If you'll excuse me, the rest of us will be over here in the corner, freaking out a little bit.
It's tempting, of course, to blame this on Obamacare, and I certainly wouldn't rule out the possibility that this is at least part of the explanation. But there's no evidence that this is the case, other than the crude time correlation. Derek Lowe suggests that the answer is simpler: the return to R&D spending in the industry has been falling for a long time, as many therapeutic areas are crowded with generics (or soon-to-be generics) that already do a very good job. The remaining areas (cancer, central nervous system, obesity) turn out to be very tough, and there's no guarantee that we'll ever find pharmaceutical interventions that do what we want.
There's an interesting discussion to be had about whether the market outcome differs from the socially optimal outcome--whether falling returns to pharmaceutical R&D mean that we should be putting more resources into it, or fewer. But I'll leave that aside for the nonce, because I'm not sure what I think, and talk about what this means for the rest of the health care system.
You might initially think that this is good news for cost control--the expensive brand name drugs will all go generic, and we'll save a bunch of money on prescription drugs. And indeed, this is absolutely true. But this will have repercussions for other areas of health care, and those repercussions are not good. While some drugs are simply an added expense (think chemotherapy prolonging the lives of people who would otherwise have died sooner), many of the real blockbusters substitute for labor-intensive treatment. Statins instead of cardiac catheterizations or coronary bypasses. Avandia instead of amputations. Hydrochlorothiazide instead of nursing home care for your massive stroke.
We'll still have all those drugs, of course. But with less R&D, we'll presumably see fewer pharmaceutical substitutes for the expensive conditions we still spend a lot of money treating, like Alzheimer's. Which means that health care expenses might actually rise faster than we expect. Most of the rest of the health care system is subject to a phenomenon known as Baumol's Cost Disease, which I described thusly a few years ago:
. . . medical productivity doesn't improve as fast as most of the rest of the economy--basically, activities that are very labor intensive don't tend to have massive productivity gains. That's why it still takes just about as many teachers to teach 50,000 sixth graders as it did fifty years ago. Similarly, it still takes one person to give you a sponge bath and administer your pills.
There's a caveat however: antibiotic resistance. Without antibiotics, a lot of our heroic interventions become a lot more deadly, which means less likely to be performed. And someone who has died from an infection following their coronary bypass will not be around to demand an expensive knee replacement.
Unfortunately, that's not exactly ac omforting thought.
In his first extended press conference at the White House, the president railed against his critics and unspooled a series of bitter complaints.
Have you ever had a job you loved, but one where you felt like you’d achieved everything you could? So you looked for a new job, went through a fairly grueling application process, if you do say so yourself, got the offer. Then you started the job, and you hated it. Worse, all the tricks you’d learned in your old job seemed to be pretty much useless in the new one. Did you ever have that experience?
The president of the United States can sympathize.
Donald Trump held the first extended press conference of his presidency on Thursday, and it was a stunning, disorienting experience. He mused about nuclear war, escalated his feud with the press, continued to dwell on the vote count in November, asked whether a black reporter was friends with the Congressional Black Caucus, and, almost as an afterthought, announced his selection for secretary of labor.
Plagues, revolutions, massive wars, collapsed states—these are what reliably reduce economic disparities.
Calls to make America great again hark back to a time when income inequality receded even as the economy boomed and the middle class expanded. Yet it is all too easy to forget just how deeply this newfound equality was rooted in the cataclysm of the world wars.
The pressures of total war became a uniquely powerful catalyst of equalizing reform, spurring unionization, extensions of voting rights, and the creation of the welfare state. During and after wartime, aggressive government intervention in the private sector and disruptions to capital holdings wiped out upper-class wealth and funneled resources to workers; even in countries that escaped physical devastation and crippling inflation, marginal tax rates surged upward. Concentrated for the most part between 1914 and 1945, this “Great Compression” (as economists call it) of inequality took several more decades to fully run its course across the developed world until the 1970s and 1980s, when it stalled and began to go into reverse.
Neither truck drivers nor bankers would put up with a system like the one that influences medical residents’ schedules.
The path to becoming a doctor is notoriously difficult. Following pre-med studies and four years of medical school, freshly minted M.D.s must spend anywhere from three to seven years (depending on their chosen specialty) training as “residents” at an established teaching hospital. Medical residencies are institutional apprenticeships—and are therefore structured to serve the dual, often dueling, aims of training the profession’s next generation and minding the hospital’s labor needs.
How to manage this tension between “education and service” is a perennial question of residency training, according to Janis Orlowski, the chief health-care officer of the Association of American Medical Colleges (AAMC). Orlowski says that the amount of menial labor residents are required to perform, known in the profession as “scut work,” has decreased "tremendously" since she was a resident in the 1980s. But she acknowledges that even "institutions that are committed to education … constantly struggle with this,” trying to stay on the right side of the boundary between training and taking advantage of residents.
It’s a great physics thought experiment—and an awful accident in 1978.
