Eh. Not much to comment on that post. I probably wouldn’t be subscribing if I didn’t agree with him mostly. The only thing he really gets wrong is homelessness and downplaying the effect of substance abuse.
Other than that, I just want to wish my fellow subscribers and commenters a happy new year. I can almost guarantee that the majority of you will be hit by omicron in the next few weeks. Take care of yourself.
I’ve decided to opt out of the pandemic as my New Year’s resolution.
I finally stopped traveling at least for a couple of weeks. I need to get caught up with Homelife.
I look forward to spirited debate with you guys in 2022.
I feel like your argument on homelessness is a bit simplistic. Oregon is a great place to look I think, because in Portland you can absolutely find cheap places to live even if rent is going up. When you have huge camps set up there where people are taking super hard drugs making them half-psychotic, it's hard to say the issue is "not about drugs" because it's such a strong factor in the psychology of the drug abusing homeless. I think there's a point when you get on this stuff that where you live is less of a priority than the drugs, and it's up to the city to disincentivize doing them in public.
Love the Slow Boring (what's in a name?). I don't always agree with the conclusions, but I always respect your reasoning. Are you still planning to tackle federal housing finance policy issues this year?
Matt, a suggestion looking forward. In light of your points about blue states or blue cities getting things done, so that we can point to those and go "Hey, look, this stuff can be done well". I'd love to see you or guest writer(s) actually write about such successes. Partly I think in a world of doomscrolling, we (and I mean this in a non-partisan way) don't celebrate our successes enough. And partly it's just good to just shine a light on what interesting things are being done outside of our normal range of vision.
I've banged on this in the comments before, but I think what Fairfax County is trying to do with the Richmond Hwy corridor is both a very difficult problem to address, and also doing it in a way that shows real flexibility and prioritization of goals. It's an effort I worked on in the initial planning phase on a citizen advisory panel, and it's sort of amazing that we're going to try to take one of the worst stroads ever built and turn it into something much, much better. I'd kill to read some deeper dives into other areas of the country and how they've tried to tackle such issues.
My favorite post was yours was the one explaining the basics of how we think inflation works. I'm just an enthusiastic laymen, so having you be explicit about what reporters were dancing around not knowing was extremely enlightening.
After spending some time in different places this year, my commitment to YIMBY is softening.
The pre- and postwar urban plans are very different. The virtue of the prewar plan is to be intense. More and better stuff on the street grid strictly adds value. Conversely, it sucks when the high street has vacancies, or you have to walk by a parking lot, or the bus comes too infrequently.
Spending some time in the postwar plan has opened my eyes. Because you don’t have a grid, traffic on the arterial stroads really is a serious and unavoidable problem, that gets worse the more subdivisions there are. Multifamily housing takes the form of entire subdivisions stamped with mid rises instead of SFHs, in an ocean of parking instead of trees. They are vile. Even I hate them. Businesses are only accessible by car and you may need to change your plans because the parking lot is full. It is pleasant to drive through open space and unpleasant to drive through the built up parts. I just don’t see how people who live in these places will ever subscribe to an ethos of “more, more, more.” The reason these places are terrible is that their framework is not scalable. If you try to scale it anyway, it just becomes a terrible place to live.
I think we need to focus more on how to retrofit suburban sprawl places into designs that can accommodate growth successfully. For example growing adjacent subdivisions towards each other and fully merging their street networks, adding some retail that can be accessed without the main road. Creating credible cycling options from one subdivision to the next, which do not involve 50mph traffic. I don’t know, I’m not a planner. But it will take serious changes to the layout to change minds on growth.
I'd love to see more healthcare discussion, specifically. It's famously America's most pressing domestic issue, and I don't think I've seen much mention of the topic here on SB. Are there a series of best practices that we should be using to drive down healthcare costs in the US economy? HMOs/narrow networks? More aggressive antitrust against big hospital chains & provider mergers? Is it true that insurance companies are simply marking up the cost of everything with an unnecessary billing department? Is expanding Medicaid a good use of government funds? Etc. etc.
