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.

Feds Set Up Perverse Incentives in Healthcare; Health Insurance Companies Do Not Rise Above the Incentives

Vertical integration is admirable when it results in efficiencies of production that in the end benefit the consumer. But the federal government has set up an opaque healthcare system with unintended perverse incentives for health insurance firms to vertically integrate–where the firms own pharmacies, pharmacy benefit managers (P.B.M.s), hospitals, and doctors practices. Reimbursement rates for drugs are set by P.B.M.s. So the insurance company’s in-house P.B.M. reimburses its in-house pharmacy generously, but reimburses outside independent pharmacies stingily–often so stingily that the outside independent pharmacies go bankrupt, increasing the customer flow to the insurance company’s in-house pharmacy. Consumers do not benefit.

I mainly blame the government. But I do not praise the insurance firms. Libertarian philosopher Robert Nozick in Anarchy, State, and Utopia argued that profit maximization was ethical and served the common good, as long as it was done subject to ethical side-constraints. The three big health insurance firms, and especially United Health, have NOT set a conspicuous example of following Nozick’s advice.

What a pitiful, frustrating, inefficient, unfair mess.

(p. D3) The small-town drugstore closed for the last time on a clear and chilly afternoon in February. Jon Jacobs, who owned Yough Valley Pharmacy, hugged his employees goodbye. He cleared the shelves and packed pill bottles into plastic bins.

Mr. Jacobs, a 70-year-old pharmacist, had spent more than half his life building his drugstore into a bedrock of Confluence, Pa., a rural community of roughly 1,000 people. Now the town was losing its only health care provider.

Obscure but powerful health care middlemen — companies known as pharmacy benefit managers, or P.B.M.s — had destroyed his business.

This has been happening all over the country, a New York Times investigation found. P.B.M.s, which employers and government programs hire to oversee prescription drug benefits, have been systematically underpaying small pharmacies, helping to drive hundreds out of business.

The pattern is benefiting the largest P.B.M.s, whose parent companies run their own competing pharmacies. When local drugstores fold, the benefit managers often scoop up their customers, according to dozens of patients and pharmacists.

The benefit managers’ power comes from two main sources. First, the three biggest players — CVS Caremark, Express Scripts and Optum Rx — collectively process roughly 80 percent of prescriptions in the United States. Second, they determine how much drugstores are reimbursed for medications that they provide to patients.

Pharmacies buy those drugs from wholesalers, in the hope that P.B.M.s will reimburse them at a profit when the medications are provided to patients. But the largest benefit managers have strong incentives to set those rates as low as possible. A key reason: They make money in part by charging employers more for certain drugs than what the P.B.M.s pay pharmacies for them.

P.B.M.s frequently pay the pharmacies at rates that do not cover the costs of the drugs, according to more than 100 pharmacists around the country and dozens of examples of insurance paperwork and legal documents.

To take just one example: For a month’s supply of the blood thinner Eliquis, several pharmacists in different states said, the big three P.B.M.s routinely paid them as much as $100 less than what it cost the pharmacies to buy the medication from a wholesaler.

By contrast, the P.B.M.s sometimes pay their own pharmacies more than what they pay local drugstores for the same medications.

Independent pharmacies are powerless to fight back. As the unprofitable transactions pile up, some are unable to stay afloat.

. . .

(p. 26) The evidence that P.B.M.s pay their own pharmacies more than independent drugstores for the same medications is not just anecdotal. One study, paid for by a pharmacy association, found that the markup that P.B.M.s were charging on brand-name drugs was 35 times higher when the drugs were sold through their own mail-order pharmacies than when the drugs were sold by independent drugstores.

Government studies have identified a similar phenomenon.

Those extra costs are borne by taxpayers or employers and can be passed on to patients in the form of higher premiums — at odds with the benefit managers’ mandate of lowering drug costs.

. . .

(p. 27) In Mississippi, . . ., the state board that regulates pharmacies said this month that Optum Rx paid independent pharmacies less than it paid itself to dispense generic drugs. On a single day in 2022, Optum Rx paid itself 22 times what it paid six independent drugstores to fill generic Prilosec, a heartburn medication. Optum Rx declined to comment on the audit.

