Category: Medicine

Elderly Health and Longevity in the US

by  Tyler Cowen in

Rising elderly life expectancy is a well-known source of fiscal pressure on Social Security and Medicare – but how have declining mortality and morbidity affected the two programs’ relative finances? Using nearly three decades of Medicare Current Beneficiary Survey data (1992-2019), we estimate that these demographic changes raised expected lifetime Social Security spending by over twice as much as expected lifetime Medicare spending: 14% compared to 6%. The slower growth of elderly lifetime health care spending than annuity spending reflects two features of how longevity has increased: the additional 2.4 years of remaining life expectancy were entirely healthy – free of physical or cognitive limitations – while the expected amount of time spent with severe health limitations fell by about 30%, reducing expected lifetime nursing-home and home-health use. We then write down a stylized life-cycle model of a risk-averse retiree facing stochastic mortality and health to illuminate the key forces that affect the optimal allocation of a fixed amount of public funds across Medicare and Social Security.

That is from a new NBER working paper by Liran Einav and Amy Finkelstein.  In general I wish to switch resources from Medicare to Social Security, or at least give individuals the option to do so.  You can use dollars to buy health care, but it is not always so easy to make the transformation in the opposite direction.

The Shingles Vaccine Reduces Dementia

by  Alex Tabarrok in

In 2023 in Can the Shingles Vaccine Prevent Dementia? I wrote:

A new paper provides good evidence that the shingles vaccine can prevent dementia, which strongly suggests that some forms of dementia are caused by the varicella zoster virus (VZV), the virus that on initial infection causes chickenpox.

We now have three more studies–from America, Australia and Canada–that find similar results using large numbers and credible research designs. Thus, I think we can up this to the Shingles vaccine reduces dementia.

Eric Topol summarizes the new evidence and writes:

If you are 50+ and have not gotten Shingrix vaccinated, you may want to consider that. You get protection vs Shingles (which can be dreadful), slowing of your biological aging (by methylation and RNA metrics), and ~20% reduction of dementia, predominantly related to Alzheimer’s disease. All of this benefit is magnified in women compared with men, but 3 of the studies showed some reduction of dementia in men. As a tradeoff, men appear to derive more cardiovascular benefit, but that evidence is not as compelling as protection from dementia from natural experiments.

Montana’s SB535 and a Potential Biotech Renaissance in America

by  Alex Tabarrok in

In 2024, China’s NMPA approved 83 new drugs, the FDA approved 50. China’s share of new commercial clinical trials jumped from 8% globally in 2013 to 30% in 2024, just behind the US at 35%. Last year, China-based Jiangsu Hengrui Pharmaceuticals overtook AstraZeneca as the top clinical trial sponsor in the world.

What’s remarkable is how China is winning: deregulation and capitalism. It’s faster and easier to set up a clinical trial in China than in the United States. China is even experimenting with the peer approval model I’ve long advocated. The Medical Tourism Pilot Zone on Hainan island lets medical institutions import and use any pharmaceutical or device approved in the EU, US, or Japan — no separate Chinese approval needed. China is using our own regulatory judgments to get treatments to its patients faster than we do.

The core problem is that our clinical trial and drug approval system is slow and expensive. Getting a new drug to market in the US takes billions of dollars and a decade or more of clinical trials — and all of that before a company earns a single dollar. The consequence is drug lag and drug loss and also learning loss. Innovation is a dynamic process. You must build to build better.

It’s not over for the United States, however. Montana’s SB535, signed into law in May 2025, is the most important regulatory innovation in drug approval in my lifetime. The law authorizes investigational drugs and therapies that have cleared Phase I trials to be prescribed and sold — bypassing the traditional FDA approval pathway. It makes Montana the first state to license experimental treatment centers, “one stop shops” for otherwise hard-to-access care.

This is a very big deal.

SB535 makes Montana the only state in the nation where firms can move more quickly from a successful Phase I trial into limited commercialization. This positions Montana as a highly attractive location for biopharma, biotherapeutics, and other life sciences companies that want to accelerate time-to-market while continuing the federal FDA approval process.

Montana’s regulatory system creates the possibility of a self-funding clinical pipeline: companies using early commercial revenues to finance the path to full FDA approval. You get treatments to patients faster, and you keep companies alive long enough to prove their treatments work. Experimental treatments are not for everyone–these treatments are cash based–no Medicaid or Medicare and probably no private insurance either–but after conventional treatments have failed experimental treatments should be available for some patients, both for their benefit and for ours.

Montana is not alone. Florida now allows non-FDA approved stem cell therapies:

A new law in Florida, CS/CS/SB 1768, allows physicians to market and administer stem cell therapies that have not been approved by the U.S. Food and Drug Administration (FDA) for orthopedic conditions, wound care and pain management.

