Streetwise Professor

“Haven’t seen you around recently. So what’s up?”, says you. “Same old, same old: Just the Trump gamma trade”, says I. (After the 2016 election I wrote that a Trump presidency meant you should be long gamma. That’s even more true after 2024).

So the tariff two step has continued. Trump caved! Xi caved!

Whatever. If you believe (as I said literally on day 1, AKA Liberation Day) that the initial tariff salvoes were a negotiating tactic, the outcome was expected. Make maximalist demands, negotiate down from there.

NB. The negotiations continue. This ain’t over.

I only remark that if Trump had announced the current (interim) levels on 2 April, the frenzy would have no doubt been about the same as it was with the 125 percent charge for China, etc. But now these levels (30 to 50+ percent, depending on how you calculate) are greeted with a huge sigh of relief and a complete reversal of the market selloff that greeted the initial announcement. In other words, if you panicked, you were played.

Another fairly recent development has been the prescription drug EO. The initial (over-) reaction has been that Trump is ordering price controls. Well, not exactly. (The irony here is that the right has been critical, and the left hypocritically silent, because Trump).

At the outset, let me say that (as I will explain in more detail below) I am ambivalent about overall policy framework. But the reason I say there has been an overreaction is that all it is right now is just a framework. The only real action item is a direction that HHS formulate a set of rules that will require pharmaceutical companies to allow consumers to purchase directly from them at “most favored nation” (“MFN”) prices. We know how long the rule process takes. We also know that the devil will be in the details of the rule, and those details will be determined in a highly politicized environment where the regulated have a huge say, so it is impossible to draw conclusions about what effects it will actually have, or when it will have them.

Trump’s basic attack–that comparisons between US and foreign prices for the same drugs prove that Americans are being ripped off–is an old one, and ironically was a talking point of Hillary in 1992-1993. The policy piece I wrote in 1993 (“Political Rhetoric and Stock Price Volatility”) addressed this very issue. (Ironically, it was that piece that put my on Hillary’s Hit List, the figurative one at least; it didn’t cost me my life, but did jeopardize my career).

Defenders of this pricing structure claim that it is purely economic conduct by pharma, specifically, price discrimination. More elastic demanders pay a lower price than inelastic American ones.

Yes, this might be why some drugs are dirt cheap in Africa, say, but it is hardly the entire story. Drug companies have to offer big price cuts to high income countries (European countries, Canada, etc.) whose demand is likely about as inelastic as the US’s, so that their national health services will buy them. One interpretation is that these countries are free riding off the innovation paid for by US consumers who pay full fare.

Which raises another issue. Presumably Trump believes that the MFN rule he has outlined will result in drug makers dropping US prices to match foreign ones. But no doubt some of the movement will go in the other direction–the companies will raise prices in other markets, and in some cases will decide to forego some smaller markets altogether rather than have their prices drive those in the really big market. Meaning that the ultimate effect on US price levels is hard to determine.

One part of the EO actually addresses this issue. It directs the U.S. Trade Representative and the Secretary of Commerce to ensure that foreign governments are not taking actions to undercut US prices. (The order incorrectly states that such undercutting raises US prices). That is, this is really a trade issue, and in particular a non-tariff barrier/IP expropriation issue that is more properly addressed in the context of trade negotiations.

The EO–as is the case with most policy proposals directed at drug prices–ignores the real drivers: patent protection, R&D costs, and third-party payments. If you think drug prices are too high, that is, the prices are in excess of what is required to induce the efficient level of innovation, then go after these issues. Examine whether drug patent protection should be attenuated (not extended as it was in recent years). Whether regulatory burdens unnecessarily inflate R&D costs. Cross-country price comparisons tell you nothing about these issues.

Insofar as third-party payment is concerned, the EO does address that issue to some degree. Specifically, the direct purchase option (subject to MFN provisions) is intended to “cut out the middleman,” namely, the Pharmaceutical Benefit Mangers (Caremark Rx, LLC (CVS), Express Scripts, Inc. (ESI), and OptumRx, Inc. (OptumRx) being the Big 3). These are accused of (a) charging high markups on drugs, and (b) excluding many drugs from their formularies.

