Cato At Liberty

Press reports have created the impression that the opioid overdose antidote naloxone is now available over the counter. But in fact, the drug is still classified in the US as prescription only, so states have developed workarounds to make it easier for patients to obtain it without going to a doctor for a prescription. In most states, patients can get naloxone by going up to the counter and asking the pharmacist, who is legally authorized by the state to dispense it. 

But some states prohibit third parties from obtaining a prescription for another person, so people in those states who wish to have the antidote available because they have a friend or relative who uses opioids cannot obtain it. And experience shows that many pharmacists choose to not stock naloxone or participate in any distribution program. Furthermore, the stigma now attached to opioid use has deterred many patients from going up to the pharmacy counter and explaining to a pharmacist why they need naloxone.

To get around such obstacles, Australia and Italy have designated naloxone as a truly over-the-counter drug. People can discreetly buy it off the shelf and check out at the cash register.

The Food and Drug Administration is on record since at least 2016 as believing that it is probably appropriate for naloxone to be rescheduled as OTC and has encouraged manufacturers to petition the FDA to that end. Yesterday  FDA Commissioner Gottlieb announced the FDA has even gone to the trouble of designing Drug Facts Labels (DFL) required of manufactures for their products to be sold over the counter, and has even tested these labels for “consumer comprehension” in front of focus groups. The Commissioner stated in the announcement that this represents an unprecedented effort to facilitate and speed up the reclassification of naloxone from prescription-only to OTC.

This is commendable. But as I have written here, here, and here, the Commissioner does not have to wait for manufacturers, who may lack the incentive, to request the move to OTC. Under FDA regulations, the FDA can undertake reclassification review at the request of “any interested person,” or the Commissioner himself. States may petition the FDA for reclassification. Finally, if all else fails, Congress can order the reclassification.

The FDA should no longer wait for manufacturers to ask them to make this lifesaving drug more accessible to those in need.

In his State of the City Address, New York mayor Bill de Blasio laid out his governing philosophy succinctly:

Here’s the truth, brothers and sisters, there’s plenty of money in the world. Plenty of money in this city. It’s just in the wrong hands!

The money, of course, is in the hands of those who earned it. In de Blasio’s view, people who earn too much are “the wrong hands.”

In the speech itself and in an interview with Jake Tapper on CNN’s “State of the Union,” he elaborated: the wealthy have too much money because they aren’t taxed enough.

There are whole books on the correct theory of taxation. De Blasio, like many politicians, seems operate on the theory most clearly enunciated in 1990 by Sen. Barbara Mikulski (D, Md.):

Let’s go and get it from those who’ve got it.

There are many theories of taxation, such as Haig-Simons, the Tiebout model, and the Ramsay Principle. But I’d bet that the Mikulski Principle explains actual taxation best. And as “progressives” are feeling their oats, we can expect more politicians and pundits to be asking, “Who’s got the money? Let’s go get it.”

Native-born American concerns about immigration are primarily about how immigration will affect the culture of the country as a whole and, to a lesser extent, how the newcomers will affect the economy.  One’s personal economic situation is not a major factor.  It’s reasonable to assume that the degree of cultural difference between native-born Americans and new immigrants affects the degree of cultural concern.  Thus, Americans would likely be less concerned over immigrants from Canada or Singapore than they would be over immigrants from Egypt or Azerbaijan. 

A large team of psychologists recently created an index of the cultural distance of people from numerous countries around the world relative to the United States.  The index is constructed from responses to the World Values Survey as well as linguistic and geographical distances.  Their index includes numerous different psychological facts such as individualism, power distance, masculinity, uncertainty avoidance, long term orientation, indulgence, harmony, mastery, embeddedness, hierarchy, egalitarian, autonomy, tolerance for deviant behavior, norm enforcement, openness, conscientiousness, extraversion, agreeableness, neuroticism, creativity, altruism, and obedience.  These are all explained in more detail in the paper.

Their paper has an index where lower numbers indicate a culture more similar to that of the United States while a higher number indicates a culture more distant from that of the United States.  As some extreme examples, Canada’s cultural distance score is 0.025 and Egypt’s is 0.24. 

Using the cultural distance index, I calculated the cultural distance of the stock of immigrants in the United States in 2015 from native-born Americans.  I then compared the cultural distance of the stock to the cultural distance of the flow of immigrants who arrived in 2012-2015.  The immigration figures come from the Annual Social and Economic Supplement of the U.S. Census Bureau.  If the stock of immigrants in 2015 was more culturally similar to native-born Americans than the flow, then the recent flow is more culturally distinct.  If the stock of immigrants in 2015 was more culturally different from native-born Americans than the flow, then the recent flow is less culturally distinct. 

Table 1 shows the results.  The immigrant flow in 2012-2015 is more culturally different from native-born Americans than the stock of immigrants was in 2015.  In other words, today’s newest immigrants are more different than those from the relatively recent past.  Relative to the stock, the cultural distinctiveness of the flow in 2012-2015 was greater by about one-fourth of a standard deviation.  In other words, the stock of American immigrants in 2015 was very culturally similar to people from Trinidad and Tobago (0.099) while the flow of new immigrants who arrived from 2012-2015 more similar to Romanians (0.11).

Table 1

Cultural Distance of Immigrants Relative to Native-Born Americans

Sources: WEIRD Index, ASEC, and author’s calculations.

There are a few problems with my above calculations.  First, those who choose to move here are likely more similar to Americans than those who do not.  There is obviously some difference in cultural values inside of a country as the average person does not choose to emigrate to the United States.  Second, American immigration laws likely select immigrants with similar cultural values through various means such as favoring the family members of Americans and those hired by American firms.  It’s reasonable to assume that foreigners who marry Americans and who are hired by American firms are more culturally similar than the average person from those countries.  Third, the cultural distance index only covers about two-thirds of the immigrant population in the United States.  It is possible that countries not on the list could shift the score significantly in either direction.

New immigrants to the United States are more culturally different than those of the past, but not by much.  This increase in the cultural difference of new immigrants could have had an outsized impact on Trump voters in 2016, but immigration overall is more popular with Americans than it used to be.