These experiments in regulatory federalism are vital and not just for patients but also for geopolitical competition. I am thrilled China is pursuing medical innovation (I predicted and applauded this in my TED talk) but I also don’t want to see America falling behind.

The Trump administration has been supportive. I would like to see HHS and the FDA working with companies operating under state right-to-try frameworks — sharing data, clarifying federal-state boundaries favorably, and treating these experiments as the biotech competitiveness infrastructure they are.

The FDA approval process has long been treated as the only legitimate path to market. The cost of that orthodoxy is measured in companies that never reached viability, innovations that never got off the ground, and patients who died when they didn’t have to. I have spent thirty years trying to get people to see the invisible graveyard. That’s hard. Most remain blind. But China’s bursting pipeline of new drugs is visible — could this be a Sputnik moment for biotech?

An American biotech renaissance — driven by AI, federalism, and regulatory innovation — is possible. The path forward is to double down on what makes America great: the laboratories of democracy are working, and in Montana and Florida, so are the labs.

General-purpose large language models outperform specialized clinical AI tools on medical benchmarks

by  Tyler Cowen in

This result does not surprise me at all.  Here is part of the abstract:

Frontier LLMs outperformed clinical AI tools in all three evaluations. Clinical AI tools performed comparably to auto-enabled Google Search AI Overview on the RCQ. These findings highlight the need for independent, real-world evaluation of AI tools before they enter clinical settings.

From Krithik Viswanath, et.al.  As a side note, this (and the more general version of the point) is one big reason why some fairly large number of Emergent Ventures proposals are rejected rather quickly.

Here Comes the Sun(screen)

by  Alex Tabarrok in

I have been banging on about FDA delay in approving new sunscreens since 2013. Well it has finally happened. Twenty six years after being approved by the European Union and thirteen years after then-FDA Commissioner Margaret A. Hamburg told lawmakers that sorting out the sunscreen issue was “one of the highest priorities” the FDA has approved a new sunscreeen ingredient.

The US has been slow because it regulates sunscreens under the the more expensive, time consuming and rigorous drug standard rather than the less expensive cosmetic standard. Does this mean that our sunscreens are safer? No.

In fact, American sunscreens may be less safe.

Sunscreens protect by blocking ultraviolet rays from penetrating the skin. Ultraviolet B (UVB) rays, with their shorter wavelength, primarily affect the outer skin layer and are the main cause of sunburn. In contrast, ultraviolet A (UVA) rays have a longer wavelength, penetrate more deeply into the skin and contribute to wrinkling, aging and the development of melanoma, the deadliest form of skin cancer. In many ways, UVA rays are more dangerous than UVB rays because they are more insidious. UVB rays hit when the sun is bright, and because they burn they come with a natural warning. UVA rays, though, can pass through clouds and cause skin cancer without generating obvious skin damage.

The problem is that American sunscreens work better against UVB rays than against the more dangerous UVA rays. That is, they’re better at preventing sunburn than skin cancer. In fact, many U.S. sunscreens would fail European standards for UVA protection. Precisely because European sunscreens can draw on more ingredients, they can protect better against UVA rays. Thus, instead of being safer, U.S. sunscreens may be riskier.

European sunscreens are also more pleasant to apply, and because they work better with makeup they are probably used more often as part of a skin care regimen, which may reduce the prevalence of skin cancer. Once again, the United States’ slower and seemingly more risk-averse approach actually increases risk.

The lesson, for those who are listening, is general.

The Nationalization of American Science

by  Alex Tabarrok in

OMB, joined by some forty grantmaking agencies—NSF, HHS, DOE, NASA, DOD among them—has proposed a sweeping rewrite of the rules governing all federal grants, the Regulation for Federal Financial Assistance.

American science has long been state funded but not state directed. Since Vannevar Bush, money has flowed through many agencies to independent universities, allocated largely by peer review. The system has flaws—conformity, gerontocracy, waste—but it had one great virtue, the system was decentralized and not under state control. This rule proposes to bring science funding under top-down, state control.

Program goals must now be “aligned with administration policies and priorities” (§ 200.202). Merit review is subordinated to politics: “senior appointees must conduct these reviews,” ensuring “that discretionary awards advance the President’s policy priorities,” while “peer review remains advisory and does not replace agency discretion” (§ 200.205). And every grant becomes terminable at will, whenever it “no longer effectuates program goals, Federal agency priorities, or the national interest *as they exist at the time of the termination*” (§ 200.340, emphasis added). Universities must even ensure their subrecipients don’t “significantly damage the reputation of… the Federal Government” (§ 200.332)—a loyalty clause for scientists.

