Author: James Bailey

Cost Plus Drugs

James Bailey1 Comment

A new online pharmacy funded by Mark Cuban promises to sell prescription drugs at a fixed markup, 15% over cost plus a $3 flat fee. What’s the catch?

As far as I can tell, there are two- they only sell generics, and they don’t take insurance. But I think this will still save many people a lot of money.

The most expensive drugs get that way because they are sold by monopolies, almost always because they were invented less than 20 years ago and are still on-patent. But it’s still possible for older drugs to be sold at huge markups, as Martin Shkreli could tell you now that he’s out of prison (Shkreli’s case is supposedly what inspired Dr. Alex Oshmyansky to start this pharmacy). Sometimes you can still blame these markups on monopolies, just induced by the FDA instead of patents. But even for generic drugs with competitive manufacturing, you still sometimes see large and variable markups at the pharmacy level. So I think there’s still huge value in a pharmacy offering a low and stable markup on generics.

What about not taking insurance? First of all, lower cash prices obviously still benefit the 28 million Americans who don’t have health insurance. But even for those with insurance, it’s surprisingly common throughout health care to find cash prices lower than their copay. I have relatively good insurance but when I checked Cost Plus Drugs for the last two prescriptions my family got, I found that one was 80% cheaper than our copay (the other was about the same as our copay, so we’d only come out even, though we’d presumably save our insurer a lot).

Cost Plus Drugs originally wanted to also work through insurance as a Pharmacy Benefit Manager, but seems to have pivoted to being an “unPBM” that just offers generics to employers to supplement their existing plans. They also want to manufacture some of their own drugs, which seems on track to happen. They were started as a Public Benefit Corporation, so while they are for-profit this lends credibility to the idea that they really do want to keep prices down, not just start with low prices to make a name for themselves. Anyway, this seems like a worthy experiment and I encourage anyone with an expensive prescription to see if you can get it cheaper here.

Sick of high drug prices? Try some low-price anti-nausea mediation

Unfashionable Investing

James Bailey7 Comments

Investors such as mutual funds, index funds, and hedge funds tend to pick a particular strategy or asset type and stick with it. It’s what they know, it’s what they’re known for, and making major changes would often create legal difficulties; something marketed as a bond fund can’t suddenly switch to stocks even if they think stocks would do much better. Other types of investors like pension funds, endowments and individuals have more flexibility to change their strategies. These investors tend to chase performance, allocating to types of investments that have performed well recently. This can create fashions, types of investment strategies that become more popular for a few years.

These strategies might involve focus on a certain asset class (stocks / bonds / commodities / private equity / real estate / et c), a certain sector or region within an asset class, a certain factor (value, growth, momentum), et c. It seems like institutional incentives, trend chasing, and FOMO lead people and institutions to over-allocate to strategies that have been successful the last 1-5 years and under-allocate to those that haven’t. Everyone sees something has recently been successful, so they pile into it, which drives up prices and makes it look even more successful for a while; but eventually this drives things to be so clearly over-valued that there’s a crash, and the crash scares people away for years until it becomes clearly undervalued. Most recently 2020-2021 saw people pile into growth/tech stocks and alternatives like SPACs/crypto, but the beginning of Fed rate hikes was the signal that the party is over and people (over?)react by pulling out.

Given this, the ideal strategy is to show up right before the party starts, then leave right at the peak; but no one can time it that well. The possibly realistic alternative is to show up early when no one’s there, then leave right when the party’s getting good (Punchbowl Capital?). Timing and identifying which strategies are too hot and which cold enough (Glacier Capital? Cryo Capital?) is the biggest practical question in how to pull this off. The simplest/dumbest way to do it is to avoid timing decisions entirely and just invest fixed proportions into all strategies; when they’re over-valued your fixed investment doesn’t buy many shares, when they’re under-valued it buys lots. This actually sounds like a decent way to go, but its more buying into the Efficient Market Hypothesis than beating it, can we do better? Here are the types of meta-strategies I’m planning to look into:

  • How variable is the timing of strategy boom/busts? Could you possibly just use fixed numbers of months/years- if a strategy’s been hot this long get out, if its been cold this long get in?
  • Use market share numbers, get in when something gets below a certain % of the market and out when it gets above
  • Use valuation numbers like P/E ratios (seems to work well for the overall stock market, may be harder to measure for some strategies/classes)
  • Flow of funds- is there a rate of change that works as a trigger?
  • Proportion of major institutions allocating to each strategy
  • What looks promising right now along these lines (May 2022)? Without looking at the numbers, the perennial strategies that have been out-of-favor a few years seem like value, emerging markets, and commodities (though commodities might be too hot again just now). These (along with real estate; right now homes seem expensive but homebuilders are cheap and I think commercial is too) all did well after the 2000 tech crash

