Astral Codex Ten

Americans

74 min read

Americans

Article

Americans is a recurring place in the Astral Codex Ten archive, appearing 5 times across 5 issues between May 21, 2021 and October 21, 2025. The archive places it in contexts such as “The Americans intentionally and publicly humiliating the English and French”; “with help from the Americans, set about bombing German civilians to hell and back”; “now they use SSRIs at a rate close to Americans”. It most often appears alongside Britain, Europe, Germany.

Metadata

  • Category: Places
  • Mention count: 5
  • Issue count: 5
  • First seen: May 21, 2021
  • Last seen: October 21, 2025

Appears In

Source Context

Recovered passages from the original issue text. When the raw archive preserved outbound links inside the source passage, they are listed directly under the quote.

Your Book Review: The Accidental Superpower
May 21, 2021 · Original source
We didn’t just get tremendous economic growth though – we got “magical” results, but they were based on a one-time confluence of factors that “overwhelmed the normal rule that lots of twenty-and thirty-somethings make for an expensive-capital environment.” What were these one-time accelerants? He identifies the peace dividend – cuts in military spending that allowed capital to be put to more productive uses – as one such change, along with the emergent dominance of the US dollar, particularly boosted by Russian demand thanks to the collapse of their currency, and a later boost in demand thanks to the East Asian financial crisis. With the Europeans’ decision to eliminate national currencies (agreed upon in a 1992 treaty, with the Euro to be introduced in 1999), they became relatively unattractive, and the Euro itself (an “unprecedented experiment in pan-government planning”) was too risky. Many holders of European currencies switched to the US dollar, such that between 1994 and 2002 (“when the euro finally got some traction and the surge dialed back”) there was a $2 trillion increase in the money supply. Zeihan also points to a collapse in commodities prices influenced by the elimination of Russian demand, but continued Russian production of oil and other commodities, followed by a collapse in demand thanks to the East Asian financial crisis. This story of capital coming to the West (“allowing consumption-driven growth not simply to soar, but to explode”) is one of chance world events. However, the story of capital coming from the Boomer cohort is one of demographics. By the 2000s, they’re the mature workers of Zeihan’s four stages described above – and as the bulge in the demographic pyramid, they started flooding the world with capital. Accordingly, “The cost of credit plummeted to levels never before experienced.” Zeihan suggests that developed-world demographics are the cause of booms in places that haven’t been well-developed, from Southern Europe to Brazil, Russia, and India. But he says it’s quickly coming to an end; Boomer savings into stocks and bonds will be moving to low-risk instruments and then turning into withdrawals rather than savings, and the cohort behind them is too small to replace all of that capital. And it’s a worldwide phenomenon: In every single developed country there is currently an American-style population inversion between the about-to-retire and the about-to-be-mature-workers age groups. Japan’s Boomers bulge is a decade older than the American equivalent, while Spain’s is roughly fifteen years younger. Everyone else falls somewhere in between. It dictates a period of chronically low growth and high credit costs, just not on precisely the same time frame. The undeveloped world is that way because it can’t self-fund, so without foreign capital, their growth will come to an end. In sum, the 1990-2005 period of high growth and easy capital was a historical anomaly; “the post-Cold War financial flight was a once-in-a-generation event” and the demographic bulge that coincided with it won’t come around again for decades, if ever. 4 2: America’s incredible advantages As noted above, Zeihan really likes America’s position in the world. He likes its demographics (relative to other developed countries) and loves its geography. Taking the population question first, in America, “the demographic inversion is only a temporary development.” America is younger than the rest of the developed world, as it urbanized later and its enormous size made having kids easier despite that urbanization (i.e., the suburbs exist). This makes the demographic crunch a single-generation issue, as the Millennials are a huge cohort. And even if they weren’t, America assimilates immigrants more easily than other places – Zeihan attributes this to it being a “settler society” – which can help with demographic problems. The rest of the developed world doesn’t have similar cohorts following their massive Boomer and Gen-X analogues. Accordingly: While the American financial world will be past its period of maximum stress by 2030, for the rest of the world 2030 will simply be another year of an ever-deepening imbalance between retirees and taxpayers, with smaller and smaller generations coming up the ranks generating less and less growth. For the developed world beyond the United States—and even large portions of the developing world—chronic capital poverty and permanent recession will be the new normal from which there is no return. Together with America’s Millennial-led growth and abundant energy (there’s a chapter explaining how shale is a done deal that, as of the mid-2014 writing, already made America the world’s largest energy producer 5), by 2030 Zeihan sees it as practically the only country with an economy worth noting. Anyone who is familiar with American geography should see the argument that’s coming about that aspect of Zeihan’s model. Isn’t the Mississippi River a pretty big deal? And those oceans on the east and west coasts seem like nice borders. Indeed, while he gives us many reasons why there was always going to be an American superpower, geography is central to his story. He has lots to say about America’s internal river systems, farmland, and other geographic features. What mountain barriers exist are apparently better than in other countries in terms of allowing internal transport; the Rockies have major passes, several of which have large cities within them, and the easiest pass in the Appalachians featured America’s first National Road, 130 miles of buried logs that linked two rivers, and thus the east coast with the best farmland in the world. As we saw with his exposition on the Nile, Zeihan puts a lot of emphasis on the value of river systems. He argues that America’s waterway network alone should be sufficient for “global dominance.” The numbers he provides in support of this point are impressive. For example, “the Mississippi is only one of twelve major navigable American rivers. Collectively, all of America’s temperate-zone rivers are 14,650 miles long. China and Germany each have about 2,000 miles, France about 1,000. The entirety of the Arab world has but 120.” He praises US barrier islands that mitigate oceanic destruction and effectively create another river system, as well as the fact that the river system is an actual network. All of this gives America more internal waterways than the rest of the world combined. Thus, we get cheap transportation for “Nebraska corn or Tennessee whiskey or Texas oil or New Jersey steel or Georgia peaches or Michigan cars,” enabling savings that “can be used for whatever Americans (or their government) want, from iPhones to aircraft carrier battle groups.” America doesn’t have to spend on artificial infrastructure, like German roads and rails, but when it does, the competition from the rivers keeps transport costs low. Cheap internal transportation has other benefits. “It’s a recipe for small government and high levels of entrepreneurship,” as small government keeps taxes low, leaving people with plenty of capital. Some people may think of the American consumer with disdain, but it isn’t a new phenomenon. Zeihan points out that America has been the world’s largest consumer market “since shortly after the Civil War.” His observation about a robust food supply forming the base of any civilization bodes well for America, which apparently has the largest connected stretch of quality farmland in the world (the Midwest), the value of which is exponentially increased by the fact that it overlaps with so many of these amazing river systems. It isn’t just the Midwest that he gushes over. California’s Central Valley and the Sacramento River, and Washington and Oregon’s farmland with the Columbia and Snake Rivers get praise. The only major farmland more than 150 miles from a navigable waterway is some of the Great Plains near the Rockies. ***** Zeihan provides a reminder that national security is actually a thing, and that at its most basic level, it’s about protection against invasions. It was something of a shock reading about America’s land borders in that context. “As Santa Anna discovered during the Texas Independence War, there is no good staging location in (contemporary) Mexican territory that could strike at American lands.” And, “Canada’s border with the United States is much longer, more varied, and even more successful at keeping the two countries separated,” thanks to mountains and thick forests over much of it. The mid-continent lands are much more connected, but Zeihan frames these Canadian areas as basically American; they’re physically separated from Canada’s core eastern provinces, so trade with them is weaker than with the closer American states. Then there are the oceans. As much as Zeihan loves deserts for protection, he loves oceans more (particularly in a post-World War II world; more on that below). We get a story about the War of 1812 nearly splitting America into three when the British attacked Baltimore. America learned about “strategic vulnerability and sea approaches,” as the attack “on Baltimore—indeed, the entire war effort—would have been impossible without launching grounds in Canada and the Caribbean.” American foreign policy since then can be understood with respect to this lesson. Zeihan cites it as inspiration for America’s steps to make its ocean borders truly impenetrable, such as working to sever Canada from Britain, and the imperial-era acquisitions of Alaska, Hawaii, Midway, Puerto Rico, and de facto control of Cuba (preventing enemies from cutting off Mississippi River-based trade from the rest of the world). There’s more to Zeihan’s being awestruck by America than his analysis of its balance of transport advantages. He argues that America has been the world leader for agriculture, technology, finance, and industry since the Civil War, and runs through a litany of reasons for its preeminence: America is like a continent-sized island (because of its effective land borders), which is always going to be a more natural naval power than a more landlocked country.
