patel asked if he could interview him for a podcast. Mr. Caplan was impressed with the result. “He wasn’t just repeating 10 questions from everyone else. He had his own close-reading questions.”
Mr. Caplan and his sons happened to spend a couple of months that summer in Austin, staying at the home of Steve Kuhn, the billionaire ex-hedge fund manager. Mr. Patel had lunch with Mr. Caplan nearly every day, and joined him at Mr. Kuhn’s house for pickleball (Mr. Kuhn founded Major League Pickleball), intellectual salons and role-playing games, including the Mr. Caplan-written “Badger and Skinny Pete,” based on two “Breaking Bad” characters.
Mr. Kuhn offered to invest in the podcast in return for equity. “Even at that age,” Mr. Kuhn says, “he in some ways commanded the room in ways not many people do.”
…Early on, when all Mr. Patel had to show for himself was a couple of blog posts and one podcast episode featuring Mr. Caplan, Anil Varanasi, co-founder of Meter, a network-infrastructure company in San Francisco, reached out and asked how much Mr. Patel would need to keep doing what he was doing for six months. (Mr. Varanasi, a former student of Mr. Caplan’s, has made similar overtures to other promising young people.) Not much, said Mr. Patel, who was then living with his parents in Austin. Mr. Varanasi sent him $10,000. Mr. Caplan opened the door to other interviews, including Tyler Cowen and other George Mason economists. Mr. Cowen, through his Emergent Ventures program, himself later gave Mr. Patel a grant.
The rest as they say is history.
On health care price transparency (from the comments)
From MR commentator Sure:
Generally such figures do not reside within the physicians’ office. On our side of the table we do some procedure with multiple specifications and generate some CPT code(s) (e.g. a lap cholycystectomy is 47562, add on a common bile duct exploration and it becomes a 47564, and if you just do cholangiography it becomes a 47563). Generally, we couple that with an ICD-10 code that specifies your exact disease (K80 for simple stones, K81 for cholecystitis, etc.). We then dump those codes into a computer.
Can either of those change? Absolutely, we find a bunch of friable neovasculature around the gallbladder, congrats you likely have cancer which means this surgery is now both a different CPT code and a different ICD-10 set. Maybe only one does – we find the gallbladder lacks an obstructing stone, but does have transmural inflammation then you get a new ICD-10 code. If we find that you actually have multiple obstructing stones and we need to go deeper into the biliary tree, then those are different CPTs.
Regardless, we do what is medically indicated, document the codes used.
At this point, unless your physician keeps billing fully in house, those get handled by a processer. Often, bills from multiple providers get handled by one processor who in turn gives insurance companies bills to their specifications. Often this involves a bunch things – where was the surgery done (through very complicated rules, critical access hospitals, for example, can charge more for the same surgery because the government wants to keep them solvent lest a bunch of people lose their local emergency room and OR), who was doing it (e.g. there is a different rate if you have medical trainees involved), and of course stuff about you (e.g. complex patients get reimbursed at higher rates with the expectation that, on average, the higher rates cover higher complication rates and insurance doesn’t incentvize surgeons to make all their complex patients drive for hours and hours). Then we get to the big buys – buyers. For Medicare, there are some committees that appear to be overwhelmingly ignorant of actual medical practice but they set baseline reimbursements for these CPT/ICD-10 combos. Those then get adjusted to account for regional costs, equity concerns, and only God knows what all else. These are normally set near the break even point on national average. Medicaid, typically, uses those rates as a baseline and then cuts them (hence why many physicians won’t take new Medicaid patients, the reimbursement rates often leave folks at a net loss). Private insurers add another layer of negotiation where they use their monopsony power to extract lower rates while, allegedly, assuring physicians of volume. The range of these negotiations can be exceedingly wide – insurers can have modifiers for quality of care (e.g. how many folks come back in the perioperative period), timeliness of care, and so on and so forth.
Okay, so somebody has haggled set a rate and we just assume that get the bog standard lap chole we have a price?
Of course not.
See that is just what has agreed, in theory, these medical services will be reimbursed at. Actual reimbursement involves a non-negligable risk on non-payment (e.g. insurance denies and the patient cannot or will not pay), delayed payment (and having to utilize credit lines to cover payroll when a large insurer has an IT glitch and doesn’t pay for two weeks is quite expensive), and of course variable legal and compliance costs. You might also be hit with clawbacks, partial payments, and a host of other payment uncertainty.
Okay, but’s lest assume a single CPT/ICD-10 setup, a prenegotiated rate that is paid on time without further processing costs, and everything is chill there. We got a price yet?
Of course not.
See all of the above is for just the surgeon’s professional fees – i.e. what is being paid for use of his hands. The OR itself? That’s a completely different bucket of money that has its own set of billing and negotiations. Facility fees make the professional fees look straight forward and simple.
But we are done now? Right?
Of course not.
See those were the professional fees for your surgeon. You also need an anesthesiologist (and/or his minions). And guess what, yep completely different bucket of money and price negotiation.
But we are done now?
Well, no. There may be different negotiations for lab fees (e.g. where does the CBC get billed), for tissue pathology, for any post-operative hospital services, and of course medications (which are billed completely differently if outpatient or inpatient) to name a few of the more common options.