For the full story see:

Reed Abelson and Rebecca Robbins. “Powerful Firms Driving Out Local Pharmacies.” The New York Times, First Section (Sunday, October 20, 2024): 1 & 26-27.

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

(Note: the online version of the story has the date Oct. 19, 2024, and has the title “The Powerful Companies Driving Local Drugstores Out of Business.” Where the wording of the two versions differs (sometimes considerably), the quotes above follow the online version.)

The academic article co-authored by Evans is:

Wu, Lingfei, Dashun Wang, and James A. Evans. “Large Teams Develop and Small Teams Disrupt Science and Technology.” Nature 566, no. 7744 (Feb. 2019): 378-82.

Davos Worries Innovative European Firms Will Relocate to U.S. for Fewer Regs and “Kinder” Trump

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. A2) The U.S. was outperforming much of the world before Trump was elected.

His agenda could extend that outperformance by making the U.S. the preferred destination for foreign investment via lower taxes and regulation and even cheaper energy, while his promised tariffs hurt others’ exports.

. . .

Many at Davos blamed Europe’s dismal outlook on the failures of its own leaders, not on Trump.

European scientists are making progress on technologies that use genetically engineered microbes to solve any number of problems, said Kasim Kutay, the chief executive of Novo Holdings, which manages the assets and wealth of the foundation that controls Danish pharmaceutical company Novo Nordisk.

It takes seven to eight years, however, to get such a product approved by European regulators, compared with two to three in the U.S., he said: “A lot of that innovation is happening in Europe, but the companies ultimately seek funding in the U.S.”

One particular source of anxiety in Europe is that its top companies will move to the U.S. in search of higher stock valuations, less regulation and kinder treatment by Trump.

Rich Nuzum, global chief investment strategist for investment consultants Mercer, said Trump’s deregulatory drive might jolt Europe into action.

“If the U.S. economy continues to power ahead, if every company wants to be headquartered in the U.S. and traded in the U.S. because of a lighter regulatory burden…European C-suites will say to European policymakers, ‘Do something, or we’re going to move overseas.’”

The U.S. accounted for 44% of Swedish telecom equipment giant Ericsson’s net sales in the third quarter of 2024, up from 31% a year earlier. Chief Executive Börje Ekholm has criticized excessive regulation for discouraging the upgrading of Europe’s networks. Asked if Ericsson would move its head office to the U.S., Ekholm said: “We are Swedish based. But I think every company in Europe will need to think about this going forward.”

Like Europe, China faces headwinds; tariffs would be just one more.

China’s problem “is not Trump,” said Keyu Jin, a British-based economist specializing in the Chinese economy. “It’s the unemployment numbers. So many companies going under. So much debt the government owes to the private sector. The problems with young people. The ‘lying flat’ problem.”

For the full story see:

Greg Ip. “Davos Dissects Risks, Rewards of Trump.” The Wall Street Journal (Thursday, Jan. 23, 2025): A2.

(Note: ellipsis between paragraphs, added; ellipsis internal to a paragraph, in original.)

(Note: the online version of the story has the date January 22, 2025, and has the title “Trump’s Arrival Brightens U.S. Outlook, Darkens Everyone Else’s.”)

Those Who Criticize the Powerful “Are Seldom Seen Distinctly by the Age in Which They Live”

Founding Father Benjamin Rush was apparently willing to take the ill-will that comes to those who challenge the lazy, incompetent, or corrupt.

The importance of being willing to be the target of ill-will was well-described by Charlie Munger.

(p. C7) During the spring of 1813, former presidents John Adams and Thomas Jefferson were united in grief at the death of a mutual friend who had recently persuaded them to forget their bitter rivalries. Like the two celebrated statesmen, the eminent physician and social reformer Benjamin Rush had been a Founding Father, one of 56 men who signed the Declaration of Independence in 1776.

. . .

. . ., after George Washington’s beaten army was pushed back across the Delaware River and Philadelphia’s militia marched to his assistance, Rush volunteered his medical skills. He helped tend the wounded from the Second Battle of Trenton, on Jan. 2, 1777, and the next day witnessed the bloody aftermath of Washington’s victory at Princeton.

