Opinion: Innovation can pull Texas health care back from the brink

Opinion: Innovation can pull Texas health care back from the brink

Joe|August 20, 2021

The Lone Star State needs a health care cost fix, and soon. Health care spending in Texas is rising by 6% per person every year, meaning it more than doubles every 12 years. At the current rate of growth, by 2030 it will cost an additional $174 billion just to keep the current number of Texans covered — that’s $60 billion more than the total annual budget of Texas’ state government. With premiums continuing to rise, only 29% of Texas’ small businesses can afford to offer insurance to their employees.

Texas is on an unsustainable trajectory toward sizable tax increases and benefit cuts. Either would lower living standards for millions and prove politically disastrous. But there’s a clear solution to the problem. We have to enable innovation and competition to put dollars back in the hands of consumers, businesses and our state budget. This will require courage from lawmakers to face down insurance companies and health care systems that don't want competition and profit off the status quo.

The Legislature made a promising start last session by allowing the Texas Farm Bureau to offer affordable health coverage to its members and requiring hospitals to post the prices of their services, helping patients shop for the best-value care. But there’s much more to be done. The tiered penalties leveled by this price-disclosure law against noncompliant hospitals — up to $1,000 a day for the biggest providers — are still too low. A similar rule at the federal level is already being widely ignored.

Texas should double down on price transparency, extending it to all care providers, not just hospitals, and enforcing stiffer penalties for rule breakers. By creating incentives for shopping and containing costs, true transparency could save Texans as much as $7 billion annually on health care spending, according to preliminary research by Josh Archambault for the Cicero Institute, a nonpartisan think tank I chair. Based on the latest estimates, this could cut annual cost increases by as much as half.

Innovation can help pave the way to cheaper and more accessible care. In telehealth, companies like Ginger are driving a revolution in treating mental health through artificial intelligence-powered virtual therapy, and Texans deserve to be included in the benefits. There’s also a major opportunity for the direct care model, in which patients pay up front for regular services instead of going through insurance as a middleman. This model is already being used for primary care, but legalizing direct care for specialists, like Tennessee already has, can supercharge savings.

Finally, Texas could crack down on crony behaviors that unfortunately are common practice between many large players in the health care industry. Lawmakers should ban the monopolistic use of exclusive contracts, such as contracts in which hospitals essentially prevent insurance companies from contracting with other hospitals in the area. Such contracts only raise prices on consumers and businesses.

I’m proud to call myself a Texan, and have always admired the bold, independent and can-do attitude of our state. But Texas is at a crossroads, and debates over “who pays” and the issue of expanding Medicaid miss the crucial point. The status quo leads to a Texas in which an angry working class, unable to afford health care, will turn to extremist ideologies. I don’t want to see a neo-Marxist governor elected in 2030. But that’s where we’re heading if we don’t stand up to our crony health systems.

If lawmakers courageously embrace innovation and competition with these measures, we can drastically slow rising costs. We won’t just keep Texas free, we’ll become a model for the nation and lift up everyone — including the least well off in our society.

This piece originally appeared in the Austin American-Statesman.

Steering American Healthcare From the Brink

Joe|May 26, 2021

A $200B Opportunity for Policymakers and Entrepreneurs

Since we published our proposal on “How to Save $900B Annually in American Healthcare” three years ago, the crisis facing the US healthcare system has deepened. Spending continues to grow at twice the rate of GDP, reaching $3.8 trillion in 2019 even as health outcomes stagnate.[1] This steady rise in expenditures is an underappreciated danger to our country’s socioeconomic well-being. Spiraling healthcare spending is steadily driving up the cost of living for working class Americans and, left unchecked, will create a fiscal emergency for state and federal governments.


Peterson-KFF

Fortunately, reeling in spending and improving health outcomes doesn’t need to be a zero-sum trade-off. We have the tools to fix our broken healthcare system. Emerging technologies offer the chance to deliver better care at dramatically lower price points. Policy reforms can reduce the staggering ~$935 billion in annual waste that plagues the healthcare system.[2] Political and business leaders have the responsibility to pursue both of these avenues to give Americans the care they deserve without sacrificing our nation’s future.

Flow of Spending in the American Healthcare System

In “How to Save $900B Annually in American Healthcare,” we outlined broad reforms that would bring down costs by aligning incentives across the healthcare system. This whitepaper hones in on specific areas where exciting new technologies combined with better steerage by private and public payers can deliver meaningful savings if entrepreneurs and policymakers are willing to take up the challenge. At 8VC, we are thrilled to partner with founders building ambitious companies in these spaces. At the Cicero Institute, we have made healthcare a priority, supporting reforms such as reference pricing for state employee health plans and creating a pathway for foreign-trained physicians to practice in the US.

Here are some concrete actions that can save US healthcare $200 billion annually:

1. Radiology ($17-24 billion in annual savings)

Annual Spend:
$227 billion

What To Do About It:
20-50% of radiological images fail to provide any incremental value for patients, either due to image duplication or human error.[3] Radiology’s highly manual workflows present a massive opportunity for healthcare entrepreneurs. Physicians cannot and should not be fully replaced by technology. However, an “iron man suit” that gives physicians superpowers in data sharing, image analysis, and task management could create $7-14 billion in savings by mitigating image overutilization, increasing productivity, and lowering labor costs.

Thanks to recent advances in artificial intelligence (AI), this vision isn’t a matter of speculation: start-ups like Nines and Sirona are developing products today that arm physicians to analyze images faster and better while minimizing burnout and waste. With the help of AI tools, radiologists can reliably identify the key features of a chest x-ray in 10 seconds.[4] On their own, humans might require 15 to 20 minutes for the same task. Likewise, the workstations that enable rapid image analysis can double as health information exchange systems that slash the chance of image duplication by 50%.[5]

An additional channel for savings would be to shift where patients receive radiological care. 60% of imaging takes place in hospital settings even though equivalent radiological imaging in outpatient clinics can be performed at less than half the cost.[6] Medicare could start reimbursing hospitals at the outpatient rate for radiology imaging procedures that can be reliably moved to clinics, reducing spending by at least $10 billion.

Promising Companies:
Nines AI, Sirona Medical, Aidoc, Zebra Medical Vision

2. Surgery ($40-60 billion in annual savings)

Annual Spend:
$888 billion

What To Do About It:
As with radiological imaging, hospital-affiliated facilities generally charge far more for services than unaffiliated outpatient facilities like clinics, independent physicians, and ambulatory surgery centers (ASCs). Price differentials are especially egregious for surgeries: private payers and Medicare often reimburse hospitals at twice the rate negotiated with ASCs located a short drive away. Yet, there is no difference in care quality between the two facility types. Not only are ASCs less prone to the monopolistic behavior of hospitals, but they have also been at the forefront of new reimbursement models (such as bundled payments) that motivate providers to take responsibility for a patient’s entire episode of care rather than simply billing them for discrete services (as occurs in fee-for-service payment models). In short, growing the number of surgeries performed at ASCs benefits patients and payers alike.

Advancing Surgical Care

ASCs have steadily increased their market share over the last two decades and now perform more than half of all outpatient surgeries. This positive trend has already saved the healthcare system $40 billion a year.[7] Still, as of 2016, only 48% of surgeries that could be safely performed at ASCs took place in these facilities (with the rest occurring at hospital inpatient and outpatient departments).[8]

Migrating eligible surgeries to ASCs could realize meaningful savings. Further efforts by payers like UnitedHealthcare to purchase and expand ASCs is one promising path. Medicare could also begin to reimburse hospitals at the same rate as other outpatient facilities for surgeries that are commonly performed in ASCs. These changes would save the healthcare system $40-60 billion per year.

Promising Companies:
Healthcare Outcomes Performance Company, CORE Institute, Remedy, Surgery Center of Oklahoma, orthopedic ASCs

3. Birthing ($2 billion in annual savings)

Annual Spend:
$116 billion

What To Do About It:
America is the most expensive nation for mothers to give birth: the average cost to deliver a child is about $30,000.[9] For uncomplicated deliveries (60-90% of births), birthing centers offer a high quality alternative to hospitals at a far lower price point.[10] These facilities can save payers $1100 per birth by providing virtual prenatal care, supplementing OB-GYNs with midwives, avoiding unnecessary c-sections, administering cheaper drugs to expectant mothers, and relying on fewer expensive (and often unnecessary) post-birthing services.[11] Payers should encourage women with a low risk profile (1.5-2 million births each year) to plan to deliver at birthing centers for a more comfortable, personalized, and cost-effective experience. This shift could yield up to $2 billion per year in cost reductions.

Promising Companies:
Oula Health, Maven Care, Quilted Health

4. Pathology ($13-20 billion in annual savings)

Annual Spend:
$124 billion

What To Do About It:
Pathology departments are beset by long turnaround times, low digitization rates, and a lack of coordination across laboratories. Providers can streamline this waste by adopting technology workflows pioneered by companies such as PathAI and Prosica. PathAI is pairing physicians with AI tooling to enable less labor-intensive, more accurate diagnoses. AI-assisted image analysis can diagnose certain types of cancer with just a 1.2% error rate - far better than the average 3% error rate for humans.[12] Any healthcare payer should leap at the chance to send patients to labs that cut diagnosis misses in half while simultaneously reducing spend.

Cancer pathology is a space where digital solutions (such as those created by Prosica) are likely to have outsized impact: a study from the National Institute of Health found that shifting to digital systems saved $5,000 in pathology costs annually for each cancer patient.[13] With 1.8M new cancer cases diagnosed annually, such a figure implies possible savings of about $7.7 billion. Applied more generally, AI and workflow automation products could reduce pathology spending by $13-20 billion.

Promising Companies:
PathAI, Prosica, Paige

5. End-Stage Renal Disease ($30B in annual savings)

Annual Spend:
$50 billion

What To Do About It:
End-stage renal disease afflicts nearly 800,000 Americans. Medicare covers all Americans suffering from this affliction, a responsibility that amounts to over 7% ($50 billion) of program expenditures.[14] Most patients undergo dialysis, a draining and unpleasant treatment that involves recycling blood through a dialysis machine for several hours three times per week.

Preventive care could save tens of billions of dollars and change hundreds of thousands of lives for the better by managing renal disease in its earlier stages. Assigning early-stage renal disease patients to nephrologists, for example, can substantially lower the probability of disease progression.[15] Perversely, however, payers have little financial motivation to engage in the interventions that forestall disease progress since the government will eventually assume financial responsibility for patients.

As we have written in the past, Medicare must rework these incentives. One promising step in this direction is Medicare’s Diabetes Prevention Program (DPP), which rewards providers for specific interventions that help at-risk patients lose weight and change their diets. DPP programs save Medicare $2120 per patient annually by measurably reducing the chance that patients develop diabetes. If applied to the entire population of Medicare beneficiaries at risk for end-stage renal disease, these programs could drastically improve Americans’ physical and financial health.

For patients already suffering from end-stage renal disease, kidney transplants offer a less expensive alternative to dialysis that also increases the likelihood of patient survival.[16] Migrating eligible Medicare beneficiaries from dialysis to kidney transplants could generate savings on the order of $20 billion. However, in addition to poor provider steerage practices, transplants have been constrained by an undersupply of kidneys. This tragic fact is a reflection of incompetence as well as true scarcity. Organ procurement organizations, government monopoly contractors charged with handling organs from deceased donors, lose 28,000 organs each year.[17] Decertifying organ procurement organizations that fail to meet minimum performance standards and ramping up production of bioartificial kidneys are two ways to unlock kidney supply (though the latter remain several years from mass clinical use).[18]

A more near-term solution to save Medicare $10 billion would entail moving patients from hemodialysis to peritoneal dialysis, a notably cheaper and equally effective form of treatment.[19]

Promising Companies:
Strive Health, Somatus, Cricket Health

6. Dual-Eligible Care ($50 billion in annual savings)

Annual Spend:
$470B

What To Do About It:
Our country fails to provide high-quality, affordable healthcare to the elderly. Currently available care options restrict senior patients’ ability to live freely: hundreds of thousands are forced to live in nursing homes because they lack the means to reside safely in their own homes.

