Libertarians Salute Trump for Keeping His Promise to Pardon Free Trade Innovator Ross Ulbricht

Libertarians believe that governments should stay out of voluntary exchanges between consenting adults. So when Ross Urlbricht set up Silk Road as a platform for exchange that excluded governments, he became a libertarian hero. (For an extensive account see Bilton 2017.) When Ulbricht was given a disproportionately severe sentence, he became a martyred libertarian hero.

Libertarians are conflicted about Donald Trump. They like his courage and perseverance, but don’t like his name-calling and bullying. They like his deregulation and downsized bureaucracies, but don’t like his tariffs and industrial policy.

Trump promised that if elected, he would pardon Ross Ulbricht. On the first full day of his second term, The Donald kept his promise. Libertarians like that–a lot!

Michael Milken was an entrepreneurial finance innovator whose RICO conviction, instigated by Rudy Giuliani in his New York City prosecutor days, was a travesty of justice. (See: Kornbluth 1992; (an aside in) Milken 2023, and Sandler 2023.) The second Bush could and should have pardoned Milken, but did not. Trump late in his first term did, putting justice ahead of political correctness.

Not many people care about Ulbricht and Milken, but those who do care, care–inclining them to keep open minds on Donald Trump.

For The New York Times‘s snidely dismissive view of the Ulbricht pardon see:

David Yaffe-Bellany and Ryan Mac. “Pardon Is Won By Leveraging Trump’s Needs.” The New York Times (Fri., January 24, 2025): A1 & A15.

(Note: the online version of the article has the date January 22, 2025, and has the title “How Trump Was Persuaded to Pardon an Online Drug Kingpin.”)

The best known account of Ulbricht’s Silk Road is:

Bilton, Nick. American Kingpin: The Epic Hunt for the Criminal Mastermind Behind the Silk Road. New York: Portfolio, 2017.

The books on Milken mentioned in my comments are:

Kornbluth, Jesse. Highly Confident: The Crime and Punishment of Michael Milken. New York: William Morrow & Co., 1992.

Milken, Michael. Faster Cures: Accelerating the Future of Health. New York: William Morrow, 2023.

Sandler, Richard V. Witness to a Prosecution: The Myth of Michael Milken. ForbesBooks: Charleston, South Carolina, 2023.

Obamacare (the So-Called “Affordable Care Act”) Has “A Complex, Often Byzantine, Eligibility and Enrollment System”

Obamacare, Medicare, and Medicaid are supposed to help the least-well-off. But the least-well-off are exactly those who are least able to navigate the red-tape of the bureaucracy. Signing up for Amazon Prime was far simpler than signing up for Medicare. (My source is personal experience.)

(p. A18) The Trump administration on Friday said that it would drastically cut annual spending on so-called navigator groups that help Americans enroll in Obamacare health insurance plans, from around $100 million to just $10 million.

. . .

The Trump administration on Friday [Feb. 14, 2025] noted that health insurance navigators enrolled only 92,000 people on the Affordable Care Act’s marketplaces last year, or less than 1 percent of plan participants, amounting to more than $1,000 per enrollment. During Mr. Trump’s first term, with funding levels similar to the one announced Friday, navigators enrolled people at “a far more efficient $211 per enrollment,” the Centers for Medicare and Medicaid Services said in its announcement.

. . .

“They are primarily there to help people navigate a complex, often byzantine, eligibility and enrollment system,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

For the full story see:

Noah Weiland. “Administration Will Cut Funds For Navigators Of Obamacare.” The New York Times (Saturday, February 15, 2025): A18.

(Note: ellipses, and bracketed date, added.)

(Note: the online version of the story has the date Feb. 14, 2025, and has the title “Trump Shrinks Funds for Navigators Who Help Americans Enroll in Obamacare.”)

Land Use Regulations Slow Home Building

Productivity in manufacturing in the U.S. between 1930 and 2020 has increased, with stagnation for the last 10 years. In contrast, residential construction productivity increased, with more variability, from 1930 until the 1970s, and then stagnated or decreased. Starting in the 1970s an increase in land use and environmental regulations caused the stagnation.