Inline links: 4, 5
The net effect is that the United States now has a multilayered defense of the homeland before one even considers its alliance structure, its maritime prowess, or the general inability of Eurasian powers to assault it.
Which brings us to the final point about why the United States is nearly immune to rivals.
Your Book Review: Humankind
May 28, 2021 · Original source
This turned out not to be true. So spectacularly untrue that we still talk about the Blitz Spirit. With our trademark humility, the British concluded that this was due to our exceptional moral fibre and, with help from the Americans, set about bombing German civilians to hell and back. Regrettably the Germans too responded by pulling together, and working harder in the war effort. Literally no one thinks this was due to their exceptional moral fibre. Instead, it seemed that crisis led to teamwork. Bregman is able to quote similar behaviour on the Titanic, on September 11th and in the aftermath of Hurricane Katrina.
The solution was actually announced two thousand years ago, by a man named Jesus. "Turn the other cheek" he said, even to your enemies. This approach has been dismissed as naive, but the truth is it's how Gandhi won India her freedom, how Martin Luther King won rights for African Americans, and how Mandela ended apartheid. Turning the other cheek works, it's just really hard to do.
1% for today (not fighting world wars helps) But pre-historic man used things like tusks for weapons. This makes it hard to distinguish between 'violent death at the hands of the tribe down the road wielding tusks' and 'violent death at the hands of an elephant which didn't fancy being eaten for dinner'. Foraging tribes today are even less use - any tribe which has been followed around by sociologists with clipboards is hardly unsullied by contact with the modern world, and indeed quite a lot of the deaths turn out to have been caused by bullets from slave traders (presumably either these slave traders have developed zombification, or else they completely missed the aim of their job) or cattle ranchers. Unless Predator was actually a documentary, one presumes primitive man didn't have to contend with this. This is the issue with pre-history - it's pre … history. We really don't know that much about it. A hundred years ago G.K. Chesterton observed that we picture cavemen as stupid thugs dragging their clubs, but the one thing we actually know about them, was that they were artists. Having dispatched the notion that we can discern pre-history from primitive tribes today, Bregman then says we can tell primitive man was peaceful by observing his favourite primitive tribes today. He is even willing to infer the political views of our distant forebears based on the views held within those tribes. Sigh. Thankfully returning to history turns up some better evidence. In 1943 Colonel Samuel Marshall, the US Chief Combat Historian (you guys have the coolest titles) was with an American camp attacked by Japanese soldiers. The Japanese made 11 attempts in all, and were nearly successful despite being outnumbered. The next day Colonel Marshall tried to find out what went wrong. He interviewed the men in groups, asking them to speak freely and allowing them to disagree with their officers. What he discovered was that only 12% of the men fired their guns. Interviews in the Pacific and Europe broadly confirmed this picture: 15%-25% is typical. The majority of soldiers don't shoot at the enemy. They're not cowards, they don't run away. They just don't fire. Separate studies in the British and Soviet armies turned out the same conclusion. Muskets from the Battle of Gettysburg in the American Civil War (hey, you've been known to write 'Paris, France') found 90% were still loaded. Which is odd because loading a musket takes ages, 20 times as long as aiming and shooting it. Odder still is that half of them are double loaded. Not double shotted: double powder spaced out as well. This doesn't work. One of them has been loaded 23 times without firing. It's almost like most soldiers don't want to shoot the enemy, and loading your rifle is the perfect excuse for why you're not shooting. Far from being blood thirsty killers with a thin veneer of civilisation, humans have a deep aversion to killing in even the most desperate of situations. Part 2: Lies, damned lies and social psychology Why we ought to lock up the Stanford Prison Experiment The second most famous psychology experiment in history is the Stanford Prison experiment. Philip Zimbardo split a group of undergrads at random into prisoners and guards. The guards were left free to choose how they would manage the prisoners, and within days the whole thing had to be called off as it had descended into a sadistic torture camp. At least that's how Zimbardo has described it for the last 50 years. In fact, everything I just said is completely false. The undergrads were not split at random - the scheme had actually been dreamt up by an undergrad called David Jaffe who had run a previous experiment himself on abusing prisoners in a fake jail. He was carefully placed into the guards group. Nor were the guards left to choose their methods, instead they were briefed by Zimbardo and Jaffe that the purpose of the experiment (for which they were being well renumerated) was to see how people cracked under pressure. The experiment would be a failure unless they could put the prisoners under terrible stress. Even Douglas Korpi's prisoner breakdown on day two, which, captured on camera, became the cinematic face of the experiment, was a fake he put on after discovering he wouldn't be able to spend the time in jail revising, and being told he would only be allowed to quit if he suffered some sort of serious mental or physical breakdown. Despite the pressure from Zimbardo and Jaffe, two thirds of the guards refused to take part in sadistic games, and much to their frustration a third continued to treat the prisoners with kindness. Nonetheless when Zimbardo came to write up the experiment about the effects on the prisoners, he realised it would be a much more compelling story if he turned it on its head, and made it about the guards instead. The truth of guards carefully drilled to be sadistic was swept away with a lie of ordinary people spontaneously becoming cruel when dressed in a uniform and given a position of power. For years no one replicated the experiment - given the results first time round it was thought unethical, but in 2001 the BBC in search of new reality television commissioned a repeat (turns out reality television runs to different ethics than the average psychology department). Now unlike normal reality TV they didn't bother manipulating the participants to be at each other's throats - there was no need, in days it was going to be a bloodbath. The result is the four most boring hours of television ever recorded. Nothing happens. The guards sit around chatting. When tensions arise with the prisoners, they defuse them by talking to them nicely. On day 6 some prisoners escaped. They headed over to the guards' canteen and all had a smoke together. On day 7 they voted in favour of turning the whole thing into a commune. Why we ought to be shocked by Milgram's shock machine So much for the second most famous psychology experiment, what about the most famous - Milgram's shock machine? Milgram experiment took pairs of volunteers, and assigned one to take a memory test, while the other administered electric shocks for wrong answers. The shocks start at 15V, with the 'shocker' instructed to raise it by 15V for each subsequent wrong answer, even beyond the danger label the machine has. As the voltage got higher the man taking the test would scream in agony. If the 'shocker' continued, then at 350V he would thump on the wall, and then go silent. Of course this wasn't actually an experiment on memory. The man taking the test was a member of Milgram's team, and there were no shocks, only acting. The point of the experiment was to find out how many people would electrocute a stranger, just because a man in a white coat told them to. Two thirds of them it turned out (well, a bit under half if you discount the ones who claimed afterwards that they only went along with it because it was a psychology experiment in a prestigious university, pretty clearly no one was actually being dangerously electrocuted). Videos show some subjects were completely torn up about inflicting pain, but in the end they still did what the forceful man with the clipboard told them. Bregman is quite candid that his aim is to do a hatchet job on Milgram's experiment, in order to protect his thesis of humanity's innate goodness (just as it was for all the other things he's discredited - set your biasometers accordingly). Bregman spends a section trying to pick holes in the experiment, without much success. He then admits that he's not had any success, and that Milgram's experiment replicates. Where does all of this leave us? My conclusions are: It's possible to get ordinary people to do terrible things, but it's not that easy. Left to their own devices they don't spontaneously turn sadistic.