Programs of All-Inclusive Care for the Elderly (PACE) care offer a superior, low-cost model where low-income seniors can receive excellent care at technology-enabled medical and social centers without needing to abandon their homes. PACE enrollees experience 24% lower hospitalizations and 16% lower readmissions compared to other dual-eligible seniors. PACE centers can also achieve efficiencies that lower Medicaid expenditures for seniors by 13%.[20]

Several companies, such as InnovAge, operate PACE businesses, but the space is highly underpenetrated. Only about 60,000 patients of the 1.8M eligible population are enrolled in PACE. Moving eligible seniors to PACE would save Medicaid $50B annually. To accomplish this goal, political leaders will need to reduce the regulatory complexity involved in setting up PACE facilities and push back against special interests such as skilled nursing lobbies that oppose reform.

Promising Companies:
InnovAge, Trinity Health PACE

7. End-of-Life Care ($19 billion in annual savings)

Annual Spend:
$380 billion

What To Do About It:
End-of-life care in the US is cripplingly expensive and uncomfortable for those in their final months. Patients pass in and out of hospitals for procedures that are painful rather than curative. Consequently, acute care for the 5% of beneficiaries who pass away each year amounts to 30% of Medicare expenditures. This model of care is callous and places a massive financial burden on younger generations. Yet, histrionic language about “death panels” has largely paralyzed reform.

Rather than mandating how these patients are treated, our society must give them the freedom to choose how they wish to spend their final months. Best-of-breed managed health organizations like Aspire Health empower the terminally ill to make these decisions, ensuring that they receive top-quality palliative care while shrinking costs by as much as $19 billion. In these organizations, care managers work with patients to decide what kind of care they wish to obtain and then coordinate across providers to reduce unnecessary procedures. Patients in programs like Aspire are 67% more likely to enroll in hospice than those receiving traditional care.[21] The result is a more humane model for end-of-life care that realizes savings north of $5000 per beneficiary.[22]

Promising Companies:
Aspire Health, Uphold Health

8. Claims Processing and Adjudication ($28 billion in annual savings)

Annual Spend:
$800 billion

What To Do About It:
The US spends $800 billion on healthcare administration each year, a far greater share than other developed countries.[23] A major driver of this overhead is the industry’s byzantine claims processing system. Physicians and hospitals hire legions of administrators who toil away at manually coding claims forms that they submit to payers for reimbursement. Payers then collect claims forms, standardize them, and review them for fraud or inaccuracy. The process is about as archaic and slow as it sounds, costing the healthcare system $150 billion each year.[24]

Automated medical coding and standardized, real-time claims submission could shrink this number by at least $10 billion. Start-ups such as Candid Health and Nym Health are building AI-enabled solutions that could increase claims processing throughput by an order of magnitude. Likewise, companies that build software to ingest individual provider claims forms and map them to a standardized form for payers would move the needle substantially on real-time claims submission.

In a similar vein, doctors and nurses waste untold hours on administrative activities like inputting data into EHRs, ordering tests, filling out prescriptions, and completing paperwork.[25] Software companies that reduce such administrative burdens will turbocharge physician productivity. Voice-to-text transcription start-up Nuance is one example of the kind of game-changing solutions that can be built here.

Together, standardized, real-time claims submission and administrative workflow software could drive $28 billion in savings for the healthcare industry.

Promising Companies:
Candid Health, Nym Health, Fathom Health, Ooda Health, Nuance

Conclusion

Reforming American healthcare is a battle for our nation’s future. Policymakers and entrepreneurs must take action to control spiraling costs by adopting promising innovations, aligning incentives, and steering patients towards less expensive and higher quality programs. Otherwise, rising expenditures will curtail economic mobility and spark vicious, zero-sum conflict. The $200 billion in savings opportunities identified in this piece provide a roadmap for our leaders to set America on a more sustainable course.

Joe Lonsdale
General Partner, 8VC

Philip Clark
Chief of Staff to Joe Lonsdale, 8VC

 

[1] “Health System Tracker: How Has the Quality of the US Healthcare System Changed Over Time?.” Peterson-KFF. April 19, 2019. https://www.healthsystemtracker.org/chart-collection/how-has-the-quality-of-the-u-s-healthcare-system-changed-over-time/#item-start.

 [2] William Shrank, Teresa Rogstad, Natasha Parekh. “Waste in the US Health Care System Estimated Costs and Potential for Savings.” JAMA. October 7, 2019. https://jamanetwork.com/journals/jama/article-abstract/2752664.

 [3] William Hendee, et al. “Addressing Overutilization in Medical Imaging.” Radiology. October 1, 2010. https://pubs.rs 

[4] Jessica Kent. “Artificial Intelligence System Analyzes Chest X-Rays in 10 Seconds.” Health IT Analytics. September 30, 2019. https://healthitanalytics.com/news/artificial-intelligence-system-analyzes-chest-x-rays-in-10-seconds 

[5] Michael Bassett. “Study finds that HIE reduces duplicate imaging, provides cost savings.” Radiology Business. February 4, 2015. https://www.radiologybusiness.com/topics/economics/study-finds-hie-reduces-duplicate-imaging-provides-cost-savings. 

[6] Jamie Cleverley. “Identifying the Gap Between Hospital and Free-Standing Prices.” Health Financial Management Association. https://www.hfma.org/topics/article/52656.html.

 [7] Tim van Biesen and Todd Johnson. “Ambulatory Surgery Center Growth Accelerates: Is Medtech Ready?” Bain & Company. September 23, 2019. https://www.bain.com/insights/ambulatory-surgery-center-growth-accelerates-is-medtech-ready/

 [8] “Study: Commercial Insurance Cost Savings in Ambulatory Surgery Centers.” Advancing Surgical Care. https://www.ascassociation.org/advancingsurgicalcare/reducinghealthcarecosts/costsavings/healthcarebluebookstudy.

[9] “Investing in Entrepreneurs that Improve Healthcare.” FCA Venture Partners. https://static1.squarespace.com/static/59244cb9db29d6a7b99e8006/t/5ddd89e6377ff72cee41b32b/1574799849113/FCA+Birth+Center+Report+-+vF.pdf. 

[10] Roosa Tikkanen et al. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries.” The Commonwealth Fund. November 18, 2020. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries.

[11] Embry Howell et al. “Potential Medicaid Cost Savings from Maternity Care Based at a Freestanding Birth Center.” Medicare Medicaid Res Rev. 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4167228/.

[12] K.S. Wang et al. “Accurate diagnosis of colorectal cancer based on histopathology images using artificial intelligence.” BMC Medicine. March 23, 2021. https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-021-01942-5#Bib1.

[13] Jonhan Ho et al. “Can Digital Pathology Result In Cost Savings? A Financial Projection For Digital Pathology Implementation At A Large Integrated Health Care Organization.” NIH. August 28, 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4168664/.

[14] “Healthcare Expenditures for Persons with ESRD>.” USRDS. https://usrds.org/media/1734/v2_c09_esrd_costs_18_usrds.pdf.

[15] Lee et al. “Effects of proactive population-based nephrologist oversight on progression of chronic kidney disease: a retrospective control analysis.” BMC Health Services Research. 2012. https://pubmed.ncbi.nlm.nih.gov/22894681/.

[16] Jeff Zaltzman- Pro. "This house resolves that kidney transplantation is better than dialysis.” St. Michael Hospital. https://www.stmichaelshospital.com/pdf/programs/renal-transplant/transplant-vs-dialysis.pdf.

[17]  JoNel Aleccia. “How Lifesaving Organs For Transplant Go Missing In Transit.” KHN. February 10, 2020. https://khn.org/news/how-lifesaving-organs-for-transplant-go-missing-in-transit/.

[18] The new CMS rules to hold organ procurement organizations to account is a step in the right direction, but they will not take effect until 2022 and no organ procurement organization could lose its government contract until 2026.

[19] “Peritoneal Dialysis: What You Need to Know.” National Kidney Foundation. https://www.kidney.org/atoz/content/peritoneal.

[20] National Pace Association. https://www.npaonline.org.

[21] Peter Ubel. “Reducing End-Of-Life Costs. It’s Not A Futile Pursuit.” Forbes. Feb 28, 2020. https://www.forbes.com/sites/peterubel/2020/02/28/reducing-end-of-life-costs-its-not-a-futile-pursuit/?sh=22e45c493285.

[22] Brad Stuart, Elizabeth Mahler, and Praba Koomson. “A Large-Scale Advanced Illness Intervention Informs Medicare’s New Serious Illness Payment Model.” Health Affairs. June 2019. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05517.[23] David Himmelstein, Terry Campbell, Steffie Woolhander. “Health Care Administrative Costs in the United States and Canada, 2017.” NIH. January 21, 2020. https://pubmed.ncbi.nlm.nih.gov/31905376/.

[24] Peter Orszag and Rahul Rekhi. “Real-Time Adjudication for Health Insurance Claims.” Lazard.

[25] Linda Carroll. “More than a third of U.S. healthcare costs go to bureaucracy.” Reuters. January 6, 2020. https://www.reuters.com/article/us-health-costs-administration/more-than-a-third-of-u-s-healthcare-costs-go-to-bureaucracy-idUSKBN1Z5261.

The 1-Hour Board Meeting

The 1-Hour Board Meeting

Joe Lonsdale|January 26, 2021

Founders who keep their investors informed and run disciplined meetings are those who get the most out of their board members. 

Too many board meetings waste time getting investors up to speed on the metrics, rather than strategic conversations getting their input and advice.

Eliminating this inefficiency was a big part of what motivated us to start Quaestor — a company whose mission is to create transparency in venture capital and bring the processes CEOs and boards use to communicate and share data into the 21st century. 

Quaestor creates a single source of truth where founders can track their company’s cash flow, burn, runway and see other important metrics. Founders can establish best-practices to stay on top of their financials and metrics, and can share that data on a permission basis with investors and executives. 

More transparency between founders and investors helps protect builders from costly financial surprises and enables them to leverage the power of their network to raise their next round and solve critical business problems as they arise.

The most productive meetings between investors and founders occur when both are well-informed of the business’ metrics and can spend time discussing how to accelerate the business rather than dwelling on the speed bumps. 

For early stage companies, a great board meeting shouldn’t require more than one hour. As a company matures, the board meetings will inevitably get longer as more members of the executive team are featured, and expectations of new investors are addressed. But as innovations like Quaestor eliminate the frictions in investor relations and facilitate information sharing, founders should be more equipped than ever to run productive board meetings no matter the stage.

Highlights & Lowlights — 2 Minutes

An effective board meeting starts with the founder’s high level perspective. Highlights and lowlights immediately help discern what is working and what isn’t. Investors are close to the business, but they’re not involved in the day to day, so this framing helps board members understand the insider perspective. 

Metric milestones, key deals, and new hires are examples of valuable highlights to celebrate. Declining metrics, talent issues, strategic misses, and unexpected capital needs are important lowlights to call out.

Financial Metrics — 8 Minutes

Quaestor minimizes surprises. If founders choose, it can update board members on financial metrics instantly so that they come into this part of the conversation well-informed. 

Still, the founder should always be prepared to speak to cash in the bank and burn, and be clear with how much runway is left based on a few different revenue and burn assumptions. These shouldn’t just be projections under bad, good, great scenarios. There should be detailed thought behind each assumption to speak to if necessary.

Product, Sales & Marketing — 10 Minutes

Covering Product, Sales, and Marketing in ten minutes is possible if you’re well prepared.

Product roadmaps must be succinct. Grouping by phases helps board members quickly understand progress and see the whole picture. The phases should be structured at a high level to show what’s complete, what’s underway, and what lies ahead both next year and in the more distant future.

Metrics on engagement are especially important before companies find product-market-fit. Founders should align with their board early and have frequent conversations about this. The North Star metric very well might be unique to each company. While standard metrics like NPS, churn, NRR, LTV/CAC can apply, founders should never assume that they alone determine what matters most to their business. 

Founders should regularly review the marketing funnel, pipeline generation, conversion rates, and weighted pipeline. Surprising variances (both good and bad) need to be called out to discuss what's driving these swings.

Marketing is the high-level sales strategy or strategic view of the battlefield. Simple tables can't capture insights on what's working or missing in the product and how those goals are interacting with the pipeline. As the company grows, cohort analysis matters, but even more important is discussing and testing the intuition on how marketing and product are interacting and what this means for the company’s resource allocation and business strategy.

Strategy & Board Asks — 35 Minutes

There’s no hard and fast rule about how to sequence discussing product, sales and marketing with strategy, the two are deeply related. Founders should jump into strategy chats on any issues that have come up in the previous section. The point is to use the bulk of the board meeting time to extract the most value out of the board.

Spend a lot of time on strategic insights, core principles, product goals, and the market. Share multiple financial scenarios for the next three years, incorporating the resources and potential evolution of your business. Call out the highest priority issues that you need help with like finding key hires or reconciling with large misses.