Not saying there's no place for QALYs, but all you need to do is read a bunch of QALY studies to see how limited they are - below is pasted part of the method section from an NIMH-sponsored study that tried to translate clinical efficacy and side effect data of a bunch of different antispychotic drugs into QALYs to quantify and compare each drug's effect on patient quality of life. (The cost effectiveness portion of the study is now obsolete because all of these drugs are now generic and available at low prices.) Here's an excerpt from the study method section describing how they tried to translate clinical efficacy and side effect data into QALY scores - this is the kind of stuff you're signing up for when you sign up for QALYs:
"A recent series of studies (18 – 20) have demonstrated a method for evaluating QALY ratings in schizophrenia. First, a factor analysis of Positive and Negative Syndrome Scale (PANSS) data gathered from a sample of almost 400 patients (21) was used to identify positive, negative, and cognitive factors on the PANSS. Then cluster analysis was used to identify eight disease-specific health states on the basis of these three factors. With input from expert clinicians, PANSS subscale scores for each health state were used to develop script and video materials to convey to lay individuals, representing the general public, the health impairments experienced with each schizophrenia state, as well as for five commonly co-occurring side effects (orthostatic hypotension, weight gain, tardive dyskinesia, pseudoparkinsonism, and akathisia) (18) . Using these eight video presentations, the states were rated by 620 members of the general public using the standard gamble, the recommended method for determining QALY ratings (13) . QALY ratings for the eight schizophrenia health states ranged from 0.44 to 0.88, while side effect weights ranged from a low of 0.857 for tardive dyskinesia through 0.959 for weight gain and 1.0 when a side effect was not present. The final QALY rating estimate is the product of the QALY rating for the schizophrenia state and the QALY ratings for each side effect. Following the recommendations of the Public Health Task Force (13) , this measure represents the health state of each subject on symptoms and side effects weighted for societal preferences (outcome measures based on individual preferences and their analysis are described in the supplement that accompanies the online version of this article). The Patient Perspective contains a clinical description of a typical patient in the study and describes the major features on which the QALY ratings are based.
I get their limitations, but the real question about costs is what procedures/drugs/etc. are we going to pay for and how much will we pay for them. (We meaning either through private or public insurance).
QALYs or something similar seem to be much better way of deciding that the current mismash we have now.
I'm not so sure of that - the CATIE study was the American public health establishment at it's finest, and its QALY study reached a conclusion manifestly at odds with the expressed and revealed preferences of patients and clinicians across the country, who prefer the newer drugs. QALYs can be technocracy at its worst, a false sense of precision, divorced from reality on the ground, and extrapolated with great overconfidence. But I do like that QALYs are a structured way to communicate that value is not the same as price. In some efficient markets price might approximate value, but healthcare as a whole is not in that ballpark due to the third-party payor structure (though there are pockets of commodity efficiency, of course, such as for bandages or multi-source generic drugs). Finding ways to measure, quantify, and allocate the value of healthcare products and services is one of the hardest, most interesting problems in healthcare - something I've been interested in a long time. QALYs are part of that but I don't think a major part simply because they are too ivory tower and methodologically limited, other than perhaps as useful talking points in a contract negotiation or litigation over value.
I'd love to see some of Matt's work applied to a couple related topics that seem very under-reported to me:
Drug overdoses, especially the massive increases (+30-40%) from already high levels that coincided with the beginning of the pandemic. We're now at 100,000 deaths per year and it seems to be buried behind the covid story. All I've seen are vague hand-waving at covid disruptions without any serious effort to see what part of the disruptions triggered 30,000 extra deaths a year.
Somewhat related - what could the US do to prevent Mexico from sliding into "failed state" territory? As far as I can tell no mainstream press is covering that story. When I google the site I find most often is Breitbart, and I think it deserves attention from a much better source.
If you think I'm exaggerating the risks of one of the US's most important relationships sliding into failed state territory, you might be right! But it's not completely exaggerated, and without better coverage from someone besides freaking breitbart how can I know?.