Months later, Rush was appointed surgeon-general of the Continental Army’s so-called Middle Department—a key geographical sector that included Pennsylvania. He had ambitious plans for reform and outlined them in a pamphlet titled “Directions for Preserving the Health of Soldiers.” In a statement true for future American wars, he observed: “A greater proportion of men have perished with sickness in our armies than have fallen by the sword.” To curb that toll, Rush urged radical changes in food, clothing and hygiene. In his improving zeal, he unleashed a barrage of unrestrained letters to his friends in Congress that swiftly kindled a feud with his superior, Dr. William Shippen.

Rush accused Shippen of neglect, incompetence and corruption but underestimated his antagonist’s political clout.

. . .

(p. C8) . . ., Rush himself had always suspected that his outspoken views would affect his reputation, observing: “The most acceptable men in practical society, have been those who have never shocked their contemporaries, by opposing popular or common opinions.” He added, with considerable prescience: “Men of opposite characters, like objects placed too near the eye, are seldom seen distinctly by the age in which they live.” Through the efforts of Mr. Fried and Mr. Unger, what Benjamin Rush characterized as “the distant and more enlightened generations” are now better placed to judge him.

For the full review see:

Stephen Brumwell. “American Hippocrates.” The Wall Street Journal (Saturday, May 20, 2017 [sic]): C7-C8.

(Note: ellipses added.)

(Note: the online version of the review has the date Sept. 20, 2018 [sic], and has the title “‘Rush’ and ‘Dr. Benjamin Rush’ Review: American Hippocrates.”)

The books under review are:

Fried, Stephen. Rush: Revolution, Madness, and Benjamin Rush, the Visionary Doctor Who Became a Founding Father. New York: Crown, 2018.

Unger, Harlow Giles. Dr. Benjamin Rush: The Founding Father Who Healed a Wounded Nation. New York: Da Capo Press, 2018.

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.”)

Innovative Research Is More Likely to Come from Small Teams

The incentives and constraints of doing research in medicine make the process very expensive, which leads it increasingly be a large group activity.
The article below suggests that large group research tends to be less innovative. We should reduce the costs by reducing regulations, including the mandate that no drug can be sold without an F.D.A.-approved Phase 3 clinical trial to prove efficacy.

(p. D3) In the largest analysis of the issue thus far, investigators have found that the smaller the research team working on a problem, the more likely it was to generate innovative solutions.  . . .

The new research, published on Wednesday [Feb. 13, 2019] in the journal Nature, is the latest contribution from an emerging branch of work known as the science of science — the study of how, when and through whom knowledge advances.

. . .

In the study, a trio of investigators led by James A. Evans, a sociologist at the University of Chicago, mined selections from three vast databases: . . .

. . .

When the team correlated this disruption rating to the size of the group responsible for the project or paper, they found a clear pattern: smaller groups were more likely to produce novel findings than larger ones. Those novel contributions usually took a year or so to catch on, after which larger research teams did the work of consolidating the ideas and solidifying the evidence.

“You might ask what is large, and what is small,” said Dr. Evans. “Well, the answer is that this relationship holds no matter where you cut the number: between one person and two, between ten and twenty, between 25 and 26.”

. . .

Psychologists have found that people working in larger groups tend to generate fewer ideas than when they work in smaller groups, or when working alone, and become less receptive to ideas from outside.

. . .

The new study suggests that a different kind of funding approach may be needed, one that takes more risk and spends the time and money to support promising individuals and small groups, Dr. Evans said.

“Think of it like venture capitalists do,” he said. “They expect a 5 percent success rate, and they try to minimize the correlation between the business they fund. They have a portfolio, one that gives them a higher risk-tolerance level, and also higher payoffs.”

For the full story see:

Benedict Carey. “Is Bigger Better? Not in This Case.” The New York Times (Tuesday, February 19, 2019 [sic]): D3.

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

(Note: the online version of the story has the date Feb. 13, 2019 [sic], and has the title “Can Big Science Be Too Big?”)

The academic article co-authored by Evans is:

Wu, Lingfei, Dashun Wang, and James A. Evans. “Large Teams Develop and Small Teams Disrupt Science and Technology.” Nature 566, no. 7744 (Feb. 2019): 378-82.