Other than strategy, founders should leverage board members for help on key resources like talent, financing, business development, and leads from their network who are helpful to the business.

Closing — 5 Minutes

Any administrative issues should be handled at the very end of the meeting. Remember to include fully diluted numbers and percentages for option grants.

No technology can or should run your board meeting. But organizing it ahead of time and coordinating with the participants through a platform like Quaestor enables founders to emulate the discipline and timeliness of top operators. 

Proud to work with the Quaestor team on a custom board deck template. Access the one-hour-deck on the Quaestor platform here.

Looking Forward: A Newcomer’s Hope for Texas

Joe|December 23, 2020

The following are notes taken from a speech I delivered, viewable here, at The Texas Summit hosted by Teneo on November 5, 2020 in the Debate Chamber at the Old Parkland in Dallas.


All four of the cardinal virtues offer us wisdom to this day, but my favorite of the four – and one that’s largely absent in today’s society – is the virtue of courage. In progressive cities all over the country, in our universities, our companies, and our institutions, it takes a lot of courage to stand up for American values today.

Texans exude courage. One hundred and fifty years ago, the great-great-great-grandfathers of Texas couldn’t have dealt with the Comanches and the Texas wilderness without enormous courage. It's core to the spirit of the place. It’s a welcoming place, it’s a friendly place, and it’s an independent place, but it’s also a courageous place. As an optimist, I’m focused on the future of Texas.

If we have courage, we’re going to have a very bright future. Every major problem in today’s society can be solved by the values that were core to the founding of Texas and core to the founding of America. All of these problems come down to people not understanding liberty, not understanding markets, and not understanding what a free society can accomplish.

If you look at our most regulated public systems, whether it’s education, whether it’s healthcare, or whether it’s the absurd housing costs plaguing the country, these problems all exist because systems are run top-down in bad ways rather than letting ideas compete and win. As people who believe in freedom, we must teach people the principles of free society, we must speak out about this, and we must not let our young people be taught incorrect far-left assumptions.

The number one thing that we need in public systems is for ideas to compete against one another. While a good politician will create programs that help people, a great politician will design systems that echo free society.

Free society works well because it works bottom-up. When individuals get to choose what to consume and produce, and to try different ideas and witness the effects, the best ideas will always win and the worst ideas will always lose. That’s the definition of progress. That’s why the economy grows year after year – because we have a constant competition of ideas in every area. And that’s why throughout our society, in America right now and throughout the world, we don’t have progress in the areas that don’t allow ideas to compete.

In public education, for example, there isn’t school choice and there’s minimal competition. With more competition and more bottom-up ideas, we would see a lot more progress. And I’m very optimistic for Texas over all, but health care is the most dangerous area in Texas right now. Texas health care costs have continued to grow six, seven, or eight percent a year, while legislators consistently guess that health care costs will only grow three or four percent. In this area, Texas can do much better.

Health care is a difficult issue for anyone who holds state power. It’s likely that many politicians purposefully guess wrong about costs because they don’t want to deal with the issue. In Texas, Republicans are in power, which means that they’re paid off by doctors and hospitals in the state to keep out competition. Doctors and hospitals aren’t bad (we need doctors and hospitals, of course), but we need competition in those areas if we’re going to make health care and state finances work.

So, the biggest issue in Texas – and one that I’m optimistic we will fix if we have the courage – is healthcare. We can’t keep stopping competition by putting in regulations that keep prices high. We need to let nurses perform to their fullest capacity. We need to allow telemedicine and emerging technologies to compete. And we need politicians who are courageous enough to fight these battles.

That said, I’m very glad to be a newcomer in Texas. I think it’s the most functional state in the country. The reason that I moved to Texas (and the reason that so many others have as well) is that I want to fight for our country. Progressive and far left politics are an imminent threat to free society because they create a zero-sum world, they rip down people who build, and they eliminate the progress. These ideals are spreading throughout California, spreading throughout Arizona, and spreading throughout our country.

Someone from the Arizona Board of Commerce recently reached out to ask if I would consider giving up on Texas and moving to Arizona instead. In response, I sent him a link to the extra surcharge tax they just passed on the wealthy and said “You guys are headed in the wrong direction.”

Texas is the last and best hope for freedom in America. It’s the best place to fight for our values. Not only is it the best right now, but if we fight to make it better, it will be an example of free society for the rest of the country. So, I’m proud to come to Texas, I’m proud to learn from the Texans who have built the state over the past decades, and I’m proud to join in the fight.

If Texas falls, America falls. It's time to take a stand. I hope that we’re all inspired by the fact that the battle will take courage because I know that if we all stand up, if we all fight, there’s no way that they can beat us.

Why we built Palantir

Joe|September 30, 2020

In 2010, I gave a speech on the computer science concept of “man-machine symbiosis”. Computers are great at integrating and organizing data from thousands of sources to build a common operating picture in ways humans cannot. Humans have a comparative advantage at higher levels of abstraction: creativity, intuition, and holistic judgements. Each is necessary. The best technologies do not automate complex problems, as many assume; they equip people to solve them faster and more effectively.

In this talk, I used the example of confronting a pandemic. You can’t “automate” the fight against a viral disease. But great information technology can help health providers, epidemiologists, and governments test and trace, map PPE supplies, and manage hospital traffic while keeping health records private in the process. In a crisis, leaders demand the best solution available to inform their decisions. Palantir’s platform was the common operating system for this year’s pandemic response efforts in 35 countries.

When I started recruiting most of the first 100 people to join Palantir in 2003, the theme of using man-machine symbiosis to solve the 21st century’s hardest problems was at the forefront of our discussions. By the early 2000s, Silicon Valley’s leading technologists were lightyears ahead of IT departments in government agencies. We were obsessed with our vision of using technology to transform the information processes that power government and enterprise.

At that time, rooting out terrorists was an existential imperative. The US was spending tens of billions gathering data but many of its IT projects were years late or hundreds of millions over budget. DC had fallen behind. We resolved to start by equipping the American Intelligence Community (IC) and DoD with a new type of collaborative information platform that would protect civil liberties at home. Our software eventually allowed counter-terrorism experts and special forces to neutralize thousands of adversaries (including infamous ones) and prevent dozens of attacks on the United States.

Palantir’s intuitive visual environment for analysts to explore and monitor terrorist networks relied on extremely complicated “back-end” architecture: dynamic ontologies for organizations with different data models, databases enabling new types of audit trails, and other systems supporting new ways of monitoring structured and unstructured information at scale based on concepts deemed relevant by analysts. We built AI to integrate hundreds of types of legacy databases, each with its own language and security paradigm. We organized data to allow computers and analysts to communicate in real time according to strict protocols and made sure our platform could flexibly accommodate changing collaboration policies between organizations and countries.

Our ambition was for the American and allied IC to securely share intelligence across a distributed network to prevent the next 9/11, without sacrificing American civil liberties. We achieved our vision within the first decade.

Palantir is often lambasted as an evil panopticon or “surveillance system”, which is the height of irony because Palantir is, to this day, the most sophisticated privacy engine in the world. I blame this faulty perception partly on a company culture that rewards building technology to solve hard problems rather than PR victories. Well before conversations about data privacy became popular, we designed our platform to protect civil liberties by defining and strictly enforcing new policies, masking private data from government agents and “watching the watchers” with a variety of safeguards and techniques. In fact, we named our company “Palantir” after the cautionary tale in the Lord of the Rings about the power of “seeing stones” that later fall into the wrong hands. Subsequent revelations of government misuse of data have only strengthened our original convictions.

Shortly after winning our initial government contracts, we made our technology available to the private sector, which now accounts for about half of Palantir’s business. We continued to develop new ways of solving the most important problems for large organizations with teams of forward-deployed engineers (FDEs) who then incorporated their solutions into the core platform. Today, a couple of FDE’s can perform in days what would otherwise require months of labor for hundreds of IT service professionals.

Palantir currently helps global energy companies integrate thousands of sources of data to make key investment and trading decisions. It helps aerospace giants coordinate with hundreds of airlines and manufacturers to improve supply, maintenance, and aircraft design. Leading banks, healthcare organizations, and others solve problems with Palantir in days or weeks that would have otherwise taken hundreds of millions of IT dollars of one-off work.

Products beat services, and our goal was always to develop a flexible platform to accommodate complex decision making based on "big data", customizing solutions with top talent as needed and integrating workflows back into the platform offerings. After releasing “Foundry”, a more comprehensive ‘productized’ platform, Palantir’s profit margins in the private and public sectors grew, and they continue to grow today.

Palantir is now one of the most powerful tools on the planet solving vital problems for governments and corporations. Our original thesis that technology should augment, not replace human beings has proven itself out hundreds of times as the world’s most important institutions have turned to Palantir to solve critical problems.

From the start, our goal was to put a top tech culture to work in the service of the US and its allies, while preserving the civil liberties that define our civilization. 17 years on, Palantir has kept our country secure and saved governments and corporations billions of dollars in the process. I’m excited to see what it does next.

The Wealth Tax is a Terrible Idea

The Wealth Tax is a Terrible Idea

Joe|March 6, 2020

It’s bad for the innovation economy, doesn’t work in practice, and is fundamentally unAmerican

 

The presidential campaigns of Senator Bernie Sanders and Senator Elizabeth Warren sparked national debate about many progressive policies that failed to gain mainstream attention in the past. Both senators are pitching a “wealth tax” as part of their arsenal to disrupt an economic system that they believe is rigged against common Americans. The wealth tax — a special tax on ultra-high-net-worth individuals — sounds like a pretty good idea to many middle- and working-class Americans. The tax would be levied on the appraised value of everything an individual already owns — real estate, stakes in private companies, cars, and even furniture — above a certain threshold ($32M for Sanders’ plan, $50M for Warren’s). Surely rich people can afford to pay a few percent tax on their net-worth, right? It turns out that wealth taxes are actually pretty complicated and that implementing one would have disastrous consequences.

A wealth tax would hobble the most dynamic parts of our economy. In particular, Silicon Valley’s innovation economy is the most vulnerable to the worst effects of a wealth tax. A wealth tax would amplify the risks already associated with volatile startup valuations. Taxes levied on valuations of private companies would expose investors and other shareholders (like owners and employees) to higher risks in the form of massive tax liabilities on those valuations. The results would be substantial declines in investment, entrepreneurship, and, ultimately, innovation. At the same time, a wealth tax would undermine our country’s appeal to the wealthiest and most productive people in the world. Driving away foreign wealth would lead to further declines in investment and innovation. Beyond the material aspects of foreign investment, attracting foreigners also holds cultural significance. America has long been the shining city on a hill. We should not forfeit that coveted status under any circumstances, but especially not for a tax that would probably lose the government more money than it would collect. The problems with wealth taxes are plenty — it is no surprise that ten out of fourteen European countries that taxed wealth in 1995 have since abandoned wealth taxes as a source of revenue.

I am cognizant that it is unpopular for a rich person to complain about wealth taxes, but I am ashamed of the silence on this issue. My fellow leaders in business and finance know how disastrous wealth taxes would be. They must join me in speaking out against this policy before it is too late.

As Senator Sanders and Senator Warren make their pitches for a wealth tax, here are some of the strongest counterarguments to keep in mind:

Wealth Taxes Disincentivize Investment

Angel investors play an important role in the innovation economy by providing crucial support to startups at their earliest stages. Angel investors are sometimes venture capitalists or established entrepreneurs, but they can also be friends and family members or even professors, as was the case with Google. A wealth tax would dramatically change the way that angel investments work, disrupting the delicate ecosystem that keeps the innovation economy growing. Angel investors would face serious risks when investing in early enterprises that could jump in value suddenly and substantially. If a company’s valuation increases sharply, as is common in Silicon Valley, an investor would be liable for huge wealth taxes on her stake, despite having no real financial benefit from those shares or guarantee that she would be able to cash them in in the future. When a company rapidly increases in value, that value is often volatile and uncertain. Companies frequently fail before their investors ever see a return on their investment. WeWork’s valuation, for example, fluctuated by nearly $40 billion over the course of a month. IPOs are now often delayed indefinitely. Other taxes on property, such as real estate taxes, work because the asset has relatively stable value. Private companies, on the other hand, are among the most unstable assets.

A common misconception is that business owners and investors have billions in liquid cash sitting in a bank account. We don’t. Without liquid cash, investors and business owners would have to sell part of their company each year to get the cash required to pay wealth taxes. Coercing founders of companies to sell shares or business assets in order to pay taxes discourages innovation and entrepreneurship, which are the basis of a successful economy.