So if we want more and better and cheaper housing, the key is less government regulation.

The study I summarize above is:

D’Amico, Leonardo, Edward L. Glaeser, Joseph Gyourko, William R. Kerr, and Giacomo A.M. Ponzetto. “Why Has Construction Productivity Stagnated? The Role of Land-Use Regulation.” National Bureau of Economic Research Working Paper No. 33188, Nov. 2024.

Musk’s Defense of Free Speech Leads an E.V. Hater to Become a Tesla Cybertruck Lover

I admire Elon Musk’s energy, his ability to focus his mind in spite of distractions, and his ambitious entrepreneurship. The kid in me who got up early to watch Apollo space launches admires his ambition to take us to Mars. But what I admire most is his willingness to put that ambition at risk by spending $44 billion to buy Twitter (now X) in order to defend free speech. Too often entrepreneurs will put their dream above everything else. Musk put free speech above his dream.

And it’s not just the $44 billion. Many of his actual and potential Tesla customers are left-wing environmentalists who criticize his purchase of Twitter, and later his leading D.O.G.E. If that dislike leads to lower sales and profits at Tesla, then Musk will have even fewer funds to take us to Mars.

But the outcome is not certain. Maybe a society with free speech is one that is more likely to allow Musk the freedom to take trial-and-error risks to get us to Mars. And there is a small chance that Tesla will sell more cars because of his principled stand.

Tesla owners who supported Harris for President are buying bumper stickers to slap on their Teslas that read “I Bought This Before We Knew Elon Was Crazy” (Peyser 2024, p. D4).

But consider Berkeley Professor Morgan Ames who bought a Tesla in 2013. Even though she did not like Elon Musk’s views she later bought a second Tesla “because she couldn’t find other electric cars that matched Tesla’s capabilities” (Peyser 2024, p. D4).

And there is Oklahoman Sean Ziese who said to his wife: “If Elon is going to start supporting conservatives and free speech, I’m going to start supporting Elon, even though I hate E.V.s” (Ziese as quoted in Peyser 2024, p. D4). Then Ziese went out and bought himself a Tesla Cybertruck.

Ziese now concludes that his driving a Tesla Cybertruck is “a really neat experience. It never would have happened if Elon never would have bought X, and, you know, got free speech going again” (Ziese as quoted in Peyser 2024, p. D4).

The source article quoted above is:

Eve Peyser. “Tesla Owners Don’t Drive Away Quietly.” The New York Times (Thurs., December 19, 2024): D4.

(Note: the online version of the Eve Peyser article has the date Dec. 11, 2024, and has the title “For Tesla Owners, a Referendum Through Bumper Stickers.”)

Once You Experience Entrepreneurship “Everything Else Is Boring”

(p. B12) C. Richard Kramlich, an early investor in Silicon Valley who co-founded the investment giant New Enterprise Associates, helping to fuel the booming tech industry, died on Saturday [Feb. 1, 2025] at his home in Oakville, Calif., in the Napa Valley. He was 89.

. . .

He co-founded his own firm, New Enterprise Associates, or NEA, building it from an initial $16 million fund in the 1970s to one that now oversees investments of nearly $26 billion.

But he stood out among Silicon Valley’s sea of swashbuckling financiers because of his grace and kindness, said Scott Sandell, the chief investment officer and executive chairman of NEA.

. . .

When he was 13, Dick followed in his father’s entrepreneurial footsteps, starting his own “little lightbulb company,” he said in a 2015 interview with the Computer History Museum. “My father encouraged me to do it if I used my own money, and so I bought half a train car worth of lightbulbs from Sylvania Corporation” and resold them from his bedroom.

He added: “I come from three generations of entrepreneurs, and once you get it in your DNA, everything else is boring.”

. . .