All this is sold as cutting “burdensome conditions,” a goal I would support, but sadly that is bullshit. The proposed rules add more paperwork and many more layers of bureaucratic review. Payment requests must include written justifications. Every disbursement gets screened through Treasury’s “Do Not Pay” system. Every recipient must run E-Verify. Applicants must disclose any employee who worked at the awarding agency within two years. And on top of the existing review machinery sits a new pre-issuance review committee of “senior appointees” second-guessing the experts. Fixed amount awards—pay for outputs, not inputs—an innovative reward mechanism are *eliminated*, so every award now gets routine cost monitoring and financial reporting.

Political review of every award, peer review demoted, agency review promoted, termination whenever “priorities” change. Chilling. It’s a nightmare of petty low-trust review of the kind that is already drowning science. I must deal with this kind of nonsense all the time. More is not better.

The machinery is centralized too. OMB’s guidance becomes binding regulation, effective government-wide with no agency rulemaking. One dial in the White House now turns every grant program in the country.

The new rules will be sold as getting rid of DEI but that is an excuse to bring in the commissars. The new rules don’t depoliticize science they create even more politicization with the sign flipped, and the drafters admit it:

In the previous administration, executive agencies frequently chose to subsidize and expressly prioritize projects based on their ideological alignment with the categories of activities discussed in the proposed version of § 200.300. See, for example, E.O. 13985, sec. 1, 86 FR 7009, 7009 (Jan. 25, 2021) (“It is therefore the policy of [the Biden] Administration that the Federal Government should pursue a comprehensive approach to advancing equity . . . .”). In this administration, executive agencies will continue to use their discretionary authorities in a manner consistent with current Executive Branch policy. If executive agencies were entitled to subsidize those types of activities during the previous administration, there is no constitutional basis to prevent the government from reaching a different policy determination regarding which activities to fund during this administration.

Read that twice. Tip your hat to the new constitution, take a bow for the new revolution. Will science prosper when it is whipped by political turnover? Research runs on decade timescales; administrations run on four-year ones.

A decentralized funding system is inefficient the way markets and federalism are inefficient—we give up some economies of scale and get experimentation, error correction, and robustness in return. A system in which every award advances “the President’s policy priorities” is efficient the way ministries of science are efficient. We know how that experiment ends.

America is moving in the wrong direction. We should double down on what made America great. Instead we are adopting all of the loser policies of authoritarian nations.

Sentences to ponder

by  Tyler Cowen in

In 2019, there were about 150,000 people working in autism therapy. Six years later, there were 654,000—more than the number of people who work in mining and logging, or telecommunications, or at the US Postal Service.

That is from Derek Thompson.  And here is the seven-minute nap story from the NYT:

At Compleat Kidz, a fast-growing chain of autism clinics based in North Carolina, the policy is firm: Naps cannot be longer than seven minutes before children are awakened to resume therapy. The company says this is necessary to prevent fraud since clinics can be paid only when children are awake and getting services. But it also allows the clinic to bill insurers or Medicaid for more hours.

I do not even need to say “model this.”

Consent-based laws and aggregate fertility

by  Tyler Cowen in

This paper examines how expanding the legal definition of sexual assault affects fertility and sexual behavior, using a panel of European countries. I find that switching to tacit consent-based legislation reduces fertility by about 4% relative to the mean. This effect is driven by a decrease in couple formation and an increase in abortion rates. Supporting evidence is consistent with a behavioral channel in which more risk-averse individuals withdraw from dating and partner markets following the reform, altering the composition of those who remain active toward a pool that is less precautionary. Consistent with this compositional shift, contraceptive use rises among younger women but declines among older age groups, while condom use falls among young men. Finally, an analysis of appeals court verdicts in Sweden following the adoption of consent-based legislation shows a decline in unanimous guilty verdicts, indicating challenges in assessing tacit consent. These results are consistent with a simple framework in which heterogeneity in risk perceptions and precautionary behavior in dating and partner markets, including reduced participation by some individuals, helps explain the observed decline in fertility following the reform.

That is by Adrian Mehic in the Journal of Health Economics.  tekl.

The chimera of universal coverage in a large, diverse country

by  Tyler Cowen in

Our findings suggest that policies intended to subsidize health insurance of higher income groups, for example, the enhanced premium subsidies, are far less efficient than policies intended to further expand public insurance to low-income groups, for example, in non-expansion states.

That is from a new NBER working paper by Anuj Gangopadhyaya & Robert Kaestner.

Quarantine sentences to ponder, that was then this is now edition…

by  Tyler Cowen in

Trump administration officials, confronted by overlapping outbreaks of Ebola and the hantavirus, have taken a more aggressive approach to locking down potentially exposed people than in past outbreaks, surprising many public health experts…

Dr. Jay Bhattacharya, acting director of the Centers for Disease Control and Prevention, drew notice during the Covid-19 pandemic for suggesting that the coronavirus should be allowed to spread freely among healthy people, and for arguing that mandatory quarantines and lockdowns were harmful to society.