Some wealth tax plans allow people to defer their wealth tax payments to the future. For example, Senator Warren’s plan allows for people to defer wealth taxes for up to five years. Deferring taxes seems to make sense for owners or investors waiting for a company to sell or IPO, but after five years if neither has occurred yet, then they are still liable for the aggregate of the taxes. The average enterprise IPO takes about twelve years, but it’s not unusual for some startups to wait more than fifteen years to exit. Even those companies that do exit often see their values slashed in IPOs and acquisitions, giving investors and founders a much smaller pay day than their “net worth on paper” had suggested. These complicating factors make wealth tax deferrals extremely risky. Consider the following example:

  • Suppose Linda wants to make her first big investment. One of her colleagues is building a promising startup, so she invests the most capital she can afford to risk — $500K — for a 20% stake to help get the company off the ground.
  • A few years later, some New York investors have taken an interest in the company, valuing it at $500M. Linda’s stake in the once-humble start-up is now worth a whopping $100M.
  • In the status quo, the high valuation is great news for Linda. She is excited about her investment and sees a payday on the distant horizon. But in a world with a wealth tax, the valuation makes Linda nervous. The tax on her 20% stake is now $1–2M a year (depending on the net worth threshold) and the company hasn’t located any buyers. The wealth tax perverts the incentive for a high valuation, so she actually wishes that the company were valued less.
  • Three years later, the once promising start-up busts. In the status quo, Linda is bummed about losing her $500K, but she isn’t bankrupt. In the world with a wealth tax, Linda is in serious trouble. She decided to defer her wealth taxes for a few years until the start-up was acquired and she got her payday. Now, the company is worthless, but she is still liable for $3M in wealth taxes — 6x her losses from the original investment.

Normally, when a company fails an investor loses their investment and the potential earnings from the company. But when there is a wealth tax, as “Linda’s” investing experience shows us, an investor also loses the amount she pays in taxes on that investment’s valuation. The risk of additional losses to taxes would require investors to have enough capital to make an initial investment and keep more money in reserve for potential taxes on that investment. As a result, fewer people could afford to invest in early enterprises. Even people who could still afford to invest would have less capital with which to do so.

In general, investors would be inclined to invest in fewer companies to limit exposure to potential taxes, whereas now investors typically make investments in many different startups. When investment declines, the biggest losers are not the wealthy people who cannot invest. The real losses are felt by the small businesses and early enterprises that rely on both the capital investment and the expertise of these experienced businesspeople to grow their companies.

Wealth Taxes Drive Away Foreign Investment

A wealth tax would apply to foreigners and non-residents who have assets in the U.S. too. Imposing a wealth tax would make the U.S. less attractive to foreign investors and wealthy immigrants. A report by Alain Trannoy, a French economist and public policy advisor, admitted, “wealth tax in some countries seems more efficient to repel the very rich than to effectively redistribute wealth.” Including both foreigners and French citizens, an estimated 10,000 people with 35 billion euros worth of assets left France to avoid the wealth tax in that country. Most other European countries abolished their own wealth taxes, attracting France’s rich exiles.

Repelling wealthy foreigners would have real consequences for the U.S. economy: in 2018, foreign direct investment to acquire, establish, or expand U.S. businesses totaled $296 billion. An estimated 7.4 million jobs are attributable to foreign direct investment (FDI) in the U.S. A decline in FDI would also disproportionately impact rural communities because the average foreign direct investment in rural America is greater than the average in metropolitan areas.

America has long attracted industrious people from around the world to build great companies, create awe-inspiring art, and invent the new staple of everyday life. A wealth tax would reverse that trend, encouraging the most successful people to leave.

Wealth Taxes Misalign Incentives for Startups

A wealth tax would fundamentally change how Silicon Valley operates. Silicon Valley’s startups drive the innovation economy, which plays a massive role in America’s productive output and is responsible for much of its economic growth. Software engineers are at the center of Silicon Valley’s miracle, bringing their unique talent, risk tolerance, and dedication to disrupting the status quo. Startups attract top engineers by giving them a stake in the success of their companies. Engineers stomach the lack of job security because of the potential for those small numbers of shares to skyrocket in value. But a wealth tax would make it risky for some top employees to accept shares in their companies. Consider the following scenario:

  • Suppose Lori is a highly respected software engineer in the middle of her Silicon Valley career. She’s had a very successful run at her first startup: she owns a house (median home price: ~$1.5 M), sets aside savings ($500K), and has $10M in illiquid shares in that startup. So, Lori has a net worth of about $12M.
  • Lori is looking for a change, and she finds an exciting opportunity at a biotech startup focused on cancer treatment. The new startup offers her a role as a senior engineer, a $300K salary (enough to live on in Silicon Valley with little savings), and a 5% stake in the early company.
  • Soon after she joins, the promising biotech startup raises capital investment at a $1.2B valuation. The company is still years away from knowing if its treatment will even work, but Lori’s stake is now worth $60M.
  • In the status quo, Lori is living happily. Her shares in the two startups are looking like a lucrative retirement plan, but she knows that she won’t be able to cash in those shares for years, if ever at all.
  • In a world with a wealth tax, Lori is devastated. Her total net worth is now $72M on paper, even though only $500,000 of that is actually cash-in-hand. The 2% wealth tax liability on her net worth above $50M (based on Senator Warren’s plan) is $440,000 annually. Between the high cost of living in the Bay Area and her other taxes, her regular income isn’t enough, so she dips into her savings to pay the remainder of the taxes. After two years, her savings are gone, and the tax burden forces her to re-mortgage her house. Her financial situation is dire.
  • At the same time, the biotech startup is about to raise more funding at an even higher valuation to facilitate expansion and work on cures for more diseases. Lori, running out of options, will have to forfeit shares to stay out of bankruptcy.
  • Lori’s friend Robert has a similar background and has two options for what to do in his career: help a risky startup that’s developing promising cures and disrupting the status quo or join a large established firm where he’s paid a much higher salary. Seeing Lori’s trouble, and having responsibility to his family, Robert decides to go work for “the man” instead.

Lori’s situation is more common in Silicon Valley than you might think. Fluctuating valuations, employee shareholding, and low liquidity among founders and employees alike are all characteristic of the innovation economy. Before a company’s IPO or acquisition, almost no one in that company has enough liquidity to pay taxes on its valuation. Thus, wealth taxes would have complicated and profound effects on how Silicon Valley operates. At a basic level, wealth taxes would create a perverse incentive for startup employees to forego or forfeit shares in the promising companies they work for, further entrenching wealth in the hands of owners, founders, and investors who might have access to more liquidity (or might not, in which case they would find themselves in the same unfortunate situation). Even if the wealth tax could be paid in shares — as some plans would allow — the incentive for shareholders would be to pressure the company to limit its size in order to keep the valuation low enough to avoid paying massive taxes. Disincentivizing growth in this way would make everyone worse off.

The Costs and Logistics of Implementation

One of the most basic issues with a wealth tax is that it relies on appraisals. The IRS would require wealthy people to annually appraise their entire estate — an onerous, arbitrary, and expensive process. High net worth individuals tend to have a greater variety of assets than the average person. Each year, the IRS would need an army of appraisers to determine the values of jewelry, cars, ancient pottery, furniture, and clothing, in addition to bigger assets like privately held companies, farms, and real estate. Real estate and business appraisals are exorbitantly expensive, costing between $10,000 to over $50,000 each. Appraisals of art, cars, boats, furniture, and heirlooms require appraisers with even more unique expertise.

The subjective nature of appraisals adds additional challenges. Expert appraisers frequently disagree on valuations with owners, with each other, and, most importantly, with the IRS. Disagreements on valuations would flood an already overburdened court system with expensive legal disputes.

The task of enforcing the new wealth tax would ultimately fall to the IRS. To contextualize the demands placed on the IRS, consider estate tax audits, which are the most similar to what wealth tax audits would look like. The IRS does about 1200 estate tax audits annually, or 30% of estate tax returns, which is the proportion estimated to ensure compliance. If 30% of potential wealth tax returns were audited to ensure compliance, that would mean 25,000 more audits each year! Tens of thousands of complex audits would overwhelm the IRS, which is already understaffed and shrinking. The institutional demands of a wealth tax would consume resources that could be used for the agency’s more important functions, like criminal tax evasion investigations.

Audits are more than just a burden for the IRS though. Wealth tax audits would be particularly intrusive since they apply to physical things inside of a household. Each year, the IRS would force thousands of families to open their homes to auditors who would then sift through their furniture, art, jewelry, and even clothing. Government agents rummaging through the households of law-abiding citizens should make us think of totalitarian dystopias — not the United States of America.

Every step of implementing a wealth tax is expensive. The costs of enforcement add up: hiring thousands of skilled appraisers, expanding the courts to accommodate disputes from elite legal teams, and equipping the IRS to carry out thousands more audits each year. Yet, the revenue a wealth tax would raise is quite small: an estimated $37.5 billion a year, or roughly a 1% increase in total annual tax revenue. Other countries ran into fiscal problems when they considered or implemented wealth taxes too. British Labour leader Denis Healey, who tried and failed to champion a national wealth tax, later wrote that even after five years of work, Labour could not draft a wealth tax that would yield enough revenue to justify the costly administrative challenges of enforcing it. In France, the “solidarity tax on wealth” failed to raise notable revenue, only generating about $3 billion annually at its peak. Between enforcement costs and lost taxes from the emigration of wealthy families, economist Eric Pichet estimates that the French government lost twice as much revenue as was collected by the wealth tax. French President Macron saw these issues and eliminated the tax in 2017, making good on his popular campaign promise to do so.

Wealth Taxes Aren’t the Answer

Americans are frustrated by wealth inequality, but a wealth tax will not achieve the results that progressives are looking for. Wealth is rarely hoarded by the “elite” — rather, most of today’s wealth is created from scratch by entrepreneurs who grow the economy. Wealth is typically reinvested in companies, leading to more growth and better quality of life for all Americans. Economic growth carries real promise for the average American. Investment in new businesses helps entrepreneurs build great companies, offer better goods and services for lower costs, and create more jobs — everyone wins. But a wealth tax would encourage investment in established companies with liquid stock rather over new ones with illiquid stock. A wealth tax would distort the incentives that foster economic growth, hurting the most innovative part of America’s economy and securing the position of incumbent businesses against newer, more efficient startups. America’s economic trajectory would regress, making everyone worse off.

In addition to causing economic pains, a wealth tax would be a more expensive and needlessly complicated approach to taxation. The costs of implementation and lost revenue from foreigners and citizens leaving the country would likely cause the government to break even or actually lose more money than it collected. In any case, using the tax levers that already exist is a safer and cheaper strategy to raise revenue than a new wealth tax.

Beyond the fiscal issues, wealth taxes simply go against the free spirit of America. Intrusive audits of property would go far beyond looking at spreadsheets — they would entail what is in essence a warrantless search of one’s home. The prospect of such incursions by government agents should be unacceptable to every American. They certainly are unacceptable to me.

I am an entrepreneur, an investor, and above all, a proud American. I care deeply about my country. I have worked hard building civically minded companies, many of which have been very successful. I use the wealth that I created to search for solutions to America’s toughest challenges. America needs effective solutions to the problems that working- and middle-class Americans face, like lowering housing costs through more development and reducing prices by eliminating crony capitalist protections on inefficient industries. But a wealth tax would not help Americans. Instead, a wealth tax would stomp on the liberties that make America exceptional and erase the essence of our republic for the immoral purpose of tearing down the success of others. I could not stand for such a reality. While I am confident that our constitution and courts protect us from this invasive, destructive idea, both political parties should oppose wealth taxes and focus on policy that actually helps the least well off.

Libertarianism is Dysfunctional, but Liberty is Great

Libertarianism is Dysfunctional, but Liberty is Great

Joe|February 4, 2020

American libertarianism has become a useless, purely performative sort of politics. Many libertarians I know seem blinded to the fact that the American social contract has fundamentally changed in character. At least since the New Deal, the political reality is that government involvement in our lives has increased in irreversible ways. But while libertarianism has become a form of unhelpful critique, liberty remains as vital as ever before. If we want to fix the most broken areas of our society, such as criminal justice, education, and healthcare, we must embrace policy solutions that mirror the competition of ideas that defines a free society. This means transparency and accountability. Wherever government is involved, we need systems that allow governing ideas to compete. Our rules need clear metrics, decision-makers need the freedom to experiment, and we must reward their successes and quickly eliminate failures.