I’m obviously not the first person to think along these lines; the concepts of the commodity cycle and Shiller’s CAPE are related, and Global Macro and Multistrategy funds do some of this. In the latest AER: Insights, Xiao Yan and Zhang echo Robert Shiller and Paul Samuelson that predicting big things like this is actually easier than predicting little things like the valuation of a specific stock:

Samuelson’s Dictum refers to the conjecture that there is more informational inefficiency at the aggregate stock market level than at the individual stock level. Our paper recasts it in a global setup: there should be more informational inefficiency at the global level than at the country level. We find that sovereign CDS spreads can predict future stock market index returns, GDP, and PMI of their underlying countries. Consistent with the global version of Samuelson’s Dictum, the predictive power for both stock returns and macro variables is almost entirely from the global, rather than country-specific, information from the sovereign CDS market

Ungated version here

But I haven’t actually heard of any fund focused on “unfashionable investing” that considers all asset classes and strategies like this. What institution out there would be capable of saying in 2021 “growth stocks are at bubbly levels, we’re switching to commodities”, or saying in 2022 “commodities are high and growth stocks crashed, we’re switching back”? Please let me know if such an institution does exist, or what else to read along these lines.

Get rich or get famous? Edward Thorp vs Myron Scholes

James Bailey3 Comments

When finance professors publish papers claiming to find inefficiencies in asset markets, my initial reaction is skepticism. The odds are stacked against them to start since asset markets are mostly efficient. Then even if the inefficiency they found is real, shouldn’t they keep that fact to themselves and get rich trading on it?

But listening to a recent interview with Edward Thorp, I realized I shouldn’t entirely discount the possibility that someone would publish a real inefficiency, even a tradeable one. After all, Myron Scholes and Fischer Black did just that when they published the Black-Scholes model in the Journal of Political Economy. This made them famous on Wall Street and in econ/finance academia, and won Scholes the 1997 Nobel Memorial Prize in Economics.

Thorp explained that he had come up with a similar model years earlier, but instead of publishing it, he started a hedge fund and got rich. He says it makes sense that he didn’t share the Nobel Prize, partly because the Black-Scholes model was better than his, but mostly because you should need to publish and share your ideas with the world to get scientific credit for them; his prize was 20% annual returns at his hedge fund.

Why do some opt to get rich, and others to get famous? I’d say academics’ first instinct is to publish everything rather than put it into practice. But Thorp was also an academic, a math professor. Thorp was already famous for publishing a book about how to beat the house at blackjack by counting cards (which is what I knew him for before this interview), so perhaps he valued additional fame less. But he was also already rich from winning at blackjack and from book sales.

Putting ideas into practice can also bring up unanticipated difficulties. When Myron Scholes finally did start working at a hedge fund in 1994 he saw initial success, but by 1998 it had become an embarrassing blunder that inspired the book “When Genius Failed: The Rise and Fall of Long-Term Capital Management”. Scholes may have been better off sticking to academic fame.

Black-Scholes formula for options pricing. The Efficient Markets Hypothesis says that markets instantly incorporate all public information, but original research like this isn’t public until you publish it, and even then it can take years for market participants to fully incorporate it

Why Many Substance Use Treatment Facilities Don’t Take Insurance

James Bailey1 Comment

According to the latest data, about one in four facilities doesn’t accept private insurance or Medicaid, and more than half don’t accept Medicare. This makes substance use treatment something of an outlier, since 91% of all US health spending is paid for through insurance. Still, there are many reasons to prefer being paid in cash: insurance might reimburse at low rates, impose administrative hassles, and generally try to tell you how to run things.

Providers generally put up with the hassles of insurance because they see the alternative as not getting paid. But if demand for their services gets high enough that they can stay busy with patients paying cash, they will often try going cash-only. Some try to generate high demand by providing excellent service. Sometimes high demand comes from a growing health crisis, as with opioids.

Demand can also be high relative to supply because supply is restricted. US health care is full of supply restrictions, but in this case I wondered if Certificate of Need laws were playing a role. As we’ve written about previously, CON laws require health care providers in 34 states to get the permission of a government board to certify their “economic necessity” before they can open or expand. But there’s a lot of variation from state to state in what types of services are covered by this requirement; acute hospital beds and long-term care beds are most common. 23 states require substance use treatment facilities to obtain a CON before opening or expanding.