Book Review: Crazy Like Us
July 15, 2021 · Original source
As part of GlaxoSmithKline’s marketing work, they replaced utsubyo with a new idea, kokoro no kaze, “cold of the soul”. This was supposed to mean that depression was a minor illness (like a cold), something everyone got occasionally (like a cold), and something that was purely biological and could/should be controlled with medication (like a cold). Japanese people were extremely excited about this and bought Paxil by the bushel, and now they use SSRIs at a rate close to Americans.
Watters focuses on two things he thinks Zanzibaris do right. First, they minimize schizophrenia. Because of the spirit-possession aspect, instead of being marked apart as ill and unusual, they’re treated as on a continuum with everyone else (since we all get possessed by spirits sometimes). Even when they take a more medicalized perspective on schizophrenia, they call it by extremely vague terms that don’t differentiate it from mild illness, eg “an attack of the nerves” (this seems to be a universal developing-world euphemism for schizophrenia, shared by eg Latin Americans). Zanzibari schizophrenics never feel that different from anyone else - everyone gets possessed by spirits sometimes, everyone gets attacks of the nerves sometimes, lots of people never leave their family homes.
Anyway, according to scientists, America has the highest expressed emotion, Europe and other developed countries are also really high, and developing countries are mostly really low. 67% of Anglo-American families studied qualified as high-expressed-emotion, compared to 48% of Brits, 42% of Chinese, 41% of Mexican-Americans, and 23% of Indians. I am a little boggled by this - my stereotypes say the opposite. EG New England WASPs who never show any emotion at all, stiff-upper-lip Brits and Germans, compared to exuberant Mexicans and extremely high-pressure Asians. I hear woke people talk about how demanding a calm, quiet, low-expressed-emotion environment is white supremacy because only white people care about that kind of thing. But nope, according to Crazy Like Us scientists have determined that white Americans are the highest-expressed-emotion culture in the world. Huh.
Semaglutidonomics
November 24, 2022 · Original source
“Wegovy” sounds like either a cooperative governance platform, or some kind of obscure medieval sin. Weight loss pills have a bad reputation. But Wegovy is a big step up. It doesn’t work for everybody. But it works for 66-84% of people, depending on your threshold. (Source) Of six major weight loss drugs, only two - Wegovy and Qsymia - have a better than 50-50 chance of helping you lose 10% of your weight. Qsymia works partly by making food taste terrible; it can also cause cognitive issues. Wegovy feels more natural; patients just feel full and satisfied after they’ve eaten a healthy amount of food. You can read the gushing anecdotes here (plus some extra anecdotes in the comments). Wegovy patients also lose more weight on average than Qsymia patients - 15% compared to 10%. It’s just a really impressive drug. Until now, doctors didn’t really use medication to treat obesity; the drugs either didn’t work or had too many side effects. They recommended either diet and exercise (for easier cases) or bariatric surgery (for harder ones). Semaglutide marks the start of a new generation of weight loss drugs that are more clearly worthwhile. Modeling Semaglutide Accessibility 40% of Americans are obese - that’s 140 million people. Most of them would prefer to be less obese. Suppose that a quarter of them want semaglutide. That’s 35 million prescriptions. Semaglutide costs about $15,000 per year, multiply it out, that’s about $500 billion. Americans currently spend $300 billion per year total on prescription drugs. So if a quarter of the obese population got semaglutide, that would cost almost twice as much as all other drug spending combined. It would probably bankrupt half the health care industry. So . . . most people who want semaglutide won’t get it? Unclear. America’s current policy for controlling medical costs is to buy random things at random prices, then send all the bills to an illiterate reindeer-herder named Yagmuk, who burns them for warmth. Anything could happen! Right now, only about 50,000 Americans take semaglutide for obesity. I’m basing this off this report claiming “20,000 weekly US prescriptions” of Wegovy; since it’s taken once per week, maybe this means there are 20,000 users? Or maybe each prescription contains enough Wegovy to last a month and there are 80,000 users? I’m not sure, but it’s somewhere in the mid five digits, which I’m rounding to 50,000. That’s only 0.1% of the potential 35 million. The next few sections of this post are about why so few people are on semaglutide, and whether we should expect that to change. I’ll start by going over my model of what determines semaglutide use, then look at a Morgan Stanley projection of what will happen over the next decade. Step 1: Awareness I model semaglutide use as interest * awareness * prescription accessibility * affordability. I already randomly guessed interest at 25%, so the next step is awareness. How many people are aware of semaglutide? The answer is: a lot more now than when I first started writing this article! Novo Nordisk’s Wegovy Gets Surprise Endorsement From Elon Musk, says the headline. And here’s Google Trends: Semaglutide is now as searched-for on Google as Prozac or Viagra. Even if this is a temporary Musk-related spike, even pre-Musk it was getting a little above half their level. But Google Trends doesn’t exactly track awareness; few people search for Prozac these days precisely because everyone already knows what it is. So all this tells us is that there’s a lot of buzz around semaglutide. Suppose for the sake of argument that 5% of obese people have heard of this drug. Step 2: Prescription Accessibility The FDA says Wegovy is indicated for obesity, defined as BMI ≥ 30, or for people with BMI ≥ 27 and certain medical conditions. Does that mean that if you have that BMI, your doctor will give you a prescription? I think most doctors will want patients to try diet and exercise first. My experience as a doctor is that most obese people have already considered diet and exercise. Sometimes if you have a very compelling reason and a very well-thought out plan you can get them to try again. But usually they are obese because diet and exercise are hard for them, or don’t work for them, or some other reason besides “they never thought of it”. Still, I hear lots of stories about patient-doctor fights here. I assume this will happen with Wegovy too. Every doctor will have their own threshold for what amount of “already tried diet and exercise” is enough to justify a Wegovy prescription, and sometimes patients won’t meet that threshold. The history of medicine includes the following story many times: there’s some condition that doctors recommend lifestyle changes for. Then an exciting new medication comes out that treats the condition effectively. Over a