The philosophy of liberty as generally understood by America's founding generation — including all it implies about speech, property, and other natural rights — should always be a vital part of the American identity. Libertarians of every age have understood that the wisest political orders must safeguard basic freedoms.

Liberty forces us to take personal responsibility for our decisions in the knowledge that each of us is the author of our own life. It is the foundation of our moral culture. Liberty is also the basic condition for aesthetic and cultural progress. “Experiments in living” produce the brilliant variety of human ingenuity and expression on display in the free world. Finally, liberty allows people to innovate and compete to deliver superior goods and services, which creates prosperity. If entrepreneurs are free to fail or to succeed in the marketplace of ideas, and entitled to the fruits of their labor, talented individuals will devise beautiful new ways to enrich the lives of others.

Too few people today understand why the word "LIBERTY" is inscribed on our coinage and our identity as a nation. Though some mock liberty as an outdated or abstract concept, it is as central to the health of our civilization as ever before.

But liberty is not enough. And I no longer call myself a libertarian.


 

The philosophy of liberty is ultimately a philosophy of restraint. It explains what government shouldn't or can't do. In libertarian theories such as Robert Nozick’s, most of the functions of modern government vanish in favor of a “night watchman state” so minimal that one would be hard pressed to find a single real example in human history.

In today's complex world, most Americans agree that the government will play a critical role in our economy, for example in education, healthcare entitlements, and the provision of a social safety net. Despite this basic reality, there are hundreds of thousands of smart libertarians on the sidelines griping at their TV screens about government dysfunction. Too many libertarians are shouting "no" instead of trying to help improve our society.

These “get off my lawn” libertarians convulsively reject any form of state activity. You see them in Congress, where Tea Party and Freedom Caucus Republicans grandstand and obstruct policy rather than fix our government. You probably even know one or two people who are so blinded by their laissez-faire ideology that they can’t recognize good policy when it’s staring them in the face. Let’s go over a quick example to teach them the value of positive policymaking.

Until about 50 years ago, many of our fellow citizens were still dying because dialysis machines were scarce and unaffordable. As a society, we decided that nobody should die of preventable kidney failure, and we decided to pay for it. In 1972 President Nixon and a bipartisan Congress amended the Social Security Act to say that government would cover dialysis as a remedy to end-stage renal disease for any American who needed it.

The knee-jerk reaction from the libertarian right is that government shouldn’t be involved in healthcare at all. Your libertarian friend might interject: “In a wealthier society charity would pick up all these costs more efficiently.” But let’s be realistic: our country will never get rid of our system of state-sponsored healthcare. Even were such a thing possible, many might die in the transition period. The political reality in the US today is that we must continue paying for end-of-life kidney care for those who can’t afford it. Anything else is disgraceful.

The better question is: why does dialysis cost taxpayers well over $35 billion annually, or a full 7% of the Medicare budget? The answer is that the federal government is willing to sponsor lifesaving care for people experiencing severe kidney failure, but not willing to sponsor preventive treatments that could effectively keep Americans from progressing into kidney failure. Our government accidentally created an incentive against preventive treatment, and even worse, against technological and medical innovations that could improve our ability to address early-stage kidney disease!

Fortunately, this is a problem we can fix. Even a libertarian should agree that if government is already paying for end-of-life care, it should certainly cover preventive measures that keep patients healthy instead of shackling patients to grim dialysis clinics. Imagine if Medicare paid for diagnostic screenings well in advance of kidney failure, and reimbursed providers for keeping early-stage patients from sliding into end-stage renal disease. We would immediately unleash innovations in preventive medicine that would save billions of dollars and keep hundreds of thousands of people from passing the point of no return![1]

Unfortunately, the hardened, dogmatic form of libertarianism that one often encounters in America today adds little to our political discourse. But an optimistic creed which draws on the lessons of liberty can improve American government in powerful ways and tackle major problems in our country.


 

In a society governed by the rule of law, individual freedom typically finds expression in a market setting where entrepreneurs peacefully compete to produce superior goods for others. A free market is a kind of “spontaneous order” which channels our acquisitive drives and instincts for glory towards service. As Albert Hirschman argued, free markets transform the sin of avarice into a civilizing virtue. Wouldn’t it be great if we steered auri sacra fames towards solving challenging social problems typically addressed by government?

Any great policy does three things: it creates a clear but general incentive for government or private sector actors, it transparently tracks the performance of those actors, and then it holds them to account for their successes or failures. Rather than prescribing procedures or setting dozens of intermediate goals, policies should outline ultimate metrics, and give people creative license to pursue these metrics in the ways they judge best. As Philip Howard puts it, “human responsibility is the oxygen of accomplishment.” Rewarding entrepreneurs and government employees for successfully achieving specific outcomes — such as preventing the escalation of kidney disease — maximizes freedom and creates the conditions for bottom-up competition in the provision of public goods. Dialysis is just one example. Consider two others:


 

Criminal justice. We incarcerate seven times as many people as we did in the 1970s, and about 70% of people reoffend within three years of their release from prison. We know that certain jails, prisons, and re-entry departments are better than others at rehabilitating offenders, but we reward them all with the same fixed fees for supervising their wards and carrying out a thousand minor procedures.

What if instead of paying our corrections officers to “warehouse” detainees we incentivized them to successfully help people reintegrate into society? In this new paradigm, corrections budgets would expand for facilities, departments, and counties that successfully reduce their return to incarceration rates. This kind of transparent rewards system would motivate state employees to iterate and figure out what can really reduce our corrections population while also reducing crime in our communities.

This model works because it harnesses the creativity and free judgment of corrections officers towards achieving a valuable social outcome. We’ve seen it work in my home state of California, which implemented exactly this model for felon probationers in 2009. As soon as the bipartisan law passed, California probation departments radically shifted their cultures and began behaving like entrepreneurs: experimenting with cognitive behavioral therapy, education, and other rehabilitative techniques to see how they could most effectively drive down recidivism rates.

In the past decade this institutional shift has steered roughly 100,000 probationers away from prison, saving state taxpayers over a billion dollars. Men and women who might have wound up in prison have been able to build lives outside of our corrections system. Imagine if the rest of American criminal justice was free to innovate and improve in the same way!


 

Higher education. Elizabeth Warren, Bernie Sanders, and others are loudly calling for the federal government to forgive some or all of the $1.5 trillion in student loans outstanding in this country. But the reason we’re in this mess is that our colleges and universities are not preparing American students for the kinds of successful careers that would allow them to pay off their student debt.

The federal government disburses nearly $100 billion in Title IV student loans per year, and nearly another $30 billion in grants to colleges and universities. This massive aid package flows to institutions of higher learning regardless of whether their students succeed or fail in the workforce.Colleges and universities are completely unaccountable, and alumni salary data has only recently become available. Is it any wonder that tens of millions of people are struggling to pay off their student loans?

To a free-thinking entrepreneur who appreciates market incentives, it’s obvious that we should make Title IV funding contingent on the performance of our colleges and universities. Policymakers typically describe “performance” in terms of graduation or degree completion rates. But imagine if colleges and universities were rewarded with more aid and more scholarship students on the basis of the real earnings of their graduates.

In this world, schools would compete furiously to figure out how to best advance the careers of their students. They would address quantified skills gaps by focusing on vocational training, partner with large corporations in need of new recruits, offer classes in the evenings when full-time workers and single moms can attend them, and try out new blends of online and physical instruction. Instead of allowing accreditation agencies to decide what schools can and can’t teach, policymakers should reward schools for producing ultimate results based on metrics (like market salaries) that can’t be gamed.

There are obviously nuances — this kind of proposal would have to adjust rewards for the fact that some students are more likely to attain high-paying jobs than others, as well as institutions like arts colleges for which this model doesn’t make sense. But the basic philosophy is clear: give colleges and universities the liberty to experiment with different pedagogies and reward them for the result we care about most.


 

There are dozens of other non-partisan reforms to pursue in our country, at the federal, state, and local levels. Libertarians need to stop griping and start harnessing the best and brightest in the country to go do them. Our group, the Cicero Institute, is working with policymakers on both sides of the aisle to bring about reforms in healthcare, housing, and criminal justice that would help tens of millions of people and save tens of billions of dollars.

As Americans, we hold many values in common. The challenge is to promote sensible laws and institutions that bring about these shared values. We must ask: how can we expand opportunities for Americans to provide for ourselves and our families? How can we fight for reasonable costs of living instead of unaffordable medical bills, housing rents, and student loans? How can we prevent cronyism and corruption at the taxpayer’s expense? And how can we address the legacies of inequality that halter working-class citizens and threaten the unity of our republic?

Libertarians should not abandon bold, controversial ideas such as replacing our welfare state with direct “universal basic income” to the poor, legalizing most drugs, liberalizing our immigration policy, or drastically simplifying the tax code. But they should first apply their perspective to solve problems on which we all agree. Let’s channel our competitive drives and national genius into positive-sum projects in the service of others, whether in healthcare, criminal justice, education, or other areas of American life.


 

A more earthy, realistic American political philosophy will insist on the value of individual liberty while also recognizing that government will continue to be an instrument for solving social challenges. We must allow entrepreneurs and government employees to compete on the marketplace of ideas, transparently track their performance, and reward those who succeed. On a trellis of clear incentives, the vine of good governance may grow freely and flourish.

Our basic liberties have allowed a meritocracy of ideas to prevail in our country and made possible the past two centuries of economic growth and political progress. We can remain faithful to the insights that inspired our founding generation while also being honest about the realities of 21st century government. What we can learn from libertarians is something that libertarians themselves seem to have missed: that the philosophy of liberty is both idealistic and pragmatic.

When we give entrepreneurs the freedom to innovate and reward them for delivering the social outcomes we care about, they deliver beautiful and unpredictable solutions. We can harness the energy of our great entrepreneurial culture to improve the lives of the least well-off and allow the best ideas to scale. We’re the best in the world at building innovative companies that transform lives across the globe. Let’s bring the same energy to championing policies that serve the American public in powerful, measurable ways.

The duty of the modern libertarian is to stop grousing about American government and start fixing it. If we remain true to the principle of LIBERTY and sustain a healthy respect for the creative energies of free people, we can transform our government and improve the lives of Americans across the country.


 

[1] As we have written elsewhere, preventive and in-home care models for patients with chronic kidney disease have been successful at lower costs. Medicare should embrace these models.

Private Philanthropy has Many Lessons for Government

Private Philanthropy has Many Lessons for Government

Joe|February 3, 2020

America’s nonprofit sector is booming. There are now over one and a half million nonprofits registered with the IRS, contributing nearly one trillion dollars to the economy. Private giving has risen to $430 billion, the highest level ever.[1] Such private philanthropy often accomplishes things government services cannot. Private philanthropy allows for experimentation with a broader range of ideas, producing a greater variety of solutions and approaches to problem-solving in general. Philanthropic organizations often achieve considerably more success than government in addressing pressing issues. In 56 out of 71 studies that compared the efficiency of public agencies and philanthropic organizations that offer the same services, the private provider was more effective.[2]

As Philanthropy magazine editor-in-chief Karl Zinsmeister recently wrote in the Wall Street Journal, private philanthropy’s comparative success has made it a target for politicians and editorialists who peddle bigger government and view philanthropy as its competitor.[3] But government should not view philanthropy as a competitor. As Zinsmeister writes, “America’s highly decentralized philanthropy is one of its most pluralistic and democratic elements. Philanthropy disperses authority, gives individuals direct opportunities to change their communities, and lets nonmainstream alternatives have their day in the sun.” Politicians and officials should see philanthropic organizations as incubators of ideas that government can scale.

Since modern philanthropy emerged in the 19th Century, nonprofits have been quick to address societal ills when politicians hesitate. Historically, government has recognized the effectiveness of many philanthropic solutions, creating a long tradition of federal, state, and local governments adopting and expanding projects started by nonprofits.