States with Substance Use–Treatment CON Laws in 2020. Created using data from Mitchell, Philpot, and McBirney

How do these laws affect substance use treatment? We didn’t really know- only one academic article had studied substance use CON, finding it led to fewer facilities in CON states. But I’ve studied other types of CON, so I joined forces with Cornell substance use researcher Thanh Lu and my student Patrick Vogt to investigate. The resulting article, “Certificate-of-need laws and substance use treatment“, was just published at Substance Abuse Treatment, Prevention, and Policy. Here’s the quick summary:

We find that CON laws have no statistically significant effect on the number of facilities, beds, or clients and no significant effect on the acceptance of Medicare. However, they reduce the acceptance of private insurance by a statistically significant 6.0%.

Overall I was surprised that CON didn’t significantly affect most of the outcomes we looked at, and appears to be far from the main reason that treatment facilities don’t take insurance. Still, repealing substance use CON would be a simple way to improve access to substance use treatment, particularly since CON doesn’t appear to bring much in the way of offsetting benefits.

Going forward I aim to investigate how these laws affect health outcomes like overdose rates, and to dig more into the text of state laws and regulations to determine exactly what is covered by substance use CON in different states. As the article explains, we identified several errors in the official data sources we were using. This makes me worry there are more errors we didn’t catch, and there are certainly things the sources just don’t specify, like in which states the laws apply to outpatient facilities. So I hope we (or someone else) will have even better work to share in the future, but for now this article is as good as it gets, and we share our data here.

College Major, Marriage, and Children

James Bailey4 Comments

The American Community Survey began in 2000, and started asking about college majors in 2009, surveying over 3 million Americans per year. This has allowed all sorts of excellent research on how majors affect things like career prospects and income, like this chart from my PhD advisor Doug Webber:

See here for the interactive version of this image

But the ACS asks about all sorts of other outcomes, many of which have yet to be connected to college major. As far as I can tell this was true of marriage and children, though I haven’t searched exhaustively. I say “was true” because a student in my Economics Senior Capstone class at Providence College, Hannah Farrell, has now looked into it.

The overall answer is that those who finished college are much more likely to be married, and somewhat more likely to have children, than those with no college degree. But what if we regress the 39 broad major categories from the ACS (along with controls for age, sex, family income, and unemployment status) on marriage and children? Here’s what Hannah found:

Every major except “military technologies” is significantly more likely than non-college-grads to be married. The smallest effects are from pre-law, ethnic studies, and library science, which are about 7pp more likely to be married than non-grads. The largest effects are from agriculture, theology, and nuclear technology majors, each about 18pp more likely to be married.

For children the story is more mixed; library science majors have 0.18 fewer children on average than non-college-graduates, while many majors have no significant effect (communications, education, math, fine arts). Most majors have more significantly more children than non-college graduates, with the biggest effect coming from Theology and Construction (0.3 more children than non-grads).

In this categorization the ACS lumps lots of majors together, so that economics is classified as “Social Sciences”. When using the more detailed variable that separates it out, Hannah finds that economics majors are 9pp more likely than non-grads to be married, but don’t have significantly more children.

I love teaching the Capstone because I get to learn from the original empirical research the students do. In a typical class one or two students write a paper good enough that it could be published in an academic journal with a bit of polishing, and this was one of them. But its also amazing how many insights remain undiscovered even in heavily-used public datasets like the ACS. We’ve also just started to get good data on specific colleges, see this post on which schools’ graduates are the most and least likely to be married.

Capstone SyllabusDownload

Eat 20 Potatoes a Day…. For Science

James Bailey3 Comments

Several people have tried eating an all-potato diet for a few weeks and reported losing lots of weight with little hunger or effort. Could this be the best diet out there? Or are we only hearing from the rare success stories, while all the people who tried it and failed stay quiet?

Right now we don’t really know, but the people behind the Slime Mold Time Mold blog are trying to find out:

Tl;dr, we’re looking for people to volunteer to eat nothing but potatoes (and a small amount of oil & seasoning) for at least four weeks, and to share their data so we can do an analysis. You can sign up below.

I was surprised to see that they are the ones running this, since they are best known for the “Chemical Hunger” series arguing that the obesity epidemic is largely driven by environmental contaminants like Lithium. The conclusion of that series noted:

Bestselling nutrition books usually have this part where they tell you what you should do differently to lose weight and stay lean. Many of you are probably looking forward to us making a recommendation like this. We hate to buck the trend, but we don’t think there’s much you can do to keep from becoming obese, and not much you can do to drop pounds if you’re already overweight. 