. . . Mr. Kramlich met a pair of entrepreneurs who were both named Steve (Jobs and Wozniak). Their company, Apple Computer, was not as good as two other personal computer companies in the market, Mr. Kramlich said in 2015. But their sense of design and entrepreneurial spark were impressive. “They had pizazz,” he said, “where the other two companies were more engineering oriented.”

. . .

Venture capital investing is designed to absorb many losses in pursuit of one home-run deal, leaving a graveyard of failed start-ups along the way. But Mr. Kramlich was known for sticking with struggling investments long after others had abandoned them.

“He used to say, ‘Never say die,’” Mr. Sandell said.

In the early 1980s, Forethought, the start-up behind PowerPoint software, was about to run out of money, and NEA’s partners refused to pony up more. So Mr. Kramlich convinced his wife that they should pause work on the house they were building on Stinson Beach and use the cash to keep the company alive instead. The gamble paid off: In 1987, Microsoft bought Forethought for $14 million, and PowerPoint went on to become one of the world’s best-known software programs.

For the full obituary see:

Erin Griffith. “Richard Kramlich, 89, A Silicon Valley Investor Revered for Humaneness.” The New York Times (Wednesday, February 8, 2025): B12.

(Note: ellipses, and bracketed date, added.)

(Note: the online version of the obituary has the date Feb. 6, 2025, and has the title “C. Richard Kramlich, Early Investor in Silicon Valley, Dies at 89.”)

F.D.R.’s Wage Controls Created a Wedge Between Patients and Doctors, With Awful Unintended Consequences

Under F.D.R.’s wage controls, firms competed for workers through perks, like healthcare benefits, since they could not legally compete by offering higher wages. That resulted in the first middlemen (in this case firms) between the customers (patients) and the suppliers (doctors). The result of adding the middlemen, and also adding a variety of regulations, is a “market” that is opaque, inefficient, and slow to innovate. Rather than drain the swamp, the response has been to add more middlemen (Medicare, Medicaid, Obamacare, and Pharmacy Benefit Managers, aka PBMs), that have only thickened the mire.

(p. B11) The roots of today’s fragmented system can be traced back to a quirk in U.S. history. Unlike most high-income countries, which created centralized government systems to ration care in the 20th century, the U.S. followed a different path shaped by historical circumstances. During World War II, wage controls prompted employers to offer health insurance as a tax-free benefit to attract workers.

Medicare and Medicaid, followed decades later by Affordable Care Act exchanges, were added over time to cover those who couldn’t get insurance through their job, creating a highly decentralized and convoluted system.  . . .

. . . the pressure to increase their earnings means insurers have looked for ways to overbill the government and skimp on patient care, always staying a step ahead of regulators. In recent years, they have become vertically integrated conglomerates, controlling doctors, pharmacies and payment-processing systems.

. . .

One of the most frustrating aspects of the system is a tactic called prior authorization, a process requiring providers to obtain insurer approval before delivering certain services. While that might be disagreeable, there is little public data on how often insurers deny care. This lack of transparency allows insurers to wield prior authorization aggressively, particularly when expensive treatments are recommended.

For the full commentary see:

David Wainer. “How to Fix Health Insurance.” The Wall Street Journal (Saturday, Dec. 21, 2024): B11.

(Note: ellipses added.)

(Note: the online version of the commentary has the date December 20, 2024, and has the title “How American Health Insurance Got So Infuriating.”)

Surgeons Respond More to Individual Incentives Than to Group Incentives

Medicare introduced a new billing code that reimburses surgeons more for repairing hernias that are at least 3 cm long. As a result the percent of repaired hernias that were less than 3 cm dropped from 60% to 49%. It is probably not too hard for surgeons to justify this change. Probably surgeries on hernias just under 3 cm, are just as hard to do as surgeries on hernias that are just above 3 cm. So probably it seems arbitrarily unfair to reimburse more for the slightly larger ones. So look at the close calls closer until you find an angle where one that on first glance was less than 3 cm, now appears to be more than 3 cm.