generation or so, doctors go from demanding the lifestyle change, to gesturing at the lifestyle change before prescribing the medication, to mostly just prescribing the medication. We saw this with cholesterol and statins, with hypertension and ACE inhibitors, with depression and SSRIs. You can form your own opinion on whether this is good or bad, but we’re probably in the very beginning of this process with obesity. Opinions will be all over the map for a while before the inevitable pharma company victory makes everyone agree that semaglutide is first-line therapy. …except that this time, Silicon Valley is short-circuiting the process with fly-by-night telemedicine companies that guarantee you’ll get the drugs you want. For example, NextMed charges $138/month ($99 first month only!) for a guaranteed GLP-1 agonist prescription, plus “support and messaging with expert doctors”. The DEA sometimes shuts these groups down when they start playing around with controlled substances (eg addictive drugs like Adderall), but Wegovy isn’t controlled, and the government probably doesn’t care that much here. These services guarantee that people with money will be able to circumvent conservative doctors and access a prescription. Only 75% of Americans have PCPs at all. If we assume half of them will eventually be able to get a Wegovy prescription from their doctor, that’s 37.5%. Step 3: Affordability Semaglutide costs $15,000/year. Well-off people like Elon Musk might be able to pay that out-of-pocket, but most people will probably need insurance coverage. Right now this is spotty. Medicare doesn’t cover obesity drugs. This isn’t a reaction to the threat of semaglutide-related cost explosions - they’re not that smart. I think Medicare laws were just written in the old days when people were less likely to think of obesity as a disease. Is it time for change? Some Congressmen have proposed a very noble-sounding law telling Medicare and Medicaid to start covering weight loss drugs. I‘m sure this is out of deep compassion for America’s obese population and not because it would make pharma companies one billion zillion dollars. One of the Congressmen even has the last name “Kind!” Some pharma lobbyist probably got a bonus for that one. Private insurers mostly have to cover whatever Medicare does, but they can choose whether or not to include extra non-Medicare-covered drugs. Some have chosen to cover semaglutide under some conditions. Others would prefer not to cover it, but can be scared into covering it by the magic words “medical necessity”. Overall I don’t understand the laws here beyond that maybe they’ll cover it and maybe they won’t. Here, too, it might be time for change. The New York Times is publishing articles trying to convince us that private insurances not covering semaglutide is an outrage. Here in the tiny gray text, I want to take a second to complain about this article. It notes that Wegovy (semaglutide for obesity) costs more per prescription than Ozempic (semaglutide for diabetes), and calls this “a gross inequity”, accusing Novo Nordisk of “charg[ing] people more for the same drug because of their obesity”. But the obesity prescription is higher dose than the diabetes prescription! Milligram per milligram, Wegovy costs *less* than Ozempic! A steelmanned version of the NYT might object - don’t most of the costs come from the intellectual property and not the manufacturing, so that dose shouldn’t matter? Yes, but if you made the obesity version cost too much less per milligram than the diabetes version, then diabetics would cheat the system by buying the obesity version and splitting it into smaller doses! Insurances that do cover it may require extra documentation that the patient has tried lots of diet and exercise, maybe including some official diet-and-exercise program like WeightWatchers. They might also want documentation that patients have tried cheaper earlier-generation weight loss drugs without success. Even when insurances do cover semaglutide, copays may be very high. I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my out of pocket limit. Harsh. People with better insurances might get hit less hard, but I don’t think anyone will be picking this up for cheap. Let’s say only 5% of people who clear all previous hurdles can afford the drug. How Many People Get Semaglutide? 140 million obese Americans * 25% interested * 5% know of semaglutide’s existence * 37.5% can get prescriptions * 5% can afford it = 33,000, which is a pretty good match for the 50,000 estimated prescriptions. I didn’t even fudge the numbers to come out right, it just happened. The Coming Decade As a service to pharma investors, Morgan Stanley modeled the economic future of obesity medications over the next decade. Their headline result: semaglutide and various semaglutide-copycat-drugs will be a $30 billion market by 2030. That’s less than the $500 billion disaster I was afraid of! But still almost 10% of all US drug spending! Here are two core analyses from the report: The first analysis asks “what if doctors medicalized obesity as comprehensively as they’ve medicalized hypertension and high cholesterol?” That is: what if we put in a society-wide effort to get every obese person to a doctor, and after only a little diet and exercise, the doctor puts them on a medication? They find that the US obesity market would multiply by a factor of 25, to about $87 billion/year. The second analysis is a more realistic projection for the next decade. Two things stand out. First, the number of patients on Wegovy or related medications goes from an estimated 46,910 now (pretty close to my 50,000 estimate!) to 11.3 million in 2030. Second, the cost per prescription goes from $15,000/year to about $4,000 year. Let’s look at this second change in more detail. Right now semaglutide is literally in a class of its own for weight loss. But remember, it started as a GLP-1 agonist diabetes drug. And there are other GLP-1 agonists already in use for diabetes. Novo Nordisk’s competitor Eli Lilly owns a closely related molecule, tirzepatide (Mounjaro®). They’ve already done studies showing it also works very well for weight loss - if anything even better than semaglutide - and they’re expected to get FDA approval to market it as a weight loss medication next year. Although capitalism fans might expect the presence of two competing drugs to immediately drive down prices, this is mysteriously not how things work in health care and prices will probably stay the same in the short term. But several other companies are working on semaglutide-like drugs, some will be cheaper to produce than semaglutide, and Morgan Stanley expects that this stronger level of competition will eventually drive costs down to $350/month ($4,000/year) by 2030. “Mounjaro” sounds like the playful animal sidekick in a Disney movie. From a purely economic perspective, semaglutide costs the health system money (because it’s expensive) but also saves the health system money (because we don’t have to pay for obesity consequences like diabetes and heart attacks). Which effect wins out? According to the Institute for Clinical and Economic Review, benefits would outweigh costs if semaglutide cost less than about $8,000/year. Since it costs $15,000 year now, it’s not cost effective. But if Morgan Stanley’s model comes true and it costs $4,000/year in 2030, then it will be cost effective. So at some point, Medicare (and so insurance companies) may start covering it more out of self-interest. I can’t tell whether the model takes this into account or not. (there’s also a third-level effect where it costs the health system money again, because it prevents people from dying of obesity-related complications, and dead people stop needing expensive health care. I think health economists are supposed to ignore this level.) 