One famous example is the establishment of Carnegie libraries. Andrew Carnegie built and donated over 1,500 public libraries across the United States to increase access to education for all Americans. Carnegie, an immigrant who had educated himself with the books he read while working from dawn to dusk starting at age thirteen, believed that public libraries would be especially beneficial for immigrants trying to assimilate and people who wanted to learn but were either too old for tax-payer funded high schools or could not afford to spend time in a formal classroom.[4] Most significantly, Carnegie broke from earlier trends in library philanthropy that produced magnificent buildings that were too expensive for local taxes to support. The Carnegie libraries were efficient and functional, an architectural innovation adopted by local governments across the country seeking their own affordable public libraries.[5]

The problems facing our growing world come at a pace too fast for the government to lumber in search of effective solutions. When governments see winning ideas that are better than their own, they should try to scale them. One form this can take is providing educators with tools that are experimentally proven to lead to more successful student outcomes. Math Shelf is a tablet-based app that has shown statistically significant improvements in mathematics performance among preschool students.[6] The program has been expanded up to first grade, and studies have shown that students can learn more than a year and a half of additional mathematics with only twenty minutes of app use each day compared to students who did not use the app at all. Studies of Head Start, in comparison, show that the federally-run program has no discernible positive impact on participating students by the time they reach third grade.[7] Head Start’s budget of $10 billion might not represent the best use of funds, whereas expanded access to tools like Math Shelf could help educators nationwide achieve better outcomes for their students.

But sometimes scaling fails. Policy makers should understand that what works to improve education outcomes for low-income students in inner-city Detroit might not work in Appalachia. In addition to adopting the winning solutions themselves, the government should incentivize local experimentation so that communities can tailor solutions to their unique situations.

In Chicago, local officials are doing exactly that. Violence plagues Chicago, and the city’s police have struggled to get homicides and shootings under control. 2016 was the most violent year in two decades for the city, with 780 murders and 4,300 shootings.[8] In 2016, only 29% of murder investigations led to an arrest. Arnie Duncan, a Chicago native and former U.S. Secretary of Education under President Obama, realized that policing was not enough. He created a non-profit organization called Chicago CRED, which has sought a more effective approach to gun violence. Duncan and his team have worked with thoughtful and experienced philanthropists like Laurene Powell Jobs, local officials, like-minded organizations, and the communities most at risk of violent crime to experiment with street outreach, life coaching, counseling, and workforce development. With private funding, CRED could allocate resources more creatively. Chicago Mayor Lori Lightfoot is adopting a similarly holistic approach to public safety through targeted investment in the South and West side neighborhoods. The results are already staggering. Shooting dropped 8% in 2018 and 9.7% in 2019.[9] There is more work to be done, but Chicago’s model of community-based solutions is a roaring success that other cities should emulate.

In general, government problem-solvers need to take chances on younger talent, higher-risk research, and a range of projects encouraged by private philanthropy in order to foster the development of the best ideas and solutions. They need to test unorthodox methods and move away from tired policies that don’t work.

This iterative approach could improve our country’s biomedical research system. The successes of privately funded biomedical research outpace those of the National Institute of Health (NIH) not because they have more resources but because they better allocate their resources. Nationally, total inputs for medical research is substantially increasing, but the results are not commensurate to this increase.[10] At the same time, the number of scientists being trained has continued to rise, breeding hyper-competition for federal funds that researchers at the National Academy of Sciences believe “suppresses the creativity, cooperation, risk-taking, and original thinking required to make fundamental discoveries.”[11]

Competition for NIH funding, in particular, has made the biomedical research system favor projects that have guaranteed results conducted by older, more established academics, rather than higher-risk, unconventional projects and younger researchers with new ideas. In 1980, NIH granted twelve times as much funding to researchers under 40 than over 50, but today five times as much funding goes to the older cohort. In the current system, younger academics feel immense pressure to conform to the tired formula of grant acquisition, producing stagnation where innovation should be encouraged. Many advocates of the NIH argue that the institution simply needs more resources, but additional funding alone will not correct the systemic problems hampering the NIH.

Damon Runyon Cancer Research Foundation has taken a different approach to funding research, and the results are impressive. Their award programs specifically target young cancer researchers early in their careers to do high-risk research that wouldn’t happen otherwise. Former grantees help determine which researchers have the most promise. Damon Runyon researchers have won twelve Nobel Prizes, and sixty-five of their scientists have been elected to the National Academy of Sciences. According to the nonprofit rating organization Charity Navigator, Damon Runyon’s results have “exceeded industry standards and outperformed most charities in its cause.”[12]

For NIH and other funders to improve, they cannot just fund scientists who have proven their success or increase funding overall. In short, NIH should take inventory of its procedures and open itself to the better practices of other organizations, such as funding riskier research and younger researchers. NIH has a prominent role in our country’s scientific community, which makes it all the more important that it incorporates the promising approaches of private research funders.

It is no surprise that studies have found that 71% of American trust nonprofits over government to solve the most pressing issues of our time. Free and dynamic societies allow private individuals to experiment, innovate, and flourish. It is a perennial challenge for government to innovate and improve quickly, but there are many relevant lessons that public officials can learn from private citizens’ philanthropic ventures. Politicians and officials should work to fix the inefficiencies that plague public programs and use solutions from private philanthropy so that our government can more effectively achieve the results its citizens deserve.

Disclaimer: The chair of the Cicero Institute, Joe Lonsdale is a donor to UCSF, IGI, and Damon Runyon.

Capture the Flag

Capture the Flag

Joe|November 5, 2019

American capitalism is under siege. Nationalist-Right politicians defend reincarnations of 20th century industrial policy and blame weak wage growth on immigrants and foreign exporters. Meanwhile far-Left politicians including Bernie Sanders and Elizabeth Warren have popularized traditional Marxist critiques of the rich and want the federal government to nationalize banks, the healthcare system, and other sectors of the economy. Each rejects market competition in favor of expanded state involvement in the American economy. Each side has it wrong.

The problem with capitalism today is that market competition itself is in decline. The gravest threat to the American economy is “crony capitalism”, whereby special interests including industry groups and unions pervert the policy making process in order to restrict competition and line their own pockets. Market competition is precisely the feature of our economy that we must fight to preserve.

A competitive market is an evolutionary system in which every business must constantly test its worth against entrepreneurs with bold, new ideas. As Joseph Schumpeter noticed long ago, entrepreneurs create value for society by destroying outmoded, inefficient modes of business and replacing them with more productive models. Market competition naturally rewards creativity, innovation, and entrepreneurial genius, no matter how unexpected their origins. It ensures that the best ideas go viral, the worst ideas vanish into obscurity, and business leaders pay for their mistakes with lost market share.

When the best ideas win, we all benefit. In the past two centuries, entrepreneurs have developed fantastic innovations and streamlined modes of production, lifting our population from agrarian poverty to standards of living that would have astounded our ancestors. It’s no overstatement to say that the profit-motive — the right to keep one’s earned income — is the main explanation for this tectonic shift in human life. But if the profit-motive is the principal reagent in the grand experiment of economic progress, it is also dangerously volatile and corrosive.

In a state of nature, our acquisitive drives bend towards violent appropriation of the wealth of others. A legal framework that enshrines individual rights to person and property is the essential bulwark against this kind of brute force. But an expansive modern government presents private corporations with thousands of new opportunities to twist the coercive power of the state to favor their private interests. In medieval times cronyism was straightforward: the crown granted monopoly charters to favored guilds and corporations in exchange for bribes. Today’s crony capitalism replicates this old system of client politics in subtle, insidious ways.

Defense

The military-industrial complex is the granddaddy of all crony industries. The scholar Gordon Adams identified an “iron triangle” of special interest linking Congress, the military, and private contractors, such as Lockheed, Raytheon, and Northrup Grumman.[2] The unholy union of pork-barrel politics, revolving door dynamics, and the plausible alibi of national security imperatives is the perfect cover for corruption and waste in the defense sector. One half of the Department of Defense budget is allocated to contractors every year and impartial decision making in military contracting alone could save our country at least $100 billion annually. [3] But the true magnitude of waste in the American defense industry is much higher.

Traditional economic laws just don’t seem to apply to the fantasyland of defense contracting. Unit economics are often mind boggling. Journalists were outraged to discover that during the Reagan administration our military spent $600 per aircraft toilet seat cover and $7,662 on a certain coffee machine.[4] But today the toilet seat covers cost $10,000 apiece, and we’re spending $1,280 per mug on reheatable coffee cups![5]

A defense contractor such as Lockheed Martin will typically secure congressional “buy-in” to a contract at a low rate, and then ratchet up the price of the contract on the premise of sunk cost. Cost overruns on complex goods such as planes range as high as 3–4x the original estimates. Congress has financially bailed out private contractors, financed mergers between private contractors, issued no-bid deals to private contractors, and lent private contractors money for arms deals at egregiously low rates.[6]

In return, defense contractors have metastasized and begun selling ludicrously overpriced, low-quality products to every government agency they can sink their fangs into. Consider that Lockheed Martin is the largest contractor not only for the Pentagon, but also for the Department of Energy and the Department of Transportation, the second largest contractor for the Department of State, and the third largest contractor for NASA.[7] We spend over $300B a year in defense contracts with private contractors alone, but when you include non-defense expenditures the number is far higher.[8]

Defense contractors typically locate production in as many congressional districts as possible so that Congress members will be able to claim they’ve “brought home jobs” to their districts when they award insane military contracts. Military executives are so completely aligned with private contractors that they often split up lobbying efforts for contracts. As Senator William Proxmire put it in 1969 “How hard a bargain will officers involved in procurement planning or specifications drive when they are one or two years from retirement and have the example to look at of over 2,000 fellow officers doing well on the outside after retirement?”[9]

Banks

If the defense contractor industry’s death grip on government is a “military-industrial complex”, American banking may justly be described as a “Wall Street-treasury complex.” Revolving door hiring is rampant. During the writing of Dodd-Frank, 47 of 50 Goldman Sachs lobbyists, 42 of 46 JPMorgan Chase lobbyists, and 35 of 46 Citigroup lobbyists had held government positions.[10] And the Treasury Department — led by former Goldman Sachs CEO Hank Paulson — was packed to the gills with former investment bankers.[11]

It is an inescapable reality that the individuals with the expertise to regulate an industry are the same individuals who achieved positions of prominence within that industry, and finance is no exception. But it would be naïve to assume that former bankers launch new careers as financial regulators tabula rasa, with pure motives.

After the mortgage crisis and the savings and loan bailouts of the 1980s, which cost taxpayers over $200 billion, the government expanded Fannie Mae and Freddie Mac — two of the most offensive examples of crony capitalism in the country. Although technically private, the two mortgage lending giants had special access to U.S. Treasury loans, federal officials on their boards of directors, and an implicit guarantee from the government. Beginning in 1992, administrations from both political parties also expanded the low-income lending goals of these two giants, until over 50% of their loans went to low-income families. These questionable loans contributed to the giants’ collapse and bailout in 2008, which cost taxpayers over $180 billion.

Other banks also benefit from implicit government guarantees. Since the bailout of the Continental Illinois bank in 1984, large banks have assumed that the government will rescue them in a crisis. The too big to fail problem creates a “moral hazard”: banks take riskier bets with the understanding that the government will bail them out if those bets sour.[12] As expected, the federal government’s Toxic Asset Relief Program (TARP) provided over $450 billion of bailout capital to banks during the 2008 crisis, at terms grossly favorable to the banks.[13] To manage the vast portfolio of troubled assets the Federal Reserve acquired after the bailout, Treasury Secretary Tim Geithner gave three no-bid contracts to BlackRock, which spends tens of millions a year hiring former government employees and lobbying the federal government.

The Dodd-Frank Act reinforced the crony relationship between our government and financial industry. Today, a bank in trouble does not go through an ordinary bankruptcy. Instead, the “Orderly Liquidation Authority” gives special debtor financing and creditor support to a failing bank. In addition, Dodd-Frank and subsequent regulations made it harder for small and new banks to compete with large incumbents. Since Dodd-Frank, over 2,000 small banks have closed their doors. And while hundreds of new banks once opened every year, since 2009 the federal government has only approved about a dozen new banking applications.[14]

A combination of anti-competitive regulation, and special government subsidies coddles America’s big banks more than virtually any businesses in the country. American taxpayers lost $200 billion in the Savings and Loan bailout, and our government is now on the hook for hundreds of billions more. America’s financial system is one of the biggest beneficiaries of crony capitalism today.

Healthcare

As we have discussed elsewhere, the American healthcare system spends twice the OECD average per patient, and wastes up to $1 trillion annually. American government is implicated in a web of financial relationships with thousands of private corporations in the healthcare industry, each of which is subject to perversion. But even more disturbing is the ease with which incumbent corporations lobby to manipulate healthcare laws and regulations in their favor.