On the other hand, consider the response when Blue Cross Blue Shield in Michigan offered to pay more to urology group practices that had more patients on active surveillance for prostate cancer. (A growing consensus suggests that most low-risk prostate cancer patients would be better off with active surveillance, rather than quick prostate surgery by urologists.) The response by Michigan urologists–no change in the percent of prostate cancer patients on active surveillance.

Why the difference? I suggest that surgeons, like other people, respond more to individual incentives than to group incentives. A person who responds to group incentives bears the costs themselves, but shares the benefits with others who may be free-riders. If the incentive is individual, no one free rides.

I became aware of the recent academic articles on how incentives do or don’t influence surgeons by reading:

Millenson, Michael L. “It’s Money That Changes Everything (or Doesn’t) for Surgeons.” Forbes.com, Jan. 26, 2025 [cited Jan 27, 2025]. Available from https://www.forbes.com/sites/michaelmillenson/2025/01/26/its-money-that-changes-everything-or-doesnt-for-surgeons/ .

The academic article showing that individual incentives matter to some surgeons is:

Hallway, Alexander, Erin Isenberg, Ryan Howard, Sean O’Neill, Jenny Shao, Leah Schoel, Michael Rubyan, Anne Ehlers, and Dana Telem. “Medicare Coding Changes and Reported Hernia Size.” JAMA (published online on Jan. 16, 2025).

The academic article showing that group incentives don’t seem to matter to surgeons is:

Srivastava, Arnav, Samuel R. Kaufman, Addison Shay, Mary Oerline, Xiu Liu, Monica Van Til, Susan Linsell, Corinne Labardee, Christopher Dall, Kassem S. Faraj, Avinash Maganty, Tudor Borza, Kevin Ginsburg, Brent K. Hollenbeck, and Vahakn B. Shahinian. “Physician Payment Incentives and Active Surveillance in Low-Risk Prostate Cancer.” JAMA Network Open 8, no. 1 (Jan. 8, 2025): e2453658-e58.

At Age 84 Scolnick Has the Passion to Persevere at Curing His Son’s Illness

Many of those with the passion to persevere in overcoming the necessary and unnecessary (regulatory) obstacles to medical innovation, do so because they have a sense of urgency due to skin in the game–they or a relative is directly affected by the disease they are passionate to cure. Dr. Edward Scolnick whose story I quote below, is a great example. In the story, we find another example, Ted Stanley, who donated $100 million to Scolnick because Stanley’s son is also suffering mental illness. And perhaps an indirect example? Rienhoff does not directly have skin in the game, but he is playing a key role because of Scolnick’s passion, and Scolnick’s passion is due to his skin in the game.

If we want more cures we will reduce the unnecessary (regulatory) obstacles so that those with less skin in the game (and so less passion to persevere) will also innovate.

[“Skin in the game” has been emphasized by Taleb in his book with that title.]

(p. A1) Dr. Edward Scolnick figures he needs five, maybe 10 more years to solve one of the brain’s greatest mysteries.

Scolnick, 84 years old, has spent most of the past two decades working to understand and find better ways to treat schizophrenia and bipolar disorder, mental illnesses suffered by tens of millions of people, including his son.

“I know I can crack it,” said Scolnick, a noted drug developer who spent his career plumbing the building blocks of DNA for new treatments.

Long before his latest quest, Scolnick spent 22 years at Merck, mostly as head of the drug giant’s laboratory research. He led development of more than two dozen medicines, including the first approved statin to lower cholesterol, an osteoporosis treatment and an anti-HIV therapy.

. . .

(p. A9) In 2021, Scolnick learned that a group of scientists analyzing DNA from thousands of people with schizophrenia had found mutations in 10 genes that substantially increased the risk of developing the illness. They estimated that a mutation on a single gene, called Setd1a, raised the risk 20-fold.