Last week, however, he issued quarantine orders that cited public health laws for two passengers who wanted to leave the Nebraska facility and isolate in their home states.

Here is the full NYT story.  Via Maxwell G.

Liberal Economists Score an Own Goal Against Bezos

by  Alex Tabarrok in

Jeff Bezos tweeted:

Yes, the United States has the most progressive tax system in the world. The top 1% pay 40% of taxes, the bottom 50% pay 3% of taxes. We can make it even more progressive by zeroing out taxes on the bottom half. It’s a small amount of the total tax revenue but very meaningful to people in this group.

Strangely, a chorus of liberal economists rushed to attack Bezos. Gabriel Zucman replied:

Contrary to what you claim, working-class people contribute significantly to funding American society today. Payroll taxes and consumption taxes absorb a high fraction of their income.

Justin Wolfers piled on:

If you only count the progressive taxes the U.S. levies, then the U.S. system is quite progressive. But if you also count regressive taxes (payroll taxes, sales taxes, etc), it’s not very progressive.

Bezos called for cutting taxes on the bottom half to make the tax system more progressive and the redistributionists came out swinging–to argue he was wrong about how progressive the current system already is. Own goal. Heretics are worse than unbelievers.

But there’s a second, more interesting thing going on. To make the regressivity case, Zucman and Wolfers have to count payroll payments as taxes. That cuts directly against eighty years of liberal doctrine. Beginning with FDR, the argument on the liberal side has always been that payroll taxes are not taxes but contributions or premiums entitling the payer to benefits as an “earned right.” Here’s FDR to Luther Gulick in 1941:

We put those payroll contributions there so as to give the contributors a legal, moral, and political right to collect their pensions and their unemployment benefits. With those taxes in there, no damn politician can ever scrap my social security program.

That framing isn’t a historical curiosity. It runs straight through liberal social security stalwarts like Arthur Altmeyer, Wilbur Cohen, and Robert Ball, and it’s alive today in Nancy Altman and Eric Kingson’s Social Security Works!, which attacks billionaires and insists Social Security benefits are “earned compensation.” The whole political durability of the program–the third rail–rests on this framing.

So the modern left wants it both ways. When the question is whether to cut Social Security, FICA is a premium and benefits are earned compensation. When the question is whether the tax system is progressive, FICA is suddenly a regressive tax. Pick a lane.

Is there a principled way to resolve this? Yes, and it follows Jim Buchanan (see my earlier post here) and Larry Summers who laid out the economics in his classic paper Some Simple Economics of Mandated Benefits. The principled test is whether a payment reduces labor supply. The wedge between marginal product and the worker’s reservation wage isn’t the statutory rate–it’s the gap between the mandated payment and the worker’s marginal benefit. Sylvain Catherine made exactly this point in reply to Wolfers:

Payroll taxes are not regressive! They are mandatory contributions to a retirement system that offers higher rates of returns at the bottom than at the top.

Consider a forced savings program: everyone must pay 12.4% of income into a 401(k). Is this a tax? For someone who was going to save 15% anyway, not at all. For someone who was going to save 10%, only the extra 2.4% bites. Mandatory does not mean tax. The marginal valuation of the mandated benefit is the key.

Now apply this to the two payroll taxes.

Medicare (HI): Every marginal dollar buys zero marginal benefit. Thus, it’s a tax. Part A eligibility is binary–40 quarters gets you in–and once in, your benefit is whatever Medicare spends on your care. No relationship on the margin. (Moreover, the raw HI schedule is unambiguously progressive: 2.9% flat, rising to 3.8% above $200K/$250K thresholds, plus the NIIT.)

Social Security (OASDI): The 90/32/15 Primary Insurance Amount bend points mean a low earner gets a much better return than a high earner. So the gross statutory rate is flat-then-regressive; but the net rate is progressive. In short, OASDI isn’t a tax for low earners but it is a tax for higher earners, thus the tax is progressive.

So: HI is a progressive tax. OASDI is a contribution at the bottom and a tax at the top. Either way, the Zucman-Wolfers framing—payroll payments as straightforward regressive taxes—is wrong and rhetorically it abandons the framing the left has spent eighty years building to protect these programs.

Personally, I’d prefer a system truer to the old rhetoric–a forced savings program with a closer connection between marginal payments and benefits. But if the left wants to reframe Social Security contributions as taxes, and thus make Social Security all about redistribution to the poor, rather than a wise savings program, roll the dice. Just remember that Altmeyer, Cohen, and Ball spent decades building the “earned right” framing precisely because they understood it was the program’s structural defense against means-testing and privatization. Drop the framing and you drop the defense. I suspect the privatizers at AEI and Cato will happily take that trade but the left may come to regret making it for them.