A paradigmatic example of special interest capture in American healthcare is the hospital industry, represented by the American Hospital Association (AHA). Hospitals are often the largest employers in their congressional districts, and routinely mobilize local doctors to persuade congress members to enact laws increasing federal funding or kill unfavorable bills in committee hearings.[15] Although hospitals drive 1/3rd of healthcare costs and are the worst special interest in the healthcare industry by far, they have successfully shifted politicians’ attention to the insurance industry.

Next, consider the case of Medicare, which insures elderly or disabled Americans. Medicare Part B sets rates for all services provided by physicians, on which the federal government spends over $300 billion annually. Prices for procedures are specified by the Specialty Society Relative Value Scale Update Committee, or “The RUC.” One could be forgiven for assuming that the RUC is comprised of government bureaucrats. In fact, it’s an offshoot of the American Medical Association — one of the most powerful trade groups in the entire healthcare industry. This cabal wields its influence to favor costly specialty care over primary care, and the prices of physician services skyrocket, year after year.[16],[17]

Another way that doctors inflate their own salaries is by legally barring nurses, chiropractors, naturopathic doctors, and other health professionals from practicing at the full scope of their medical training. Although many states have taken measures to shift “scope of practice” laws, over 76% of non-physician health workers currently face restrictions — at the American consumer’s expense. For example, occupational licensure regulations that require nurse practitioners to be supervised by MDs when prescribing drugs increase physician wages by about 7%, with a corresponding increase in consumer costs.[18]

Finally, consider the pharmaceutical industry. In what most regard as a Faustian bargain, the Obama administration secured the pharmaceutical industry’s support for the ACA by barring Medicare from negotiating the price of pharmaceutical drugs. Consequently, prices for physician-administered drugs grew at a compound annual rate of 10.1%, and prices for prescription drugs grew at a rate of 11.3% from 2013–2017.[19] Drug manufacturers also engage in profiteering by gaming intellectual property law. The intended lifespan of a pharmaceutical patent is 20 years. But for the 12 best selling drugs in the United States, drug makers file hundreds of patent applications, extending their true patent exclusivity to 38 years! Prices have increased by 68% since 2012 for these blockbuster drugs.[20]

As consumers and taxpayers, Americans not only generate enormous piles of lucre for healthcare corporations but effectively subsidize healthcare costs for the rest of the world. Here, as in so many other industries, lobbyists use traditional financial contributions to open doors, and then manipulate politicians and regulators with a typhoon of misinformation and scare tactics. As Congress debated the Affordable Care Act in 2009, there were six registered healthcare lobbyists swarming Capitol Hill for every one member of Congress. Think-tanks and patient advocacy groups make some headway in reforming our healthcare system each year, but crony capitalists in American healthcare have an overwhelming advantage.

Trial Lawyers

Tort litigation is lawsuits about harms that violate civil, not criminal law. The field emerged in the late 19th century and won a series of major victories in the 1960s and 1970s under the banner of Ralph Nader’s consumer protection movement.[21] Today the trial lawyers’ lobby is closer to a cartel aimed at extorting businesses than a consumer advocacy lobby aimed at keeping Americans healthy and safe.

In the past decade, lawyers and law firms have spent $780 million on federal campaigns, and $725 million on state campaigns.[22] The chief trial lawyer industry group is the American Association for Justice, which often funds million-dollar campaigns to defeat tort reforms and instead elect lawyer-friendly state judges to the bench. These judges then hand down verdicts which expand the grounds for new tort lawsuits. In addition, the AAJ lobbies for state legislation to expand definitions of consumer fraud, eliminate statutes of limitation on tort claims, outlaw arbitration clauses in employment contracts so they can force cases to trial, and facilitate “legal fishing” expeditions which allow tort lawyers subpoena documents on the shakiest of grounds.

The result of these crony lobbying efforts is an entire sub-industry of lawyers who bring tort lawsuits with little pretext save to enrich their own practices. The class-action settlement rate is an abysmal 33%, which is lower than tough federal cases, but lawyers persist in suing American companies in the wild hope that they’ll win and take a lucrative cut of the payout.[23] For top personal injury lawyers and other varieties of tort litigators, payouts are lucrative indeed. By some reports a hundred or more trial lawyers are currently flying around the country on their own private jets.

The destructive effect of tort litigation is obvious when one considers the social cost of medical malpractice lawsuits. The annual administrative expenses associated with the medical liability system are $4 billion per year, and malpractice liability payments are $5.7 billion a year. Some of these cases are clearly warranted. But the true cost of medical malpractice suits is that doctors are incentivized to practice defensive medicine and order extraneous and unnecessary services in order to minimize their legal liabilities.

A recent study by Jonathan Gruber, one of the principal architects of the Affordable Care Act, investigated the Military Health System, where doctors are often immune from liability for medical malpractice. Gruber found that the intensity of inpatient care for active-duty patients (who may not sue their doctors) is approximately 5% lower than the intensity of care for non-active duty patients, or soldiers who receive care in private civilian facilities — with no difference in health outcomes.[24] In particular, doctors exempt from liability tended not to prescribe useless, expensive diagnostic tests.

Broadening this result to the general economy suggests that medical malpractice suits alone are easily responsible for tens of billions if not over a hundred billion dollars in pointless damages and legal fees per year. Speculative tort lawsuits in other sectors account for tens of billions more in societal resources squandered on lawsuits rather than productive ventures. Despite the claims of tort reformers, when the country is subject to rule by trial lawyers, it is the American consumer who ultimately loses.

Public Sector Unions

Public sector unions may not qualify as capitalist, but they are certainly crony. Government employee unions have a zombie grip on our political apparatus. Groups such as prison guards, firemen, clerks, and teachers’ unions typically coerce government employees into paying union dues which are then used to elect union-friendly politicians and bully incumbent politicians into passing legislation that favors union interests. It’s political patronage, pure and simple.

The makeup of unionized workers in America is shifting. 2009 marked the first year that public sector union employees outnumbered private sector union employees, 7.9 million to 7.4 million.[25] Between 1960 and 1980, the portion of full-time unionized public employees jumped from 10% to 36% of the public-sector work force. The American Federation of State, County, and Municipal Employees (AFSCME) grew from 99,000 members in 1955 to just under 1 million members and the American Federation of Teachers grew from 40,000 to more than half a million members.

Public sector unions are now wildly powerful players in American politics and have become extraordinarily successful at securing crony benefits for their members. In general, the salaries of public sector union members are anywhere from 17–37% higher than their private sector counterparts, and government employees make $14 more per hour in total compensation than private sector workers.[26] Between 2000 and 2008, the price of state and local public services has increased by 41% nationally, compared with 27% for private services. But the larger problem is that government employees retire at early ages to receive taxpayer-funded pensions for the rest of their lives.

Consider the example of the California Correctional Peace Officers Association (CCPOA). The CCPOA has extensively lobbied the state government to build new prison facilities, increase the number of prison guards in the state’s employ, and give prison guards and parole agents cushy salaries, benefits, and pension plans. Between 1980 and 2000, California constructed 22 new prisons for adults, and by 2006 the average prison guard made over $100,000 annually with overtime. Corrections officers can retire at 50 and take 90% of their salaries for the rest of their lives. Today a full 11% of the state budget — more than the state spends on higher education — goes to the California penal system.[27]

Public employee pensions are frighteningly underfunded. Unlike a traditional 401k, public employee pensions pay defined benefits to pensioners, regardless of how the market is performing. And public employee pensions typically use over-optimistic projected returns and discount rates, promise an unreasonably high level of benefits to pensioners, and then have to revise the expected rate of return downwards, increasing total liabilities drastically. For instance, the two largest public employee pensions in California — CalPERS and CalSTRS — initially projected returns of 7.5% but gradually revised that number to 7%, with the result that expected liabilities miraculously doubled.[28][29] Actual returns are even lower.

Pension liabilities are stripping revenue away from our basic government programs, even after a decade of stock market growth. For example, Oakland schools recently cut their budget by $15 million after a 30% state tax increase.[30] Pension costs have forced cities into insolvency in many states, and in a completely unprecedented development the entire state of Illinois may now go bankrupt, despite high tax rates.[31],[32] Estimates of total unfunded liabilities for state and local pensions range around $5 trillion.[33][34] Unless we take immediate steps to rectify this problem, government employees are in for major benefit cuts over the next decade.

NIMBYS

A final example of crony capitalism is the capture of local government by owners of urban real estate. Nowhere is the division between insiders and outsiders clearer or more literal than in housing. In many of America’s most dynamic cities, wealthy insiders have labored to prevent outsiders from moving into those cities. “NIMBY” (“Not in My Back Yard”) homeowners aim to create a false scarcity of land in order to retain the historic character of their neighborhoods and protect their home values against competition from new developments.

Although only 3% of America is urbanized, NIMBYs have used zoning and permitting requirements to make hundreds of millions of acres around cities effectively off-limits to new building. Some of these insiders have seen their properties appreciate by four or five times their original values, while outsiders must pay between four or five times the amount of rent or suffer torturous commutes to access opportunities in American cities.

It wasn’t always this way. For most of American history, a new home cost about three times the average family’s income. As incomes climbed, families bought bigger and better homes, but the proportion of their income going to housing stayed the same. Beginning in the 2000s, housing suddenly spiked to five times a family’s income. Many commentators described this phenomenon as a housing price bubble attributable to Americans gorging on cheap loans. Now we know the truth.[35]

Most of American cities never saw a housing price “bubble,” because they never restricted new development. Today, just as before 2008, housing around Austin, Texas, or Columbus, Ohio, still costs about three times average income. Yet in a handful of cities, such as San Francisco, New York, or Boston, homes cost from five to nine times a families’ income![36] These cities’ prices have already surpassed their peak during the “bubble,” and will continue rising as long as these cities keep restricting new development.[37]

While long-time residents of these cities have made millions off their appreciated housing, the rest of America remains locked out of these dynamic regions. One recent paper estimated that just removing housing restrictions in the Bay Area and New York would increase the average American family’s annual income by $2,000, due to increased competition for high-quality jobs.[38] NIMBYs don’t just hurt local renters and would-be homeowners, they cripple the entire economy.

Conclusion

Too frequently our elected leaders describe American politics as a grand struggle between the forces of good and evil. This kind of mythological rhetoric obscures the true nature of the complex systems at work in our economy. The central problem facing our economy is the way in which private corporations and individuals interact with the different faces of our government.

The problem is not that conservatives or progressives are evil but rather that our economic system and mode of government gravitate towards an equilibrium in which special interests have captured our political institutions. As the case of NIMBYism so clearly illustrates, the problem isn’t them, it’s you. We are too quick to demonize our fellow Americans and impatiently demand titanic policy reforms. Instead we need to make a conscious effort to identify when we or our employers are milking the political process at the expense of others.

We must work hard to ensure that every level of American government impartially serves the general public and resist the impulse to profit from illegitimate special relationships as a matter of conscience. Both Republicans and Democrats need to find the courage to stand up to special interests, especially the special interests on their own side. A breed of leaders who fight corruption even when it is politically inconvenient to do so could make our country grow and prosper at rates that we haven’t seen in many decades.

There are more instances of cronyism in the American economy than any essay could indict. The threat today is that our government is silently lapsing by degree into a feudal order in which special interest cartels dictate the economic life of our people. To achieve another century of economic progress and preserve the integrity of our republic, we must combat crony capitalism in every branch and jurisdiction of American government.


[1] Smith, Adam. “The Wealth of Nations.” Chapter 3, Part 2. https://www.marxists.org/reference/archive/smith-adam/works/wealth-of-nations/book04/ch03b.htm

[2] https://en.wikipedia.org/wiki/Iron_triangle_(US_politics)

[3] In 2017, for example, the total DoD budget was $605.7 billion of which $320 billion went to private contractors. See: Schwartz et al. “Defense Acquisitions: How and Where DOD Spends Its Contracting Dollars.” Congressional Research Service, July 2, 2018.

[4] Hartung, William. “Prophets of War.” Nation Books, 2012. p.136

[5] Taibbi, Matt. “The Pentagon’s Bottomless Money Pit.” Rolling Stone, March 17, 2019.

[6] Hartung, William. “Prophets of War.” Nation Books, 2012. p.114, 170, 196

[7] Hartung, William. “Prophets of War.” Nation Books, 2012. p.29.

[8] Hartung, William. “Here’s Where Your Tax Dollars for Defense are Really Going.” The Nation, October, 2017.

[9] https://www.govinfo.gov/content/pkg/CRECB-2011-pt15/html/CRECB-2011-pt15-Pg20187-2.htm

[10] Salter, Malcolm. “Crony Capitalism, American Style: What Are We Talking About Here?” Edmond J. Safra Working Papers, №50. October 22, 2014. https://www.hbs.edu/faculty/Publication%20Files/15-025_c6fbbbf7-1519-4c94-8c02-4f971cf8a054.pdf.