11.3 million prescriptions at $4,000/year comes to $45 billion, but Morgan Stanley expects that not everyone will fill their prescriptions consistently or stay on the medication the same amount of time, leading to their $31 billion figure. Towards The Glorious Post-Obesity Transhuman Future The Morgan Stanley report shows that even the greediest pharma investors, openly plotting to medicalize obesity, can’t bring themselves to believe in more than 11 million US semaglutide patients by 2030. That’s less than 10% of the US obese population. Isn’t that kind of disappointing? We’ve got > 100 million people dealing with a condition that not only makes them unhealthy, but also causes them psychological distress, and makes lots of people low-grade disappointed in and repulsed by our society. And we’ve got an effective drug that treats the condition. And we’re going to use it on less than 10% of the people involved? In 2032, semaglutide goes off-patent. It will probably take a few years to sort out legal issues and ramp up generic production, but by the mid-2030s, its price will go way down. I don’t think there are technical barriers to getting it down as low as $10 - $100 per month. By then, maybe there will be even more exciting branded weight loss drugs for wealthy people to choose from. But at the very least, semaglutide itself should become much more widely available even to poor or uninsured patients. I’m not sure what will happen. Will there be an inflection point, where so many people use semaglutide that obesity becomes unusual again, and then the remaining obese people start using it just to fit in? Will obesity become an optional fashion statement, like shaving your head or getting a tattoo? Or will semaglutide end up disappointing us in some way, like so many promising drugs have before? I come at semaglutide from a transhumanist perspective. I want to hack genetics and biology until everyone is as tall as they want, as strong as they want, as smart as they want, and whatever gender they want. If you want wings, you should be able to have wings. And yes, part of this vision is everyone having the weight they want. I’m not sure this will happen, but for the first time I can see a clear path to how it might. Postscript 1: Should You Take Semaglutide? I can’t answer this, please ask your doctor. But I do want to add that there are potential side effects I haven’t mentioned in this post, including nausea, gastrointestinal problems, pancreatitis, and kidney problems. Semaglutide has been accused of slightly increasing risk of pancreatic and thyroid cancers. Studies have found trends in this direction, but these conditions are so rare that even over thousands of patients over many years, the increase hasn’t yet reached clear statistical significance. The current consensus position is that it may increase thyroid cancer by a tiny amount not relevant to most patients, and that it probably doesn’t increase pancreatic cancer. I think my father has looked over these data more and is less sure than other people about the lack of pancreatic cancer risk, but he can’t get the resources he needs to prove anything, and I can’t remember his exact argument. More broadly: like all medications, semaglutide has benefits and risks, and you shouldn’t blindly take it after reading one blog article. Postscript 2: Is There A Way To Cheat The System To Get Semaglutide For Lower Cost? Health care is much like airline tickets: everyone pays a different price for everything and there’s usually a secret way to get what you want for much less money. Is this true of semaglutide? Pharma company Novo Nordisk offers a Savings Card that they say brings the price down to as low as $25 per month. I’m a little suspicious of this - pharma company offers are rarely as good as they sound - but I don’t notice any obvious tricks in this one and it should probably be your first bet. This startup claims that they can get insured people semaglutide for a $25/month copay “after their deductible is met” by negotiating with the insurance company very effectively. I can’t imagine how that works or what they have to negotiate with, but they seem pretty convinced, so I would welcome more information. Otherwise, you don’t have many great options. Although there are two older forms of semaglutide not FDA-approved for weight loss - Ozempic and Rybelsus - these are both more expensive, milligram per milligram, than Wegovy itself. Canada is also of no help. The usual Canadian pharmacies don’t seem to carry Wegovy, and charge about the same amount for Ozempic as American pharmacies do. This article in Drug Discovery Trends says that compounding pharmacies have been selling semaglutide for $300/month, less than a quarter of the sticker price. This is a bit confusing: compounding pharmacies are small local operations permitted to dispense unusual medications by mixing existing ones together in nonstandard ways. They’re arguing that they can legally dispense the semaglutide because they’re mixing it with vitamins, which, fine, but how are they getting it in the first place? Everyone else seems as confused as I am: "Nobody knows how [compounding pharmacies are] getting it," said Karl Nadolsky, an endocrinologist at Spectrum Health. "Who's making it? [The pharma company that makes it] Novo [Nordisk]'s not giving it to them. They're the ones with the rights to the molecule, so how is anybody getting semaglutide?" Has nobody asked compounding pharmacists about this? Do they have a conspiracy of silence? Does the FDA sometimes send their goons in to extract the information, but the compounding pharmacists compound sleeping gas / smoke grenades and vanish into the night? Anyway, the usual authorities warn you not to take compounded semaglutide under any circumstances, but they’re the same people who tell you never to buy drugs from a Canadian pharmacy because they might be adulterated. You can decide how much you want to trust them. Postscript 3: What About Europe And The Rest Of The World? Countries that are not the US usually negotiate with pharmaceutical companies over price. Because of some combination of “negotiation works” and “they are free-riding off Americans’ hard work”, they usually get much lower prices. What does semaglutide cost elsewhere? This is hard to find out because government health agencies sometimes keep their prices secret, plus Wegovy mostly isn’t available in other countries yet. The only information I could find was from Britain, which is in the process of making Wegovy available to patients. It looks like NHS will “restrict the expensive drug’s availability to very obese people attending specialist weight-loss clinics”, but that it might be possible to get it from private clinics for £199/month = £2400/year. Wegovy has been approved in the EU but doesn’t seem to have made it there yet. I can’t find any information about any other country. Non-weight-loss-indicated versions of semaglutide are available in many countries, but I wouldn’t expect their health care systems to be flexible about redirecting it for weight. Canadian regulators have approved Wegovy, but it doesn’t seem to be available there yet. I haven’t seen any evidence that Ozempic costs less in Canada than it does in the US, and I’m not sure why. Maybe the pharma companies have figured out that anything that happens in Canada gets imported into the US, and they’re playing hardball this time. I don’t know whether Canadians will be able to get it for cheaper than Americans or not. Postscript 4: Predictions (all predictions are conditional on no singularity or global catastrophe) 10 million Americans on semaglutide (or yet-to-be-approved equally good or superior alternatives) by 2030: 75%