“It got my blood boiling,” Scolnick said. He began pursuing an emerging class of treatments called LSD1 inhibitors, hoping to develop a new drug. Scolnick enlisted Dr. Hugh Young Rienhoff Jr., who recently developed an LSD1 inhibitor to treat blood disorders.

. . .

Rienhoff anticipates testing a new drug for safety as early as next year, first in animals. He said he saw Scolnick’s passion about fielding a breakthrough treatment but didn’t fully understand why until Scolnick shared about his son’s lifelong struggles with mental illness.

Jason Scolnick, 54, said his doctor has been regularly fine-tuning his medications for bipolar disorder over the years to minimize their debilitating side effects. Using the drugs currently prescribed for schizophrenia or bipolar disorder is like undergoing chemotherapy, he said. “There’s no guarantee it will work and it makes you feel terrible, but the cancer will feel worse or kill you.”

There remains a long road ahead for any new medicine. It takes more than a decade, on average, to get a drug from the research lab through government approvals to patients.

. . .

After leaving Merck, Scolnick was hired in 2004 by the Broad Institute of MIT and Harvard to lead research on psychiatric disorders. He fostered ties with Ted Stanley, a memorabilia entrepreneur whose son also suffered with mental illness. In 2007, Stanley gave $100 million to launch the Stanley Center for Psychiatric Research at the Broad, headed by Scolnick for five years.

. . .

Scolnick and Rienhoff had sat together at a Blackstone dinner years earlier. During the meal, Scolnick shared stories with his table companions about Merck’s development of Crixivan, the anti-HIV drug. “I was hearing a piece of history,” Rienhoff said, “not just HIV history.”

Scolnick became emotional describing how the drug developers, facing various obstacles, wrestled with whether or not to keep going. He pushed for the study to continue, given the urgency. At the time, AIDS was killing tens of thousands of people a year in the U.S.

“I said to Ed, ‘You are thinking like a doctor not a scientist,’” Rienhoff said. “That was the beginning of our relationship.”

. . .

Rienhoff has a team of chemists making and testing compounds at labs in the U.S. and abroad.

“I am optimistic something will come of this,” Rienhoff said. “I can do it, but I wouldn’t have done it if not for Ed. I am, really, doing this in a way for Ed.”

. . .

Biotech company Oryzon Genomics in Spain is developing LSD1 inhibitors for cancer and other conditions. Columbia University researchers tried Oryzon’s drug in mice and found it reversed cognitive impairments caused by the Setd1a genetic mutation connected to schizophrenia. Oryzon is running a small trial in Spain of the LSD1 inhibitor in patients with schizophrenia.

Dr. Joseph Gogos, who led the Columbia research, said it was possible such treatments would be approved for people.

Scolnick is more certain—of both a revolutionary new treatment and his living to witness it.

“Before I die, we will see new medicines, new diagnostics, better outcomes for patients burdened by schizophrenia or bipolar illness,” he said. “I will not be happy to die. But I will die happy that my life helped.”

For the full story see:

Amy Dockser Marcus. “Aging Scientist Races Against Time.” The Wall Street Journal (Friday, Nov. 29, 2024): A1 & A9.

(Note: ellipses added.)

(Note: the online version of the story has the date November 26, 2024, and has the title “A Scientist’s Final Quest Is to Find New Schizophrenia Drugs. Will He Live to See Them?”)

The Free Market Gets a Bum Rap When Blamed for High and Chaotic Drug Prices

The Law of One Price in economics says that in the absence of transaction costs, similar goods will have the same price. If the price of a Tesla truck is $100,000 in Omaha and $200,000 in Des Moines, some enterprising arbitrager will buy a few in Omaha for $100,000, and sell them for slightly less than the going price in Des Moines. As the arbitrager arbitrages, the price of the truck in Omaha will converge with that in Des Moines, a close-enough confirmation of the Law of One Price. If this does NOT happen then either transaction costs are very high or we are not dealing with a free market. As the article quoted below shows, prices of medical drugs vary widely and persistently. Medical drugs are NOT sold in a free market. Arbitrage is NOT allowed. Who can sell to whom is highly regulated. To blame the free market for high and chaotic drug prices is an outrageous bum rap.