We gotta emphasize just how pervasive the obesity epidemic really is. Some people do lose lots of weight on occasion, it’s true, but in pretty much every group of people everywhere in the world, obesity rates just go up, up, up. We’ll return to our favorite quote from The Lancet: 

“Unlike other major causes of preventable death and disability, such as tobacco use, injuries, and infectious diseases, there are no exemplar populations in which the obesity epidemic has been reversed by public health measures.”

That said, they did still offer some advice based on the contaminant theory that is consistent with the potato diet:

1. — The first thing you should consider is eating more whole foods and/or avoiding highly processed foods. This is pretty standard health advice — we think it’s relevant because it seems pretty clear that food products tend to pick up more contaminants with every step of transportation, packaging, and processing, so eating local, unpackaged, and unprocessed foods should reduce your exposure to most contaminants. 

2. — The second thing you can do is try to eat fewer animal products. Vegetarians and vegans do seem to be slightly leaner than average, but the real reason we recommend this is that we expect many contaminants will bioaccumulate, and so it’s likely that whatever the contaminant, animal products will generally contain more than plants will. So this may not help, but it’s a good bet. 

Overall though I think the idea here is to ignore grand theories and take an empirical approach. The potato diet works surprisingly well anecdotally, so lets just see if it can work on a larger scale. Seems worth a try; I’m sure plenty of my ancestors in Ireland and Northern Maine did 4-week mostly-potato diets and lived to tell about it. You can read more and/or sign up here. Let us know how it goes if you actually try it!

Inflation and GDP Growth Around the World

James Bailey3 Comments

Kalshi cofounder Tarek Mansour recently shared this graph:

In hindsight it seems like an obvious graph to make, and a good way to teach Aggregate Supply / Aggregate Demand models, but I don’t actually recall seeing much like this. One obvious improvement is to include more countries. I do so below using data from Trading Economics, showing all 182 countries that have recent data on both annual GDP growth and inflation. I also flip the axes to be more consistent with the convention in economics:

This makes clear both the costs and benefits of including all countries. We see just how extreme some outliers are: hyperinflation in Venezuela, Sudan, Lebanon, and Syria; a severe contraction in Libya; and huge growth in Azerbaijan and the Maldives (errors in the data?). But all the more typical countries blend together. So here I zoom in on the more typical countries:

This makes clear the strong aversion to deflation that most countries have. Well over a hundred countries here, many with very low inflation, but only in South Sudan does inflation actually go negative. Real GDP growth does not exhibit the same sharp divide at zero, presumably because its much harder to central banks to fine-tune. Now I try to zoom and enhance one more time:

But things are starting to just get messy, so its time to drop more countries. Here I focus on the 30 largest economies (minus Turkey, which breaks the scale on inflation):

Here we see:

  • Japan is demonstrating stagnation/ low aggregate demand / “running cold”
  • Brazil, Stagflation (negative supply shocks?)
  • Poland, high aggregate demand / running hot
  • Saudi Arabia and Israel, high growth without high inflation (positive supply shocks?)

The US is on the higher end of inflation, and I still think we should be doing more about this, but in this graph we don’t look like a huge outlier. We’re all still working through Covid-related shocks. But the very latest quarterly data today (not reflected in these graphs) showed negative GDP growth in the US, sending us toward the “Stagflation” quadrant and making the Fed’s job much harder.

Fed Dot Plot vs Markets

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After their last meeting in March, the Federal Open Market Committee released the summary of economic projections. Most of the variables they project are inherently difficult to predict: GDP, unemployment, inflation. But their forecasts of the Federal Funds rate should be pretty good, since they’re the ones that get to pick what it will be. The median FOMC member thinks the the Federal Funds rate will be just under 2% by the end of 2022.

I said in my last post that the Fed is under-reacting to inflation. Markets seem to agree, but they also think that the Fed will change. Kalshi runs prediction markets on what the Fed Funds rate will be, which they recently started to summarize using this nice curve:

So traders think that the Fed will raise rates faster than the Fed thinks they will, with rates getting to 2.5% by year end. Traders at the Chicago Mercantile Exchange see an even bigger change, with rates at 2.75% by year end, and 3.5% by July 2023 (the longest-term market they offer).

I lean toward the markets on this one; if they are wrong there is plenty of money to be made by betting so.