Inline links: https://substackcdn.com/image/fetch/$s_!gShh!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fe4b4ffd4-3d5b-445c-961d-f562ca14ac0f_818x220.png, Source, here, in the comments, lose more weight, this report, Novo Nordisk’s Wegovy Gets Surprise Endorsement From Elon Musk, https://substackcdn.com/image/fetch/$s_!RABx!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F366df26d-e420-431d-8034-e2c4a6a8de60_1149x471.png, NextMed, a very noble-sounding law, https://substackcdn.com/image/fetch/$s_!l_X7!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F1dbb9e98-6e07-4237-988e-3b7a61af3e5a_1381x834.png, is publishing articles, https://substackcdn.com/image/fetch/$s_!R-zS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0f24b293-27de-462a-84fd-bed2ba7cf07f_1723x831.png, https://substackcdn.com/image/fetch/$s_!zSOS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0906b28a-1ad4-421d-a055-87ed95db59ce_918x261.png, https://substackcdn.com/image/fetch/$s_!QJj9!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fb966f730-6b24-48e1-98b1-e710cda9264c_903x656.png, this is mysteriously not how things work in health care, https://substackcdn.com/image/fetch/$s_!5poy!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fc201f05a-7d1f-4738-911f-11d0d051adf9_2880x1562.png, Institute for Clinical and Economic Review, don’t think there are technical barriers, offers a Savings Card, This startup, about the same amount for Ozempic, This article in Drug Discovery Trends, Everyone else seems as confused as I am, NHS will, private clinics
Semaglutide is now as searched-for on Google as Prozac or Viagra. Even if this is a temporary Musk-related spike, even pre-Musk it was getting a little above half their level. But Google Trends doesn’t exactly track awareness; few people search for Prozac these days precisely because everyone already knows what it is. So all this tells us is that there’s a lot of buzz around semaglutide. Suppose for the sake of argument that 5% of obese people have heard of this drug. Step 2: Prescription Accessibility The FDA says Wegovy is indicated for obesity, defined as BMI ≥ 30, or for people with BMI ≥ 27 and certain medical conditions. Does that mean that if you have that BMI, your doctor will give you a prescription? I think most doctors will want patients to try diet and exercise first. My experience as a doctor is that most obese people have already considered diet and exercise. Sometimes if you have a very compelling reason and a very well-thought out plan you can get them to try again. But usually they are obese because diet and exercise are hard for them, or don’t work for them, or some other reason besides “they never thought of it”. Still, I hear lots of stories about patient-doctor fights here. I assume this will happen with Wegovy too. Every doctor will have their own threshold for what amount of “already tried diet and exercise” is enough to justify a Wegovy prescription, and sometimes patients won’t meet that threshold. The history of medicine includes the following story many times: there’s some condition that doctors recommend lifestyle changes for. Then an exciting new medication comes out that treats the condition effectively. Over a generation or so, doctors go from demanding the lifestyle change, to gesturing at the lifestyle change before prescribing the medication, to mostly just prescribing the medication. We saw this with cholesterol and statins, with hypertension and ACE inhibitors, with depression and SSRIs. You can form your own opinion on whether this is good or bad, but we’re probably in the very beginning of this process with obesity. Opinions will be all over the map for a while before the inevitable pharma company victory makes everyone agree that semaglutide is first-line therapy. …except that this time, Silicon Valley is short-circuiting the process with fly-by-night telemedicine companies that guarantee you’ll get the drugs you want. For example, NextMed charges $138/month ($99 first month only!) for a guaranteed GLP-1 agonist prescription, plus “support and messaging with expert doctors”. The DEA sometimes shuts these groups down when they start playing around with controlled substances (eg addictive drugs like Adderall), but Wegovy isn’t controlled, and the government probably doesn’t care that much here. These services guarantee that people with money will be able to circumvent conservative doctors and access a prescription. Only 75% of Americans have PCPs at all. If we assume half of them will eventually be able to get a Wegovy prescription from their doctor, that’s 37.5%. Step 3: Affordability Semaglutide costs $15,000/year. Well-off people like Elon Musk might be able to pay that out-of-pocket, but most people will probably need insurance coverage. Right now this is spotty. Medicare doesn’t cover obesity drugs. This isn’t a reaction to the threat of semaglutide-related cost explosions - they’re not that smart. I think Medicare laws were just written in the old days when people were less likely to think of obesity as a disease. Is it time for change? Some Congressmen have proposed a very noble-sounding law telling Medicare and Medicaid to start covering weight loss drugs. I‘m sure this is out of deep compassion for America’s obese population and not because it would make pharma companies one billion zillion dollars. One of the Congressmen even has the last name “Kind!” Some pharma lobbyist probably got a bonus for that one. Private insurers mostly have to cover whatever Medicare does, but they can choose whether or not to include extra non-Medicare-covered drugs. Some have chosen to cover semaglutide under some conditions. Others would prefer not to cover it, but can be scared into covering it by the magic words “medical necessity”. Overall I don’t understand the laws here beyond that maybe they’ll cover it and maybe they won’t. Here, too, it might be time for change. The New York Times is publishing articles trying to convince us that private insurances not covering semaglutide is an outrage. Here in the tiny gray text, I want to take a second to complain about this article. It notes that Wegovy (semaglutide for obesity) costs more per prescription than Ozempic (semaglutide for diabetes), and calls this “a gross inequity”, accusing Novo Nordisk of “charg[ing] people more for the same drug because of their obesity”. But the obesity prescription is higher dose than the diabetes prescription! Milligram per milligram, Wegovy costs *less* than Ozempic! A steelmanned version of the NYT might object - don’t most of the costs come from the intellectual property and not the manufacturing, so that dose shouldn’t matter? Yes, but if you made the obesity version cost too much less per milligram than the diabetes version, then diabetics would cheat the system by buying the obesity version and splitting it into smaller doses! Insurances that do cover it may require extra documentation that the patient has tried lots of diet and exercise, maybe including some official diet-and-exercise program like WeightWatchers. They might also want documentation that patients have tried cheaper earlier-generation weight loss drugs without success. Even when insurances do cover semaglutide, copays may be very high. I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my out of pocket limit. Harsh. People with better insurances might get hit less hard, but I don’t think anyone will be picking this up for cheap. Let’s say only 5% of people who clear all previous hurdles can afford the drug. How Many People Get Semaglutide? 140 million obese Americans * 25% interested * 5% know of semaglutide’s existence * 37.5% can get prescriptions * 5% can afford it = 33,000, which is a pretty good match for the 50,000 estimated prescriptions. I didn’t even fudge the numbers to come out right, it just happened. The Coming Decade As a service to pharma investors, Morgan Stanley modeled the economic future of obesity medications over the next decade. Their headline result: semaglutide and various semaglutide-copycat-drugs will be a $30 billion market by 2030. That’s less than the $500 billion disaster I was afraid of! But still almost 10% of all US drug spending! Here are two core analyses from the report: The first analysis asks “what if doctors medicalized obesity as comprehensively as they’ve medicalized hypertension and high cholesterol?” That is: what if we put in a society-wide effort to get every obese person to a doctor, and after only a little diet and exercise, the doctor puts them on a medication? They find that the US obesity market would multiply by a factor of 25, to about $87 billion/year. The second analysis is a more realistic projection for the next decade. Two things stand out. First, the number of patients on Wegovy or related medications goes