There isn’t “a” price for a surgery. There are, potentially, a dozen diferent prices that can be combined in a multitude of ways with some buckets covered by one payer and other parts covered by another (and things get crazy fun when you have overlapping payers).
But aren’t there cash only surgical places with listed prices? Yes. And they have an extremely limited set of procedures with everything owned in house – i.e. a setup that is pretty much illegal to set up de novo post Obamacare.
Why does everyone have all these bizarre negotations. Why don’t you just pay the surgeon everything and then he pays the hospital, the anesthesiologist, the pathologist, etc. from that cut? Because that is an invitation for your surgeon to be charged with a crime. It is federal crime to underbill or to underbill when it comes to government monies (and in many states, private insurance monies). We are required not just to I Pencil up a price, but to make that price transparent to regulators. If a hospital wants to grant me cheaper OR time because I have reliable stream of patients, keep the OR cleaner (reducing turnaround time enough to fit another case per day in), and don’t create ancillary malpractice risk at the going rate … the hospital risks being tagged with inducement. If I negotiate a cheaper rate with the lab for my patients’ tests, it is considered prima facie evidence for kickbacks and I then have a positive burden to prove that I am not getting clandestine remuneration from the lab.
Separate, disjointed, billing through bureaucratic negotiation is legible. It is legible to the courts, to regulators, and to malpractice insurers.
But doesn’t all this massive change efficiency of care delivery?
Not that I can easily see. I have personal experience with IHS, TriCare, Kaiser, the VA, and for-profit, non-profit, and even prison care; full Beveridge like IHS is often the least efficient.So where do cash prices come from? Outside of cash only practices, those are overwhelmingly fictions that somebody pulled out of their nether regions in a likely futile attempt to BS the counterparty to an insurance negotiation.
Why is this all so complicated:
1. Principle agent. The patient has a wildly different incentive structure than the collective payer (insurance or government) and American healthcare is insanely deferential to the patient compared to alternatives. The folks with the most direct control feel at most a small fraction of the price pain have near zero incentive to economize for anything big.
2. Taxes. The original sin of American healthcare was making insurance, rather than medical procedures themselves, tax deductible. This creates very strong incentives for people to bundle non-healthcare into insurance premiums in hard to define manners (e.g. is a health insurer offering a rebate for gym membership incentivizing exercise, allowing folks who would already have gym memberships to pay pre-tax, or just selecting for healthier patients).
3. People are terrified of physician abuse. Most folks, even other physicians, have a very hard time knowing if their physician is taking them for a ride. So they turn to something powerful to regulate physicians. But, not knowing what actually matters, these folks find it extremely hard to navigate market transactions. Healthcare would far rather have 100 unattributable deaths and 2x costs than to have 1 attributable death that regulation could avoid.
4. A complete disconnect between what folks experience for prices (e.g. my tape easily costs 10x more than department store specials, my EMR internal word processor is an order of magnitude more expensive than MSWord let alone Emacs or the like) and how medical expenses run.
5. A failure to appreciate the costs of having things on standby. We have folks ready incase a simple IR procedure perfs the vessel walls. We have countless folks handy in case your infusion leads to anaphylaxis. Or your blood transfusion moves on to TRALI. Just opening the doors typically means that we need to have a few dozen physicians and their support staff available at all times. I’ve seen a simple gallbladder turn into a massive transfusion with staging, SICU, and the whole works. I have seen STD treatment turn into a catastrophic emergency of the sort that gets Derm to come in at oh ass hundred.None of those go away if we post prices. And a lot of people will be upset – somebody will decry us pricing differently for different patients – everyone deserves the same care at the same cost. Somebody will decry us for not pricing differently enough – people should be reward for making good decisions.
Long run, healthcare is going to get more expensive. I expect it will eventually be on part with mortgage payments (you know you live in your body 24/7). But there is an evergreen fantasy that … if only … then we could reduce prices.
You can’t. You can, maybe, make them rise more slowly, normally for harsh tradeoffs Americans won’t stand. And just about every significant intervention that really moves the price needle … is either selection (e.g. health share ministries have wildly healthier populations because they are heavily selected about drugs, promiscuity, and the rest) or given entirely back by the patient dying later. And the handful of things to do pass muster (e.g. HPV vaccination, Hep C treatment) … it becomes yet another morass of how much to pay whom.
Healthcare is not a normal market. We should stop pretending it could be one.
Generative AI and Entrepreneurship
This paper studies how Generative AI (Gen AI) is reshaping the U.S. startup ecosystem. Exploiting the release of ChatGPT, we show that startups with greater pre-release Gen AI task exposure reduced employment within two quarters, primarily among junior and implementation roles. Displaced workers experienced longer unemployment spells and moved to lower-paying but less exposed jobs. Conversely, exposed startups increased productivity, scaled faster, and accelerated through financing rounds. Venture capital shifted toward frequent, smaller investments, boosting new firm formation. Overall, incumbent contraction was offset by new firm formation, leaving aggregate employment unchanged but shifting composition to senior roles.
That is from a new and important paper by Abhinav Gupta, Franklin Qian, Elena Simintz, & Yifan Sun.