What would happen if you stuck your body inside a particle accelerator? The scenario seems like the start of a bad Marvel comic, but it happens to shed light on our intuitions about radiation, the vulnerability of the human body, and the very nature of matter. Particle accelerators allow physicists to study subatomic particles by speeding them up in powerful magnetic fields and then tracing the interactions that result from collisions. By delving into the mysteries of the universe, colliders have entered the zeitgeist and tapped the wonders and fears of our age.
By excusing Donald Trump’s behavior, some evangelical leaders enabled the internet provocateur’s ascent.
The Conservative Political Action Conference (CPAC) takes place this week near Washington, D.C., the first such gathering since Donald Trump took office. The conference purports to be a gathering for like-minded folks who believe, generally, in the well-established principles of the conservative movement, as enunciated by the American Conservative Union.
This year, aside from President Trump himself, activist Milo Yiannopoulos was briefly granted a featured speaking slot, and it caused a lot of disruption, garment-rending, gnashing of teeth, and in-fighting on the right.
Yiannopoulos, who prefers to go by MILO (yes, capitalized), is a controversial figure with dubious conservative credentials, most famous for being outrageous during speeches on his college campus tour, soberly called the “Dangerous Faggot” tour. Throughout the 2016 election, Yiannopoulos seemed to enjoy nothing quite so much as the crass, antagonistic side of candidate Trump. He didn’t just celebrate it; he rode it like a wave to greater stardom.
The preconditions are present in the U.S. today. Here’s the playbook Donald Trump could use to set the country down a path toward illiberalism.
It’s 2021, and President Donald Trump will shortly be sworn in for his second term. The 45th president has visibly aged over the past four years. He rests heavily on his daughter Ivanka’s arm during his infrequent public appearances.
Fortunately for him, he did not need to campaign hard for reelection. His has been a popular presidency: Big tax cuts, big spending, and big deficits have worked their familiar expansive magic. Wages have grown strongly in the Trump years, especially for men without a college degree, even if rising inflation is beginning to bite into the gains. The president’s supporters credit his restrictive immigration policies and his TrumpWorks infrastructure program.
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The Italian philosopher Julius Evola is an unlikely hero for defenders of the “Judeo-Christian West.”
In the summer of 2014, years before he became the White House chief strategist, Steve Bannon gave a lecture via Skype at a conference held inside the Vatican. He spoke about the need to defend the values of the “Judeo-Christian West”—a term he used 11 times—against crony capitalism and libertarian capitalism, secularization, and Islam. He also mentioned the late Julius Evola, a far-right Italian philosopher popular with the American alt-right movement. What he did not mention is that Evola hated not only Jews, but Christianity, too.
References to Evola abounded on websites such as Breitbart News, The Daily Stormer, and AltRight.com well before The New York Timesnoted the Bannon-Evola connection earlier this month. But few have discussed the fundamental oddity of Evola serving as an intellectual inspiration for the alt-right. Yes, the thinker was a virulent anti-Semite and Nazi sympathizer who influenced far-right movements in Italy from the 1950s until his death in 1974, but shouldn’t his contempt for Christianity make him an unlikely hero for those purporting to defend “Judeo-Christian” values?
Trump’s attacks on the free press don’t just threaten the media—they undermine the public’s capacity to think, act, and defend democracy.
Are Donald Trump’s latest attacks on the press really that bad? Are they that out-of-the-ordinary, given the famous record of complaints nearly all his predecessors have lodged? (Even George Washington had a hostile-press problem.)
Are the bellows of protest from reporters, editors, and others of my press colleagues justified? Or just another sign that the press is nearly as thin-skinned as Trump himself, along with being even less popular?
I could prolong the buildup, but here is the case I’m going to make: Yes, they’re that bad, and worse.
I think Trump’s first month in office, capped by his “enemy of the people” announcement about the press, has been even more ominous and destructive than the Trump of the campaign trail would have prepared us for, which is of course saying something. And his “lying media” campaign matters not only in itself, which it does, but also because it is part of what is effectively an assault by Trump on the fundamentals of democratic governance.
The provocateur at the center of the controversy that engulfed the right this weekend offers a qualified mea culpa.
NEW YORK — Milo Yiannopoulos has a new mode, and it’s contrition.
Yiannopoulos appeared before reporters on Tuesday in a rented Soho loft to announce his resignation from Breitbart News and apologize to abuse victims for over-a-year-old remarks on pedophilia that incited a political firestorm over the weekend. Wearing a conservative navy blue suit and sunglasses, which he switched to regular glasses shortly into the conference, Yiannopoulous read a prepared statement in which he said he had been the victim of sexual abuse between the ages of 13 and 16. Yiannopoulos said he was “partly to blame” for the remarks on the tape and that he was “certainly guilty of imprecise language.”
“I haven’t ever apologized before,” Yiannopoulos said. “I don’t anticipate ever doing it again. Name-calling doesn’t bother me, misreporting doesn’t bother me. But to be a victim of child abuse and for the media to call me an apologist for child abuse is absurd. I regret the things I said. I don't think I've been as sorry about anything in my whole life.”