The Fed is Still Under-Reacting to Inflation

James Bailey6 Comments

In March the Federal Reserve raised rates for the first time since Covid began:

They also began to shrink their balance sheet:

Hard to see but its already down $25 billion from a peak of $8.962 trillion

These moves are in the right direction, but represent a slow start to tackling inflation that is the highest of my lifetime, with the CPI up 8.5% over the last year. While temporary supply constraints are contributing to this, it seems clear to me that excessive aggregate demand is a major driver of this inflation. The labor market has already recovered, with unemployment at 3.6% like it was in late 2019. The Covid-induced output gap is fully eliminated by one standard measure:

But market-based measures of inflation expectations remain high. The TIPS spread predicts that inflation rates over the next 10 years will be much closer to 3% than to the Fed’s target of 2%:

My preferred measure, the NGDP gap, is at 3% (i.e., 3% over the ideal level of 0)

Source: https://www.mercatus.org/publications/monetary-policy/measuring-monetary-policy-ngdp-gap

Overall, its seams clear that Fed policy is currently too loose. The harder question is, what exactly to do about it? How much should they raise rates? The simplest way to answer this is to use the Taylor Rule. Using the version of the rule that Bernanke describes here and using core PCE as the inflation measure (currently just 5.4% yoy, vs 8.5% for headline CPI) implies that the Fed Funds rate should be:

5.4% + 0.5*0% + 0.5*(5.4%-2) + 2 = 9.1%

As Bernanke and many others have explained, you don’t want to take the Taylor rule literally, and the Fed raising rates to 9.1% Volcker-style at their next meeting would be a terrible idea. But keeping the Fed Funds rate under 0.5% would also be a terrible idea. Markets do expect the Fed to keep raising rates this year, but slowly, so that they would be around 2.25% by December. I’ll go on record as worrying that this is too slow, and recommending that they raise rates by at least 0.5% at their next meeting, and continue doing so until market-based measures of medium-run inflation are down to 2%.

Disclaimer: I’m a microeconomist whose last post on inflation was at best only directionally right. Consider this the view of one “insider-outsider” and then go read smarter people like Scott Sumner.

Highlights from EAGx Boston

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Last weekend I was at Effective Altruism Global X Boston, a great conference that worked very differently from the academic ones I usually attend. The attendees were younger and the topics were different, but the big innovation was the use of Swapcard to encourage 1-on-1 meetings. At academic conferences I spend most of my time listening to formal presentations or talking to people I already know, but here I talked to 13 new people for a half hour each, and many others more briefly.

That said, the talks I did attend were excellent. Alvea is a 3-month-old company that already has a novel DNA-based Omicron-targeted Covid vaccine in Phase 1 trials. My notes on co-founder Ethan Alley’s talk:

Learning by doing is the way to go. I learned more in 3 months as a founder than 12+ months as an MIT grad student. Like that you have to pay a company $125k to randomize your clinical trial, and they take 8 weeks to do it

Richard Cash talked about the Oral Rehydration Therapy he helped develop that has saved tens of millions of lives. In short, many people who died of diarrheal diseases like Cholera were simply dying from dehydration, and he realized that this can be prevented cheaply and easily in most cases by having them drink a solution of water, glucose, and certain salts (basically Gatorade). He noted that much of the basic research behind this had been done in the US well before it was applied in the developing countries where it has helped most, so it was crucial to simply notice how important and broadly applicable the findings were. On the other hand, some things really did work differently in developing countries; here the medical conventional wisdom was that people shouldn’t eat while they had diarrhea, but if kids are already malnourished it turns out they are better off eating anyway.

Wave is a mobile payment company that is hugely successful in Senegal but has been slow to expand elsewhere. I asked their Chief Technical Officer Ben Kuhn why this was, and his answer made perfect economic sense:

Fixed costs plus local network effects. Fixed costs: need to get approval of a country’s central bank to operate, need to hire local staff, et c. Network effects: our system gets more valuable as more of the people you send money to/from use it, and these are usually within-country. Makes more sense to keep expanding within a country until its nearly totally saturated, and only then move to the next country. There’s also a limit of how much $ we have to expand, especially since we don’t want VCs to control the company.

(My notes, not a verbatim quote)

As I talked to people I was trying to narrow down my post-tenure plans. This didn’t really work, because people gave me good new ideas without convincing me to abandon any of my old ideas. Although I talked to several senior researchers at NGOs, the ideas that stuck with me most came from talking to undergrads, and were all things that sound obvious in hindsight but that I hadn’t actually been planning to do. The one I’ll mention here as a commitment device is to post my research ideas on my website. I have many more paper ideas than I have time to write about them, and I no longer care much about whether I get credit/publications for them or someone else does. This summer I’ll post a list of ideas there, and perhaps a series of posts fleshing them out here.

P.S. If you identify at all with Effective Altruism, I recommend trying to attend a conference. I’m planning to go next to the one in DC in September.