(p. A1) The cost of prescription drugs in the U.S. isn’t like the tabs for other products. The price for a single medicine can range by thousands of dollars depending on the drug plan.

It is a symptom of America’s complicated—and costly—system for paying for medicines.

Medicare is paying wildly different prices for the same drug, even for people insured under the same plan.

. . .

Take commonly used generic versions of prostate-cancer treatment Zytiga. They have more than 2,200 prices in Medicare drug plans. The generics ring in at roughly $815 a month in northern Michigan, about half of what they cost in suburban Detroit, while jumping to $3,356 in a county along Lake Michigan, according to a recent analysis of Medicare data.

The same is true with other popular medicines such as psoriasis treatment Otezla, blood thinner Xarelto and generic versions of the cancer drug Tykerb, known as lapatinib, which has 460 prices, according to the analysis by 46brooklyn Research, a nonprofit drug-pricing analytics group.

. . .

(p. A2) The reason for the huge price differences: America’s complicated drug-reimbursement system, which uses middlemen to negotiate prices.

. . .

Not only is it confusing and costly for seniors, the wide range of drug prices costs Medicare. The program, which farms out drug-price negotiations to the firms, pays tens of millions of dollars extra for prescriptions.

“It’s a broken system. It’s really confusing for seniors. It’s really confusing for providers. It’s costing the government way too much,” said Dared Price, who owns eight pharmacies in the Wichita, Kan., area, and complains the stores are underpaid.

The middlemen [are] known as pharmacy benefit managers or PBMs, . . .

. . .

“The inconsistent and disconnected way that PBMs arrive at drug prices makes Medicare look less like a trustworthy marketplace intended to yield low, sober prices and more like a casino,” said 46brooklyn Chief Executive Antonio Ciaccia.

. . .

To find out the prices that the big three and other PBMs negotiated, 46brooklyn looked at what standalone Part D and Medicare Advantage plans say they will reimburse pharmacies on behalf of Medicare for branded and generic drugs during the second quarter. They reported the prices that Medicare would pay.

Some 61 drugs had monthly prices that diverged by at least $30,000, including a $223,037 range for a drug, called nitisinone and sold under the brand name Orfadin, treating a rare metabolic disorder. About 300 medicines had more than 1,000 monthly prices when the difference between the lowest price and the highest was more than $1,000.

It didn’t matter that the same PBM was negotiating the prices. Prices varied widely among health plans, even if a plan used the same PBM.

The 30 mg dose of Otezla had among the most different prices among branded medicines. It had 633 different prices across health plans that used Express Scripts, while Optum Rx carried 569 different prices and Caremark had 431.

The largest PBMs notched some of the biggest number of different prices for lower-priced copies of Zytiga, which is sold as a generic under the drug’s chemical name abiraterone acetate.

Caremark has logged 643 different prices for Zytiga generics, while Express Scripts has 500 and Optum Rx carries 445. By comparison, Capital Rx, a PBM with fewer beneficiaries than the three largest firms, had two prices.

Capital Rx had few prices—either $106 or $117—because it pegged them to the benchmark that the U.S. government uses to calculate drug costs, called the National Average Drug Acquisition Cost, which is based on a survey of retail pharmacy prices, said Chief Executive Anthony Loiacono. Capital Rx’s prices were much less than the sums that many other health plans reported.

“We don’t make money on drug spend, and I do not set prices. I use what CMS gives us as the starting point,” Loiacono said.

For the full story see:

Jared S. Hopkins and Josh Ulick. “Medicare Payouts Vary Widely for Same Drug.” The Wall Street Journal (Wednesday, Nov. 27, 2024): A1-A2.

(Note: ellipses, and bracketed word, added.)