The first issue is again related to relative prices, not price levels. That is, it is really about who captures the monopoly rent that ultimately derives from patent protection. The main concern is double marginalization–the inefficiency that results from back-to-back monopolists. Double monopolization can lead to prices that are higher than monopoly prices. Another concern could be that the PBMs exercise monopsony power, thereby reducing the returns to R&D and suppressing innovation. (This makes PBMs analogous to foreign governments).

I am always skeptical of “cut out the middleman” arguments because they ignore Chesterton’s Fence: why do the middlemen exist in the first place? If they bring cost but no benefit, how can they survive?

I don’t know the answer in this case. But (a) I am sufficiently skeptical based on long experience so as to not fully credit the seductive cut-out-the-middleman argument (which is almost always wrong, unless the middleman is a government creation), and (b) relatedly, would not be surprised if PBMs are ultimately the creation of the baroque (and broken) regulatory structure in the US. If my suspicion (b) is correct, going after middlemen attacks the symptom, not the cause, and the underlying problem will persist.

All that said, just as the case with foreign-benchmarked MFN pricing, it is naive to think that the direct purchase mandate will lead drug companies to reduce direct-to-consumer prices to the level they charge PBMs. The rules would totally change the negotiating dynamic between them. And again–and this is crucial–this is mainly about how monopoly rents will be distributed/split, not the amount of the rent (and thus not the final price to the consumer), which is driven by the underlying market power inherent in patent protected medicines.

In sum, I think this EO’s significance has been vastly overstated, because (a) it is essentially a “mission order” that sets out a broad objective, and the effects of which will be driven by the tortuous politicized rulemaking process required to carry it out, and (b) does not touch the underlying drivers of pharma prices.

Another major issue of the past few weeks is the (in Trump’s words) “Big Beautiful [budget] Bill” working its way through the House.

First off, let me say that it is almost certainly the case that nothing Big in government is really beautiful. Hell, who even knows what’s in it, precisely because it is so big? It be like “Yeah the chick in the burkha is really beautiful! And she’s actually a chick! Take my word for it!”

Its main attribute is that it will–if the legislative legerdemain works–mitigate the logrolling and secret last minute deals that corrupt the standard budgeting process. Mitigate, not fix.

The “beautiful” bill has some real warts. Hell, cancers, maybe. A sample.

• An elevated state and local tax (SALT) exemption. Elevated so high as to be virtually non-binding. A sop to high income, high tax states which seriously undermines their incentives to control spending and taxation. If California, New York, Illinois, etc., want to raise taxes and spend more, let them fuck their own citizens, not the rest of us. Maybe that will force their citizens to get their minds right, and set their governments straight.

• Serious backsliding on the rollback of Biden’s grotesque, and grotesquely named, “Inflation Reduction Act.” It should be terminated in its entirety, with extreme prejudice. But this bill–which mind you cannot bind future Congresses–delays implementation of subsidy cuts and mandates until four years from now, at the earliest.

Gee, why four years, I wonder?

The renewables subsidies and mandates make energy excessively costly in return for no meaningful environmental benefits. They are also unaffordable given America’s parlous fiscal situation.

Notably, Rumpublicans are among those pushing to save these monstrosities.

• Virtually noting meaningful on entitlement reform. Even extremely modest changes to Medicaid have elicited shrieks and wails, and not just from Democrats.

The US fiscal situation is far and away the greatest danger our to economic prosperity and national security. But nobody–least of all Trump–is taking it seriously. Like Scarlett O’Hara, they will think about that tomorrow.

Except, apropos CCR, that day never comes.

So we seem destined–doomed–to go bankrupt like Hemingway’s Mike Campbell, “Gradually and then suddenly.”

DOGE and Musk held out the (false) promise of preventing this fate by attacking “waste and inefficiency.” Even if such massive inefficiencies exist, DOGE didn’t go through them like a buzzsaw: instead, DOGE has been buzzsawed and Elon has slunk away, achieving a dime on the promised dollar at the very most.

And at the outset, I expressed skepticism–though not enough–that the supposedly “easy” route of restoring fiscal sanity through attacking waste would actually work. The brutal fact is that without addressing entitlements we are on the highway to fiscal hell.

The most depressing takeaway is that the supposedly transformative and revolutionary Trump presidency is at most tinkering with an unsustainable status quo, and even that elicits frenzied, and indeed unhinged, opposition. The nation is as unserious about addressing its existential fiscal problems as was France in the 1780s, and just as politically poisonous.

And we know how that worked out.