You have drugs cartels regularly assassinating or paying off mayors, governors, congresspeople, candidates. They've shot down military helicopters and kidnapped or killed marines. soldiers and their families. There are daily stories of bodies hung off bridges, dismembered bodies left with threatening messages, torture and execution videos, etc.. When one of El Chaps's sons was arrested a couple years ago, the entire city of Culiacan was held hostage by gunmen creating roadblocks and sewing terror until the government released him. Similar tactics have been used in other cases.
Most of this violence and lawlessness is funded by drug smuggling, and to a lesser extent human smuggling which connects it quite directly to US policies and politics. Again - it just shocks me that I never much of this reported in mainstream press, especially given that "if it bleeds it leads" is conventional wisdom for drawing clicks. My guess is it shines too much of a negative light on some of the current shibboleths of the left related to crime, policing and immigration and so that's why it's been ignored.
This is the source I usually get by Mexico criminal news from:
I suspect that the biggest reason for turning a blind eye toward Mexico is the fear of stirring up Trumpland with anything that might lead to talk about immigration.
How should drugs be regulated? There remain extensive regulations around the consumption, sale and production of alcoholic drinks. I cannot see how drugs like heroin and other stuff can be freely allowed for importation and retail sale because of the addiction potential. That’s not to say that things such as needle exchanges are a bad idea, just that letting Walmart sell your kids heroin is probably worse than the status quo.
As an aside, when people argue for ‘ending the war on drugs’, that is very much like arguing for ‘defunding the police’ - it’s a weasel phrase for a number of very different ideas about drugs policy that don’t necessarily sit well with each other.
To be fair, I think "ending the war on drugs" is a phrase where people mean what they say more than with defund the police.
As for me, at least when I argue for legalizing drugs, I simply mean it. The government should not ban any drug for any reason. (I can see the argument for retaining the government in some capacity for drug purity-testing, though I think it's likely unnecessary). Oddly, I don't want this so much because I care about heroin or marijuana or all the rest - I just want to stop the FDA.
Well there are certainly multiple partisan political interpretations. I don't necessarily think your is invalid. But I'm not really seeing NYTs or Vox articles reporting the above stories with any regularity, so my guess is that although some of the editors might agree with the furthest left take, they don't think that the average reader will.
And that far left position is pretty far from an evidence-driven approach to solving problems, at least nothing like it has quite been tried. In that sense a far-right position could be equally argued, perhaps with more real-world evidence from East Asia in particular.
The thing about the the human interaction theory is then you would expect overdoses to decline again as lockdowns lessened. You'd also expect the increase to be greater in stricter localities and lesser in less strict localities. Here's a link with data on that: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. You can find more detail in CDC's Wonder database, where I'm seeing a pretty steady rate of drug overdoses for every month of 2020 from May onwards.
In any case I'm not sure I buy that the average heroin user is risk-averse enough to lockdown for the past 20 months in the way the typical white collar worker has been able to. I know those 2 categories are overlapping, so I want to emphasize the word typical.
To me the most obvious place to start looking is the various legislation and accompanying low unemployment that started putting more money in people's pockets. Suddenly users in more dire circumstances have more money - some of that is going to go to more drugs.
I'd really like to see more cross-pollination from other Substacks -- sort of the 2022 version of a blogroll or re-bloging. I miss having a chance to see a wider ecosystem.
Are we sure immigration doesn’t reduce wages? Even the most basic labor mobility models from college-level International Trade classes suggest that it does so.
Became a subscriber in 2021. Appreciate you. I also subscribe to The Dispatch and notice that they, too, read and respect you. Keep up the good work.
What do you mean by "the effect sizes of politics are small"?
Often times I disagree but your thoughts are well thought out and can alter my assumptions. That's what I want from a newsletter. Thank you.
Write more about parenting & kids! Kind of a niche topic but having a kid almost the same age as Matts, I’d be interested.
Eh. Not much to comment on that post. I probably wouldn’t be subscribing if I didn’t agree with him mostly. The only thing he really gets wrong is homelessness and downplaying the effect of substance abuse.