[11] Creswell, Julie and Ben White. “The Guys from ‘Government Sachs’.” New York Times, October 17, 2008.

[12] For evidence of the implicit guarantee see https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2554386

[13] The Treasury and the Fed bought the investment banks’ most toxic assets for high prices rather than their best assets for low prices, insured the banks at below market rates, and so on.

[14] https://www.economist.com/finance-and-economics/2018/05/31/the-number-of-new-banks-in-america-has-fallen-off-a-cliff

[15] Cooper et al. “Politics, Hospital Behavior, and Health Care Spending.” Cowles Foundation, Yale University. August, 2017.

[16] For example, the RUC set the price of an arterial stent at $12,000, despite the fact that it’s a simple procedure that could be performed in a doctor’s office. The number of stent implants performed nationally increased by 70% in the next few years. See: Glock, Judge. “How Physicians Write Their Own Paycheck: The Relative Update Committee.” The Cicero Institute, April 28, 2019.

[17] Poses, Roy. 2011. “Conflicts of Interests Among the RUC’s Members,” Health Care Renewal.

[18] Kleiner et al. “Relaxing occupational licensing requirements: analyzing wages and prices for a medical service.” NBER, February 2014.

[19] Lieberman, Steven and Paul Ginsburg. “CMS’s International Pricing Model for Part B Drugs: Implementation Issues.” Health Affairs, July 9, 2019.

[20] https://www.i-mak.org/wp-content/uploads/2018/08/I-MAK-Overpatented-Overpriced-Report.pdf

[21] Nader, Ralph. “Suing for Justice.” Harper’s, April, 2016.

[22] “Trial Lawyers Inc.” Center for Legal Policy at the Manhattan Institute. 2010.

[23] https://www.forbes.com/sites/danielfisher/2013/12/11/with-consumer-class-actions-lawyers-are-mostly-paid-to-do-nothing/#7ad51c451472

[24] Frakes, Michael and Jonathan Gruber. “Defensive Medicine: Evidence from Military Immunity.” NBER, July 2018.

[25] DiSalvo, Daniel. “The Trouble with Public Sector Unions,” National Affairs. Fall 2010. https://www.nationalaffairs.com/publications/detail/the-trouble-with-public-sector-unions.

[26] https://oversight.house.gov/sites/democrats.oversight.house.gov/files/documents/Biggs-AEI%20Statement%20Federal%20Compensation%205-18.pdf

[27] Sherk, ibid.

[28] https://www.ppic.org/publication/public-pensions-in-california/

[29] Crane, David. “More Pension Math.” February 15, 2018.

[30] Dougherty, Conor and Jose A. Del Real. “California Today: Is the Long Looming Pension Crisis Already Here?” New York Times, March 9, 2018.

[31] Sherk, James. “Time to Rein in Public Sector Unions.” The American Interest, September 7, 2015.

[32]https://www.realclearpolicy.com/articles/2018/06/07/illinois_is_better_off_bankrupt_110660.html

[33] https://www.wsj.com/articles/the-pension-hole-for-u-s-cities-and-states-is-the-size-of-japans-economy-1532972501

[34] https://us.pensiontracker.org/

[35] https://www.longtermtrends.net/home-price-median-annual-income-ratio/

[36] https://www.citylab.com/equity/2018/05/where-the-house-price-to-income-ratio-is-most-out-of-whack/561404/

[37] https://www.citylab.com/equity/2018/05/where-the-house-price-to-income-ratio-is-most-out-of-whack/561404/

[38] https://faculty.chicagobooth.edu/chang-tai.hsieh/research/growth.pdf

Regulating Speech Won’t Fix Our Politics

Regulating Speech Won’t Fix Our Politics

Joe|August 12, 2019

View original article on National Review.


No matter who holds power, individuals and groups have the right to spend money to communicate their ideas.

Since the landmark political-speech case Citizens United v. FEC (2010), there has been broad public support for campaign-finance reform, fueled by a deep suspicion of both politicians and moneyed interests. According to a Gallup poll before the 2018 midterm election, more than half of Americans view members of Congress as corrupt and beholden to special interests rather than to their constituents. Nothing has exacerbated those concerns so much as the decision in Citizens United, which empowers corporations and unions to advocate for political candidates and positions, so long as their efforts are not coordinated with candidates.

Many Americans are legitimately worried about special interests and corporations using campaign spending as a quid pro quo to gain political access and influence. Elections do need appropriate oversight. But we must be careful that oversight does not come at the cost of our constitutional right to speak, or — what is a necessary corollary of that right — our ability to spend money to use or build media platforms that communicate our ideas.

The first oral arguments of Citizens United demonstrate the unanticipated perils of campaign-finance regulations for speech. In that case, Chief Justice Roberts asked the federal government’s solicitor general whether some books could be banned under the current law: “It’s a 500-page book, and at the end it says, and so vote for X! The government could ban that?” The solicitor general, to the shock of the Court, affirmed that, under the current law, such a book could be banned and the author imprisoned. This exchange explains why the unconstitutional restrictions on political speech were overturned.

Our Founders understood that free speech helps protect Americans no matter who holds power. The Citizens United decision is a natural extension of the rights of individuals to speak freely; anything less would have betrayed the very concept of the First Amendment. As law professor John McGinnis wrote in the Los Angeles Times in 2016: “If the 1st Amendment protects an individual’s right to speak, then why . . . shouldn’t a group of individuals, banded together in a partnership or other association, also enjoy that right? And if an association has that right, why would it lose it when it takes corporate form?” Lest we forget: In 1964 it was a corporation, the New York Times, that fought for its constitutional right to publicly criticize racist government officials with impunity, and it won that right in the famous Supreme Court case of New York Times Company v. Sullivan.

The freedoms afforded to the press and to corporations are intimately tied to the freedoms of citizens to speak without restriction. If money cannot be used to make political statements, then the government can regulate who can buy or start media companies, and it can censor what kinds of statements and endorsements media companies and their investors can make and when. This means that independent journalism requires the liberty to spend money freely. One need only look to our own history to understand that governments cannot be trusted to impartially regulate the press. After passage of the Alien and Sedition Acts of 1798, Federalist-party officials prosecuted Democratic-party journalists who opposed them. Imagine that your political adversary is in charge of the government agency regulating the media’s political activities. Do you trust the government to make decisions about which news is fit to print?

It can be tempting to restrict political spending in order to make American politics “more fair.” But the dangers of arbitrarily silencing people with political-speech laws are far greater than the risks associated with disproportionate influence. Giving everyone an “equal voice” without violating everyone’s fundamental rights is an impossible chimera. Wealthy people can afford to advertise their views, but they are not the only ones with outsized influence  — others are able to shape perception through media or academic channels or to attract attention through their celebrity. The only way to equalize all speech would be to forbid all of it.

Contrary to the rhetoric of reformers, campaign-finance reforms often benefit the already powerful and well-connected elite. Special interests that have longstanding relationships wield a far more extensive arsenal of influence — political networking, nepotism, the revolving door, etc. — than simple campaign donations. In many cases, money is one of the few tools that grassroots advocacy groups and candidates have to employ in politics. The campaigns of independent and third-party candidates such as Ross Perot and Theodore Roosevelt (in 1912), who appealed to and performed strongly among voters from across the political spectrum, were possible only through substantial initial funding by private donors. If citizens were not permitted to use money to amplify their speech to take on the politically entrenched, the result would be disastrous for the American experiment in democracy: an ossified ruling class.

It is important to remember that ideas, not money, are the most powerful form of influence — and it shows in political-spending numbers. It might be surprising that heated elections such as those in 2016 elicited only about $6.5 billion in total campaign expenditures, which included spending by presidential candidates, Senate and House candidates, political parties, and independent interest groups. That is less than 0.2 percent of the federal government’s spending in just a single year. Given the stakes of control over the federal government, it is almost alarming that, as George Will has pointed out, U.S. presidential contests cost only about as much as Americans spend annually on Easter candy.

The reason there is so little money in politics is that in most races, cash is irrelevant to electoral results. As many as 80 to 90 percent of congressional races are “effectively predetermined” by factors such as the district’s partisan makeup and incumbency advantage — symptoms of gerrymandering, unlimited tenure, and other important, tangential issues. While advertising can help achieve basic name recognition early in campaigns, returns diminish quickly thereafter and rarely shift votes. In 1994, Stephen Levitt, the co-author of Freakonomics, did a famous study of congressional elections in which the same two candidates had faced each other more than once but who spent different amounts of money each time; Levitt found that a 50 percent increase in spending by one candidate caused only a 0.33 percent change in the vote. Moreover, political donations do not seem to sway legislators in favor of special interests. In a recent study, John Matsusaka of the University of Southern California found that at least 65 percent of the time, a legislator’s voting aligns with the wishes of the majority of constituents and that, in the remaining 35 percent of the time, voting most often aligns with the individual ideology of the politician rather than with the interests of their largest donors alone.

Rather than succumb to popular hysteria about money in politics, we ought to take a more philosophically rigorous view of the issue. Our Founding Fathers, while noting the potential danger of special interests, still believed that “factions” must play a role in democratic debate. James Madison and others understood that any attempt to abolish factionalism would limit freedom. In Federalist No. 10, Madison wrote that “liberty is to faction what air is to fire, an aliment without which it instantly expires. But it could not be less folly to abolish liberty, which is essential to political life, because it nourishes faction, than it would be to wish the annihilation of air . . . because it imparts to fire its destructive agency.”

The same must be said of speech.

Instead of eliminating the influences of special interests by restricting the liberties afforded to all citizens, in a large and diverse republic, Madison suggested, factions of citizens would compete to advance their ideological agendas. Adversaries such as the National Rifle Association and the Brady Center seek to organize like-minded citizens and rally political support through policy research, fundraising, advertising, and other means. Corporations and industry trade groups offer policy prescriptions that are then contested by non-governmental organizations and academics who rigorously analyze the policy prescriptions offered by those corporations.

Most political expenditures by interest groups aim to inform and excite the American public through legitimate avenues. Citizens who may oppose a competing interest should not silence that interest through legal restriction but rather signal their commitments by volunteering, contributing, and voting for their preferences. The importance of this approach is emphasized by the fact that some of the most effective special interests, such as the American Hospital Association, influence politicians primarily through slanted research, not financial contributions. Only about 2 percent of the AHA’s budget is spent on campaign contributions, but this understates its electoral activities, since AHA can mobilize hundreds of doctors for political efforts in a given congressional district without spending any money at all.

Even so, citizens should be vigilant and pay attention to the way that politicians interact with money, but the best way to moderate those interactions is to make them transparent. An example of this kind of reform is the un-adopted amendment that Representative Rodney Davis (R., Ill.) attached to to H.R.1 — the For the People Act of 2019, a campaign-finance-reform bill that the House passed this spring and that is unlikely to pass the Senate. Davis’s amendment would help voters know if their representatives’ campaigns are being financed largely by groups outside their district. Given access to information about campaign-finance expenditures, voters would be empowered to discern what constitutes unsavory politics and what does not. Imagine if all members of Congress wore NASCAR suits that labeled all of the major special interests that supported them — don’t you think lawmakers would start acting differently? As law professor Bradley Smith pointed out in 2010 in an essay in National Affairs, politicians are not obstinate: “Votes — not dollars — are what ultimately get put into ballot boxes. And it would make little sense to anger one’s constituents for a contribution that can only be used to try to win those constituents back.”

Madison believed that we should trust the ability of citizens to make political decisions to elect “fit characters” or to vote out unfit representatives. No amount of money can overcome the voter’s ultimate power. Fortunately, the Supreme Court in Citizens United maintained faith in the American citizen, declaring that “the right of citizens to inquire, to hear, to speak, and to use information to reach consensus is a precondition to enlightened self-government and a necessary means to protect it.”

Our citizens today are enfranchised irrespective of race, sex, and creed. We are, in this respect, more fit to make political decisions than any those in any previous political epoch. American citizens are afforded liberties by our forefathers, because the founders of our nation had confidence in their posterity to use and protect them wisely. The Founding Fathers did see the potential problems that liberties — those of citizens and of factions of citizens — could present a republic. Yet they knew that the freedom to speak was the foundation of any successful republic, and that any cure for the so-called problems of speech — as with other forms of liberty — would be worse than any of its associated illnesses.