(Note: the online version of the story has the date November 26, 2024, and has the title “Same Drug, 2,200 Different Prices.” Where there is a slight difference in wording between the print and online versions, the passages I quote above follow the online version.)

Ozempic 25 Years Sooner Would Have Saved and Improved Many Lives

Apparently Ozempic had been discovered in the late 1980s and could have been on the market roughly 25 years ago. Pfizer decided that the likely potential revenues were not sufficient to justify the huge costs. But what if the costs had not been so huge? For instance what if we adopted the proposal suggested by Milton Friedman, and advocated by me, to stop mandating hyper-expensive Phase 3 clinical trials to prove efficacy? (The mandates to prove safety through Phase 1 and Phase 2 trials would be retained.) With lower costs, Pfizer might have moved forward. Or if Pfizer had not, some other firm probably would have entered the breach sooner. If Ozempic had been available sooner, by now it would be much cheaper. Many lives would have been saved that have been lost. Other lives would have been healthier and happier.

(p. A26) They called 2023 the year of Ozempic, but it now seems GLP-1 drugs might define an entire decade — or an even longer era. The game-changing drugs, which mimic the hormone GLP-1, offer large benefits for not just diabetes management and especially weight loss but also, apparently, heart and kidney and liver disease, Alzheimer’s and dementia, Parkinson’s and addiction of all kinds. And perhaps because of widespread use of the drugs, the obesity epidemic in America may finally and mercifully be reversing.

But of all the things we learned this year about GLP-1s, the most astonishing could be that the revolution might have started decades earlier. Researchers identified the key breakthrough for GLP-1 drugs nearly 40 years ago, it turns out, long before most Americans had even heard the phrase “obesity epidemic.”

This summer, a former dean of Harvard Medical School, Jeffrey Flier, published a long personal reflection that doubled as an alternate history of what may well be the most spectacular and impactful medical breakthrough of the century so far. In 1987, Flier co-founded a biotech start-up that pursued GLP-1 as a potential treatment for diabetes, not long after it had first been identified by researchers who’d also found that the hormone enhanced insulin secretion in the presence of glucose.

The startup obtained worldwide rights to develop GLP-1 as a metabolic therapy from a group of those researchers, based at Massachusetts General Hospital. They even generated clinical results that suggested it might have promise as a weight-loss drug as well — only to have Pfizer, which had agreed to fund the research, withdraw its support, without providing the researchers with an especially satisfying explanation. Instead, Pfizer told Flier and his partners that the company didn’t believe there would be a market for another injectable diabetes treatment after insulin. Well, Flier tells me, “they were wrong.”

. . .

. . . Flier’s memoir is not just a lament for what might have been. In the aftermath of the pandemic emergency, as citizens and officials alike have embraced a more libertarian attitude toward public health, there’s been a similar drift in the public conversation about drug discovery and development. Operation Warp Speed is often held up as a new model — calls for an Operation Warp Speed 2.0 have been followed by those for an Operation Warp Speed for everything — . . .

Many of the same reformers will complain about all the red tape at the F.D.A. and C.D.C., tallying up huge mortality costs imposed by slow-moving government, arguing for human challenge trials in which individuals volunteer to take untested drugs and be deliberately infected and even talking about the invisible graveyard of unnecessary regulation and delay.

This is all fine and good — there are surely lots of things those agencies can speed up. And in recent years, reformers of various stripes have lobbied some worthy additional proposals into the biomedical zeitgeist — for a system based not on patents but on huge and direct cash prizes for medical breakthroughs, for instance, or one helped along by advance market commitments or benevolent patent extensions. Just last week the researchers Willy Chertman and Ruxandra Tesloianu published “The Case for Clinical Trial Abundance,” an invigorating manifesto for drug development reform.

. . . in focusing on government bureaucracy as the major biomedical bottleneck, we are seeing just one piece of the picture and overlooking what is perhaps the central challenge of research and development — that it is, at present, so complicated that difficulties or bad decisions at any stage can stifle the whole decades-long process, distorting the actual medical and public-health functions of drug development in countless ways.