Otherwise “Savvy Consumers,” Mistakenly Trusting the F.D.A., Let Down Their Guard on Drug Quality

(p. 6) In the fall of 2012, a young consumer safety officer at the Food and Drug Administration volunteered for a job that few of his colleagues wanted: inspecting the Indian manufacturing plants that make many of America’s low-cost generic drugs.

In a world of drab auditors, Peter Baker stood apart.

. . .

America needs generic drugs. They make up 90 percent of the American drug supply. Without them, every large-scale government health program — the Affordable Care Act, Medicare Part D, the Veterans Health Administration, charitable programs for the developing world — would be unaffordable.

. . . what Mr. Baker uncovered in six years of doing foreign inspections exposed the dangerous compromises behind the production of generic drugs, and the F.D.A.’s limits as a global regulatory agency.

. . .

. . ., first in India and then in China, he uncovered fraud or deceptive practices in almost four-fifths of the drug plants he inspected. Some of the plants used hidden laboratories, secretly repeated tests and altered results to produce fake data that fundamentally misrepresented drug quality, then submitted that data to regulators.

. . .

The F.D.A. declares that “Americans can be confident in the quality of the products the F.D.A. approves.” Because of that reassurance, even savvy consumers — the sorts of people who are well versed in the quality distinctions between Velveeta and artisanal Cheddar — don’t think about how and where their drugs are made when they head to a pharmacy. Their only question usually is: Can they afford, or will their insurance cover, the drug being dispensed?

The F.D.A., which approved more than 1,000 new generic drug products last year, faces a vast challenge in safeguarding these medications. Nearly forty percent of all our generic drugs are made in India. Eighty percent of active ingredients for both our brand and generic drugs come from abroad, the majority from India and China. America makes almost none of its own antibiotics anymore.

. . .

In the United States, F.D.A. investigators typically show up unannounced to inspect plants. But overseas, the F.D.A. has opted to announce the vast majority of its foreign inspections in advance. Overseas plants even “invite” the F.D.A. to inspect; the investigators then become the company’s guests and agree on an inspection date in advance. Plant officials have served as hosts and helped to arrange local travel.

The F.D.A. has defended this system as the best way to ease the complex logistics of getting visas and ensuring access to the plants. But the resulting inspections are largely “staged,” say a number of F.D.A. staff members. With advance notice and low-cost labor, the plants can make anything look like anything. “You give them a weekend, they’ll put up a building,” as one F.D.A. investigator put it.

. . .

And there was an additional negative consequence to the F.D.A.’s system of advanced notice. With the companies serving as travel agents, F.D.A. investigators spoke of inappropriate perks: hotel upgrades, for which the investigators would never see a bill; golf outings, massages, and trips to the Taj Mahal. The result was what some F.D.A. employees referred to as “regulatory tourism.” The F.D.A. said in response that “any allegations of improper conduct by F.D.A. personnel are investigated.”

A new head of the F.D.A.’s India office, Altaf Lal, arrived in mid-2013. To tame the twin problems of company fraud and compromised investigators, Mr. Lal made a novel pitch to agency officials. He proposed a pilot program to make all inspections in India either on short notice or unannounced. By December 2013, he had a green light. The results were instantaneous.

In January 2014, the F.D.A. was planning an unannounced inspection at a plant in northern India on a Monday. Fearing that plant officials had heard they were coming, Mr. Baker and his colleague went a day early, unannounced. They proceeded to the quality control laboratory, expecting it to be quiet on Sunday morning. Instead, they were stunned to see a hive of activity. Dozens of workers hunched over documents, backdating them. On one desk, Mr. Baker found a notebook listing the documents the workers needed to fabricate in anticipation of the inspectors’ arrival. There were Post-it notes stuck to some surfaces, noting what data to change.

In large swaths of India’s generic drug industry, the pilot program uncovered a long-running machinery dedicated not to producing perfect drugs but to producing perfect data. At one plant, Mr. Baker went straight to the microbiology laboratory and found the paperwork for testing the sterility of the plant in perfect order: microbial limits testing, biological indicators, all the samples with perfect results. Yet most of the samples didn’t exist. The plant was testing almost nothing. The laboratory was a fake.

At the vast majority of the unannounced inspections, the investigators found things the plants no longer had time to fix: Infestations of birds and insects. A pile of critical manufacturing records, tossed in a trash bin. An employee bathroom near a sterile manufacturing area in one plant lacked drainage piping, so urine puddled directly onto the floor.