from an estimated 46,910 now (pretty close to my 50,000 estimate!) to 11.3 million in 2030. Second, the cost per prescription goes from $15,000/year to about $4,000 year. Let’s look at this second change in more detail. Right now semaglutide is literally in a class of its own for weight loss. But remember, it started as a GLP-1 agonist diabetes drug. And there are other GLP-1 agonists already in use for diabetes. Novo Nordisk’s competitor Eli Lilly owns a closely related molecule, tirzepatide (Mounjaro®). They’ve already done studies showing it also works very well for weight loss - if anything even better than semaglutide - and they’re expected to get FDA approval to market it as a weight loss medication next year. Although capitalism fans might expect the presence of two competing drugs to immediately drive down prices, this is mysteriously not how things work in health care and prices will probably stay the same in the short term. But several other companies are working on semaglutide-like drugs, some will be cheaper to produce than semaglutide, and Morgan Stanley expects that this stronger level of competition will eventually drive costs down to $350/month ($4,000/year) by 2030. “Mounjaro” sounds like the playful animal sidekick in a Disney movie. From a purely economic perspective, semaglutide costs the health system money (because it’s expensive) but also saves the health system money (because we don’t have to pay for obesity consequences like diabetes and heart attacks). Which effect wins out? According to the Institute for Clinical and Economic Review, benefits would outweigh costs if semaglutide cost less than about $8,000/year. Since it costs $15,000 year now, it’s not cost effective. But if Morgan Stanley’s model comes true and it costs $4,000/year in 2030, then it will be cost effective. So at some point, Medicare (and so insurance companies) may start covering it more out of self-interest. I can’t tell whether the model takes this into account or not. (there’s also a third-level effect where it costs the health system money again, because it prevents people from dying of obesity-related complications, and dead people stop needing expensive health care. I think health economists are supposed to ignore this level.) 11.3 million prescriptions at $4,000/year comes to $45 billion, but Morgan Stanley expects that not everyone will fill their prescriptions consistently or stay on the medication the same amount of time, leading to their $31 billion figure. Towards The Glorious Post-Obesity Transhuman Future The Morgan Stanley report shows that even the greediest pharma investors, openly plotting to medicalize obesity, can’t bring themselves to believe in more than 11 million US semaglutide patients by 2030. That’s less than 10% of the US obese population. Isn’t that kind of disappointing? We’ve got > 100 million people dealing with a condition that not only makes them unhealthy, but also causes them psychological distress, and makes lots of people low-grade disappointed in and repulsed by our society. And we’ve got an effective drug that treats the condition. And we’re going to use it on less than 10% of the people involved? In 2032, semaglutide goes off-patent. It will probably take a few years to sort out legal issues and ramp up generic production, but by the mid-2030s, its price will go way down. I don’t think there are technical barriers to getting it down as low as $10 - $100 per month. By then, maybe there will be even more exciting branded weight loss drugs for wealthy people to choose from. But at the very least, semaglutide itself should become much more widely available even to poor or uninsured patients. I’m not sure what will happen. Will there be an inflection point, where so many people use semaglutide that obesity becomes unusual again, and then the remaining obese people start using it just to fit in? Will obesity become an optional fashion statement, like shaving your head or getting a tattoo? Or will semaglutide end up disappointing us in some way, like so many promising drugs have before? I come at semaglutide from a transhumanist perspective. I want to hack genetics and biology until everyone is as tall as they want, as strong as they want, as smart as they want, and whatever gender they want. If you want wings, you should be able to have wings. And yes, part of this vision is everyone having the weight they want. I’m not sure this will happen, but for the first time I can see a clear path to how it might. Postscript 1: Should You Take Semaglutide? I can’t answer this, please ask your doctor. But I do want to add that there are potential side effects I haven’t mentioned in this post, including nausea, gastrointestinal problems, pancreatitis, and kidney problems. Semaglutide has been accused of slightly increasing risk of pancreatic and thyroid cancers. Studies have found trends in this direction, but these conditions are so rare that even over thousands of patients over many years, the increase hasn’t yet reached clear statistical significance. The current consensus position is that it may increase thyroid cancer by a tiny amount not relevant to most patients, and that it probably doesn’t increase pancreatic cancer. I think my father has looked over these data more and is less sure than other people about the lack of pancreatic cancer risk, but he can’t get the resources he needs to prove anything, and I can’t remember his exact argument. More broadly: like all medications, semaglutide has benefits and risks, and you shouldn’t blindly take it after reading one blog article. Postscript 2: Is There A Way To Cheat The System To Get Semaglutide For Lower Cost? Health care is much like airline tickets: everyone pays a different price for everything and there’s usually a secret way to get what you want for much less money. Is this true of semaglutide? Pharma company Novo Nordisk offers a Savings Card that they say brings the price down to as low as $25 per month. I’m a little suspicious of this - pharma company offers are rarely as good as they sound - but I don’t notice any obvious tricks in this one and it should probably be your first bet. This startup claims that they can get insured people semaglutide for a $25/month copay “after their deductible is met” by negotiating with the insurance company very effectively. I can’t imagine how that works or what they have to negotiate with, but they seem pretty convinced, so I would welcome more information. Otherwise, you don’t have many great options. Although there are two older forms of semaglutide not FDA-approved for weight loss - Ozempic and Rybelsus - these are both more expensive, milligram per milligram, than Wegovy itself. Canada is also of no help. The usual Canadian pharmacies don’t seem to carry Wegovy, and charge about the same amount for Ozempic as American pharmacies do. This article in Drug Discovery Trends says that compounding pharmacies have been selling semaglutide for $300/month, less than a quarter of the sticker price. This is a bit confusing: compounding pharmacies are small local operations permitted to dispense unusual medications by mixing existing ones together in nonstandard ways. They’re arguing that they can legally dispense the semaglutide because they’re mixing it with vitamins, which, fine, but how are they getting it in the first place? Everyone else seems as confused as I am: "Nobody knows how [compounding pharmacies are] getting it," said Karl Nadolsky, an endocrinologist at Spectrum Health. "Who's making it? [The pharma company that makes it] Novo [Nordisk]'s not giving it to them. They're the ones with the rights to the molecule, so how is anybody getting semaglutide?" Has nobody asked compounding pharmacists about this? Do they have a conspiracy of silence? Does the FDA sometimes send their goons in to extract the information, but the compounding pharmacists compound sleeping gas / smoke grenades and vanish into the night? Anyway, the usual authorities warn you not to take compounded semaglutide under any circumstances, but they’re the same people who tell you never to buy drugs from a Canadian pharmacy