Other than that, I just want to wish my fellow subscribers and commenters a happy new year. I can almost guarantee that the majority of you will be hit by omicron in the next few weeks. Take care of yourself.
I’ve decided to opt out of the pandemic as my New Year’s resolution.
I finally stopped traveling at least for a couple of weeks. I need to get caught up with Homelife.
I look forward to spirited debate with you guys in 2022.
I feel like your argument on homelessness is a bit simplistic. Oregon is a great place to look I think, because in Portland you can absolutely find cheap places to live even if rent is going up. When you have huge camps set up there where people are taking super hard drugs making them half-psychotic, it's hard to say the issue is "not about drugs" because it's such a strong factor in the psychology of the drug abusing homeless. I think there's a point when you get on this stuff that where you live is less of a priority than the drugs, and it's up to the city to disincentivize doing them in public.
Love the Slow Boring (what's in a name?). I don't always agree with the conclusions, but I always respect your reasoning. Are you still planning to tackle federal housing finance policy issues this year?
Damn, some Fannie/Freddie talk ?? Now we're talking niche
Best Slow Boring post title yet!
Matt, a suggestion looking forward. In light of your points about blue states or blue cities getting things done, so that we can point to those and go "Hey, look, this stuff can be done well". I'd love to see you or guest writer(s) actually write about such successes. Partly I think in a world of doomscrolling, we (and I mean this in a non-partisan way) don't celebrate our successes enough. And partly it's just good to just shine a light on what interesting things are being done outside of our normal range of vision.
I've banged on this in the comments before, but I think what Fairfax County is trying to do with the Richmond Hwy corridor is both a very difficult problem to address, and also doing it in a way that shows real flexibility and prioritization of goals. It's an effort I worked on in the initial planning phase on a citizen advisory panel, and it's sort of amazing that we're going to try to take one of the worst stroads ever built and turn it into something much, much better. I'd kill to read some deeper dives into other areas of the country and how they've tried to tackle such issues.
I like this idea!
My favorite post was yours was the one explaining the basics of how we think inflation works. I'm just an enthusiastic laymen, so having you be explicit about what reporters were dancing around not knowing was extremely enlightening.
After spending some time in different places this year, my commitment to YIMBY is softening.
The pre- and postwar urban plans are very different. The virtue of the prewar plan is to be intense. More and better stuff on the street grid strictly adds value. Conversely, it sucks when the high street has vacancies, or you have to walk by a parking lot, or the bus comes too infrequently.
Spending some time in the postwar plan has opened my eyes. Because you don’t have a grid, traffic on the arterial stroads really is a serious and unavoidable problem, that gets worse the more subdivisions there are. Multifamily housing takes the form of entire subdivisions stamped with mid rises instead of SFHs, in an ocean of parking instead of trees. They are vile. Even I hate them. Businesses are only accessible by car and you may need to change your plans because the parking lot is full. It is pleasant to drive through open space and unpleasant to drive through the built up parts. I just don’t see how people who live in these places will ever subscribe to an ethos of “more, more, more.” The reason these places are terrible is that their framework is not scalable. If you try to scale it anyway, it just becomes a terrible place to live.
I think we need to focus more on how to retrofit suburban sprawl places into designs that can accommodate growth successfully. For example growing adjacent subdivisions towards each other and fully merging their street networks, adding some retail that can be accessed without the main road. Creating credible cycling options from one subdivision to the next, which do not involve 50mph traffic. I don’t know, I’m not a planner. But it will take serious changes to the layout to change minds on growth.
This whole post would be at home in yimby twitter.
I'd love to see more healthcare discussion, specifically. It's famously America's most pressing domestic issue, and I don't think I've seen much mention of the topic here on SB. Are there a series of best practices that we should be using to drive down healthcare costs in the US economy? HMOs/narrow networks? More aggressive antitrust against big hospital chains & provider mergers? Is it true that insurance companies are simply marking up the cost of everything with an unnecessary billing department? Is expanding Medicaid a good use of government funds? Etc. etc.