For the full commentary see:

David Wallace-Wells. “We Could Have Had Ozempic Years Ago.” The New York Times, SundayOpinion Section (Sunday, Jan. 5, 2025): 11.

(Note: ellipses added.)

(Note: the online version of the commentary has the date Dec. 25, 2024, and has the title “Pfizer Stopped Us From Getting Ozempic Decades Ago.”)

Dr. Flier’s published “memoir” mentioned above is:

Flier, Jeffrey S. “Drug Development Failure: How GLP-1 Development Was Abandoned in 1990.” Perspectives in Biology and Medicine 67, no. 3 (Summer 2024): 325-36.

“The Clinical Trial Manifesto” mentioned above is the introductory essay in the compilation referenced below. Another essay that looks promising in the compilation is “Unblocking Human Challenge Trials for Faster Progress.”

Chertman, Willy, and Ruxandra Tesloianu, eds. The Case for Clinical Trial Abundance: A Series of Short Papers Outlining Reform Possibilities for Our Nation’s Clinical Trials. Washington, DC: The Institute for Progress (IFP), 2024.

In 2023, Costs of Medical Care Rose 40% Faster Than Overall Inflation

If rising healthcare costs were clearly due to improving health outcomes, few would be angry. The anger arises from rising fraud, inefficiency, and inertia. Many healthcare workers are paper pushers and the paper pushed is often inaccurate and opaque. Other healthcare workers enforce protocols that slow innovation. And of course mandated regulations, most notably Phase 3 clinical trials, enormously increase costs.

(p. A3) The killing of a health insurance executive in New York City prompted a furious outpouring of anger over the industry and healthcare prices. So just how much have healthcare costs and spending been going up?

The short answer: a lot. National healthcare spending increased 7.5% year over year in 2023 to $4.867 trillion, or $14,570 per person, according to data released Wednesday by the Centers for Medicare and Medicaid Services.

. . .

The 7.5% rise represented a much faster pace of growth than the 4.6% increase in 2022.

. . .

Over the past couple of decades, the price index for what the Labor Department classifies as medical care—which includes visits to doctors, hospital stays, prescription drugs and medical equipment—has risen roughly 40% faster than the overall pace of inflation. Healthcare tends to rise more quickly than overall inflation because of high labor costs in the sector, as well as advancements leading to new and more expensive drugs and treatments. Demand for healthcare is also increasing as the population ages.

. . .

Hospitals are . . . adding billions of dollars in “facility fees” to medical bills for routine care at outpatient centers, according to reporting by The Wall Street Journal. That means patients are often paying hundreds of additional dollars for standard care like colonoscopies, mammograms and heart screenings.

. . .

Employers are shouldering a lot of those costs. For example, the average worker spent $6,296 in premiums for family coverage in 2024, according to KFF [a healthcare nonprofit]. Employers spent $19,276.

But when a company is paying more for insurance premiums for its workers, that leaves it with less money for giving out raises or reinvesting and expansion.

“It’s ultimately all of us who pay for [healthcare] either in the form of lower wages for people who have employer insurance or in the form of higher taxes to cover Medicare and Medicaid,” said Katherine Baicker, professor of health economics at the University of Chicago.

For the full story see:

Harriet Torry. “Nation’s Healthcare Tab Is Surging Amid Rising Wages, Hospital Fees.” The Wall Street Journal (Friday, Dec. 20, 2024): A3.

(Note: ellipses added. The first bracketed words were added by me; the second bracketed word was in the original.)

(Note: the online version of the story was updated December 18, 2024, and has the title “Why Are Americans Paying So Much More for Healthcare Than They Used To?” Where there is a slight difference in wording between the print and online versions, the passages I quote above follow the online version.)

The source for some of the data discussed in The New York Times article appears to have been:

“National Health Expenditures 2023 Highlights.” Centers for Medicare & Medicaid Services (CMS), Last modified on Dec. 18, 2024.