(p 7) Under the pilot program, the rate of inspections resulting in the F.D.A.’s most serious finding, “official action indicated,” increased by almost 60 percent, according to my own analysis of F.D.A. records. Before long, drugs from numerous plants in India had been banned from the United States market. Given these results, it seemed logical for the F.D.A. to make unannounced inspections or short notice the norm around the world. But in July 2015, F.D.A. officials decided to terminate the program and return to largely pre-announced inspections in India. When asked why, the agency declined to explain its reasoning and stated that “after evaluation of the pilot a decision was made to discontinue the pilot.”

For the full essay see:

Katherine Eban. “Can You Trust Generic Drugs?” The New York Times Sunday Opinion Section (Sunday, May 12, 2019 [sic]): 6-7.

(Note: ellipses added.)

(Note: the online version of the essay has the date May 11, 2019 [sic], and has the title “Americans Need Generic Drugs. But Can They Trust Them?” In the original of both print and online versions, the word “anything” is in italics both times it appears. In the quotes above where the online and print versions differ, the quotes follow the somewhat more detailed online version.)

The essay quoted above is adapted by Eban from her book:

Eban, Katherine. Bottle of Lies: The inside Story of the Generic Drug Boom. New York: Ecco, 2019.

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.”)

“Magnificently Unreconciled to Oppression”

(p. A19) WARSAW — Last week, a friend asked me what I could learn from a four-day trip to Ukraine I was planning that I couldn’t glean just by reading the news. It was a fair question. With the trip now behind me, I can answer.

. . .

I learned that, for all the aid we’ve given Ukraine, we are the true beneficiaries in the relationship, and they the true benefactors. Ben Wallace, Britain’s usually thoughtful defense minister, suggested after this month’s NATO summit that Ukrainians should show more gratitude to their arms suppliers. That gets the relationship backward. NATO countries are paying for their long-term security in money, which is cheap, and munitions, which are replaceable. Ukrainians are counting their costs in lives and limbs lost.

I am writing this column from Warsaw Chopin Airport. Parked outside the terminal are jetliners destined for Doha, Istanbul, Rome, Toronto, New York. The sight of them here could scarcely have been imagined 40 years ago. It came true because the Polish people remained, in Ronald Reagan’s apt words, “magnificently unreconciled to oppression.”

For the full commentary, see:

Bret Stephens. “What I Learned in Ukraine.” The New York Times (Monday, July 25, 2023): A19.

(Note: ellipsis added.)

(Note: the online version of the commentary has the date July 24, 2023, and has the same title as the print version.)

Almost $2 TRILLION in Compliance Costs for Biden’s 1,213 New Regs over 10 Years

I am queasy about Trump’s tariffs but hopeful about his deregulation. Besides attacks on freedom of speech, regulations are currently the most binding constraint on innovation and flourishing in the U.S. I hope that the tariffs will be a bargaining ploy that in the long run will result in less protectionist policies for both us and our trading partners. But even if my hope is dashed and higher tariffs become a sustained policy, I believe (but cannot prove) that heavy regulations are the greater evil.

(p. A13) By the time Mr. Biden left office, his administration had issued 1,213 new regulations, according to the American Action Forum. The Washington think tank tracks federal regulations, their cost and added paperwork hours on its Regulation Rodeo website. Mr. Biden’s red tape will result in $1.9 trillion in compliance costs over the first 10 years the new rules are in effect, according to AAF.

By comparison, in Mr. Trump’s first term, his administration issued slightly more regulations—roughly 1,340—but many reduced costs to businesses and consumers. In total, they cost only $64.7 billion, less than 4% of Mr. Biden’s total.

Mr. Biden’s regulatory regime was far more expensive than even Barack Obama’s. Over two terms, the Obama administration issued 2,997 regulations, at a price tag of $870.5 billion. That’s less than 46% of the regulatory cost Mr. Biden racked up in four years.

For the full commentary see:

Karl Rove. “Trump Sets Out to Break Burdensome Rules.” The Wall Street Journal (Thursday, Jan. 23, 2025): A13.

(Note: the online version of the commentary has the date January 22, 2025, and has the same title as the print version.)