Is there any answer to that question that doesn't involve some version of QALYs?
Not saying there's no place for QALYs, but all you need to do is read a bunch of QALY studies to see how limited they are - below is pasted part of the method section from an NIMH-sponsored study that tried to translate clinical efficacy and side effect data of a bunch of different antispychotic drugs into QALYs to quantify and compare each drug's effect on patient quality of life. (The cost effectiveness portion of the study is now obsolete because all of these drugs are now generic and available at low prices.) Here's an excerpt from the study method section describing how they tried to translate clinical efficacy and side effect data into QALY scores - this is the kind of stuff you're signing up for when you sign up for QALYs:
"A recent series of studies (18 – 20) have demonstrated a method for evaluating QALY ratings in schizophrenia. First, a factor analysis of Positive and Negative Syndrome Scale (PANSS) data gathered from a sample of almost 400 patients (21) was used to identify positive, negative, and cognitive factors on the PANSS. Then cluster analysis was used to identify eight disease-specific health states on the basis of these three factors. With input from expert clinicians, PANSS subscale scores for each health state were used to develop script and video materials to convey to lay individuals, representing the general public, the health impairments experienced with each schizophrenia state, as well as for five commonly co-occurring side effects (orthostatic hypotension, weight gain, tardive dyskinesia, pseudoparkinsonism, and akathisia) (18) . Using these eight video presentations, the states were rated by 620 members of the general public using the standard gamble, the recommended method for determining QALY ratings (13) . QALY ratings for the eight schizophrenia health states ranged from 0.44 to 0.88, while side effect weights ranged from a low of 0.857 for tardive dyskinesia through 0.959 for weight gain and 1.0 when a side effect was not present. The final QALY rating estimate is the product of the QALY rating for the schizophrenia state and the QALY ratings for each side effect. Following the recommendations of the Public Health Task Force (13) , this measure represents the health state of each subject on symptoms and side effects weighted for societal preferences (outcome measures based on individual preferences and their analysis are described in the supplement that accompanies the online version of this article). The Patient Perspective contains a clinical description of a typical patient in the study and describes the major features on which the QALY ratings are based.
https://ajp.psychiatryonline.org/doi/10.1176/ajp.2006.163.12.2080
I get their limitations, but the real question about costs is what procedures/drugs/etc. are we going to pay for and how much will we pay for them. (We meaning either through private or public insurance).
QALYs or something similar seem to be much better way of deciding that the current mismash we have now.
I'm not so sure of that - the CATIE study was the American public health establishment at it's finest, and its QALY study reached a conclusion manifestly at odds with the expressed and revealed preferences of patients and clinicians across the country, who prefer the newer drugs. QALYs can be technocracy at its worst, a false sense of precision, divorced from reality on the ground, and extrapolated with great overconfidence. But I do like that QALYs are a structured way to communicate that value is not the same as price. In some efficient markets price might approximate value, but healthcare as a whole is not in that ballpark due to the third-party payor structure (though there are pockets of commodity efficiency, of course, such as for bandages or multi-source generic drugs). Finding ways to measure, quantify, and allocate the value of healthcare products and services is one of the hardest, most interesting problems in healthcare - something I've been interested in a long time. QALYs are part of that but I don't think a major part simply because they are too ivory tower and methodologically limited, other than perhaps as useful talking points in a contract negotiation or litigation over value.
As someone who moved out of a major city last year, it's interesting to observe how little salience the homelessness issue has in the suburbs.
I'd love to see some of Matt's work applied to a couple related topics that seem very under-reported to me:
Drug overdoses, especially the massive increases (+30-40%) from already high levels that coincided with the beginning of the pandemic. We're now at 100,000 deaths per year and it seems to be buried behind the covid story. All I've seen are vague hand-waving at covid disruptions without any serious effort to see what part of the disruptions triggered 30,000 extra deaths a year.
Somewhat related - what could the US do to prevent Mexico from sliding into "failed state" territory? As far as I can tell no mainstream press is covering that story. When I google the site I find most often is Breitbart, and I think it deserves attention from a much better source.
If you think I'm exaggerating the risks of one of the US's most important relationships sliding into failed state territory, you might be right! But it's not completely exaggerated, and without better coverage from someone besides freaking breitbart how can I know?.
You have drugs cartels regularly assassinating or paying off mayors, governors, congresspeople, candidates. They've shot down military helicopters and kidnapped or killed marines. soldiers and their families. There are daily stories of bodies hung off bridges, dismembered bodies left with threatening messages, torture and execution videos, etc.. When one of El Chaps's sons was arrested a couple years ago, the entire city of Culiacan was held hostage by gunmen creating roadblocks and sewing terror until the government released him. Similar tactics have been used in other cases.
Most of this violence and lawlessness is funded by drug smuggling, and to a lesser extent human smuggling which connects it quite directly to US policies and politics. Again - it just shocks me that I never much of this reported in mainstream press, especially given that "if it bleeds it leads" is conventional wisdom for drawing clicks. My guess is it shines too much of a negative light on some of the current shibboleths of the left related to crime, policing and immigration and so that's why it's been ignored.
This is the source I usually get by Mexico criminal news from:
www.borderlandbeat.com
I suspect that the biggest reason for turning a blind eye toward Mexico is the fear of stirring up Trumpland with anything that might lead to talk about immigration.
I think the fear would be of portraying Mexico as a “sh*thole country” full of, and run by, criminals. Might be seen as validating Trumpism.
How should drugs be regulated? There remain extensive regulations around the consumption, sale and production of alcoholic drinks. I cannot see how drugs like heroin and other stuff can be freely allowed for importation and retail sale because of the addiction potential. That’s not to say that things such as needle exchanges are a bad idea, just that letting Walmart sell your kids heroin is probably worse than the status quo.
As an aside, when people argue for ‘ending the war on drugs’, that is very much like arguing for ‘defunding the police’ - it’s a weasel phrase for a number of very different ideas about drugs policy that don’t necessarily sit well with each other.
To be fair, I think "ending the war on drugs" is a phrase where people mean what they say more than with defund the police.
As for me, at least when I argue for legalizing drugs, I simply mean it. The government should not ban any drug for any reason. (I can see the argument for retaining the government in some capacity for drug purity-testing, though I think it's likely unnecessary). Oddly, I don't want this so much because I care about heroin or marijuana or all the rest - I just want to stop the FDA.
Well there are certainly multiple partisan political interpretations. I don't necessarily think your is invalid. But I'm not really seeing NYTs or Vox articles reporting the above stories with any regularity, so my guess is that although some of the editors might agree with the furthest left take, they don't think that the average reader will.
And that far left position is pretty far from an evidence-driven approach to solving problems, at least nothing like it has quite been tried. In that sense a far-right position could be equally argued, perhaps with more real-world evidence from East Asia in particular.
The thing about the the human interaction theory is then you would expect overdoses to decline again as lockdowns lessened. You'd also expect the increase to be greater in stricter localities and lesser in less strict localities. Here's a link with data on that: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. You can find more detail in CDC's Wonder database, where I'm seeing a pretty steady rate of drug overdoses for every month of 2020 from May onwards.
In any case I'm not sure I buy that the average heroin user is risk-averse enough to lockdown for the past 20 months in the way the typical white collar worker has been able to. I know those 2 categories are overlapping, so I want to emphasize the word typical.
To me the most obvious place to start looking is the various legislation and accompanying low unemployment that started putting more money in people's pockets. Suddenly users in more dire circumstances have more money - some of that is going to go to more drugs.
I'd really like to see more cross-pollination from other Substacks -- sort of the 2022 version of a blogroll or re-bloging. I miss having a chance to see a wider ecosystem.
Are we sure immigration doesn’t reduce wages? Even the most basic labor mobility models from college-level International Trade classes suggest that it does so.
It can reduce nominal wages, but because we would be able to produce far more, your effective wage would go up.