because they might be adulterated. You can decide how much you want to trust them. Postscript 3: What About Europe And The Rest Of The World? Countries that are not the US usually negotiate with pharmaceutical companies over price. Because of some combination of “negotiation works” and “they are free-riding off Americans’ hard work”, they usually get much lower prices. What does semaglutide cost elsewhere? This is hard to find out because government health agencies sometimes keep their prices secret, plus Wegovy mostly isn’t available in other countries yet. The only information I could find was from Britain, which is in the process of making Wegovy available to patients. It looks like NHS will “restrict the expensive drug’s availability to very obese people attending specialist weight-loss clinics”, but that it might be possible to get it from private clinics for £199/month = £2400/year. Wegovy has been approved in the EU but doesn’t seem to have made it there yet. I can’t find any information about any other country. Non-weight-loss-indicated versions of semaglutide are available in many countries, but I wouldn’t expect their health care systems to be flexible about redirecting it for weight. Canadian regulators have approved Wegovy, but it doesn’t seem to be available there yet. I haven’t seen any evidence that Ozempic costs less in Canada than it does in the US, and I’m not sure why. Maybe the pharma companies have figured out that anything that happens in Canada gets imported into the US, and they’re playing hardball this time. I don’t know whether Canadians will be able to get it for cheaper than Americans or not. Postscript 4: Predictions (all predictions are conditional on no singularity or global catastrophe) 10 million Americans on semaglutide (or yet-to-be-approved equally good or superior alternatives) by 2030: 75%
Inline links: NextMed, a very noble-sounding law, https://substackcdn.com/image/fetch/$s_!l_X7!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F1dbb9e98-6e07-4237-988e-3b7a61af3e5a_1381x834.png, is publishing articles, https://substackcdn.com/image/fetch/$s_!R-zS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0f24b293-27de-462a-84fd-bed2ba7cf07f_1723x831.png, modeled the economic future of obesity medications over the next decade, https://substackcdn.com/image/fetch/$s_!zSOS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0906b28a-1ad4-421d-a055-87ed95db59ce_918x261.png, https://substackcdn.com/image/fetch/$s_!QJj9!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fb966f730-6b24-48e1-98b1-e710cda9264c_903x656.png, this is mysteriously not how things work in health care, https://substackcdn.com/image/fetch/$s_!5poy!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fc201f05a-7d1f-4738-911f-11d0d051adf9_2880x1562.png, Institute for Clinical and Economic Review, don’t think there are technical barriers, offers a Savings Card, This startup, about the same amount for Ozempic, This article in Drug Discovery Trends, Everyone else seems as confused as I am, NHS will, private clinics
Here in the tiny gray text, I want to take a second to complain about this article. It notes that Wegovy (semaglutide for obesity) costs more per prescription than Ozempic (semaglutide for diabetes), and calls this “a gross inequity”, accusing Novo Nordisk of “charg[ing] people more for the same drug because of their obesity”. But the obesity prescription is higher dose than the diabetes prescription! Milligram per milligram, Wegovy costs *less* than Ozempic! A steelmanned version of the NYT might object - don’t most of the costs come from the intellectual property and not the manufacturing, so that dose shouldn’t matter? Yes, but if you made the obesity version cost too much less per milligram than the diabetes version, then diabetics would cheat the system by buying the obesity version and splitting it into smaller doses! Insurances that do cover it may require extra documentation that the patient has tried lots of diet and exercise, maybe including some official diet-and-exercise program like WeightWatchers. They might also want documentation that patients have tried cheaper earlier-generation weight loss drugs without success. Even when insurances do cover semaglutide, copays may be very high. I have a pretty minimal insurance and it looks like if I got semaglutide my copay would be about $500/month until I reach my out of pocket limit. Harsh. People with better insurances might get hit less hard, but I don’t think anyone will be picking this up for cheap. Let’s say only 5% of people who clear all previous hurdles can afford the drug. How Many People Get Semaglutide? 140 million obese Americans * 25% interested * 5% know of semaglutide’s existence * 37.5% can get prescriptions * 5% can afford it = 33,000, which is a pretty good match for the 50,000 estimated prescriptions. I didn’t even fudge the numbers to come out right, it just happened. The Coming Decade As a service to pharma investors, Morgan Stanley modeled the economic future of obesity medications over the next decade. Their headline result: semaglutide and various semaglutide-copycat-drugs will be a $30 billion market by 2030. That’s less than the $500 billion disaster I was afraid of! But still almost 10% of all US drug spending! Here are two core analyses from the report: The first analysis asks “what if doctors medicalized obesity as comprehensively as they’ve medicalized hypertension and high cholesterol?” That is: what if we put in a society-wide effort to get every obese person to a doctor, and after only a little diet and exercise, the doctor puts them on a medication? They find that the US obesity market would multiply by a factor of 25, to about $87 billion/year. The second analysis is a more realistic projection for the next decade. Two things stand out. First, the number of patients on Wegovy or related medications goes from an estimated 46,910 now (pretty close to my 50,000 estimate!) to 11.3 million in 2030. Second, the cost per prescription goes from $15,000/year to about $4,000 year. Let’s look at this second change in more detail. Right now semaglutide is literally in a class of its own for weight loss. But remember, it started as a GLP-1 agonist diabetes drug. And there are other GLP-1 agonists already in use for diabetes. Novo Nordisk’s competitor Eli Lilly owns a closely related molecule, tirzepatide (Mounjaro®). They’ve already done studies showing it also works very well for weight loss - if anything even better than semaglutide - and they’re expected to get FDA approval to market it as a weight loss medication next year. Although capitalism fans might expect the presence of two competing drugs to immediately drive down prices, this is mysteriously not how things work in health care and prices will probably stay the same in the short term. But several other companies are working on semaglutide-like drugs, some will be cheaper to produce than semaglutide, and Morgan Stanley expects that this stronger level of competition will eventually drive costs down to $350/month ($4,000/year) by 2030. “Mounjaro” sounds like the playful animal sidekick in a Disney movie. From a purely economic perspective, semaglutide costs the health system money (because it’s expensive) but also saves the health system money (because we don’t have to pay for obesity consequences like diabetes and heart attacks). Which effect wins out? According to the Institute for Clinical and Economic Review, benefits would outweigh costs if semaglutide cost less than about $8,000/year. Since it costs $15,000 year now, it’s not cost effective. But if Morgan Stanley’s model comes true and it costs $4,000/year in 2030, then it will be cost effective. So at some point, Medicare (and so insurance companies) may start covering it more out of self-interest. I can’t tell whether the model takes this into account or not. (there’s also a third-level effect where it costs the health system money again, because it prevents people from dying of obesity-related complications, and dead people stop needing expensive health care. I think health economists are supposed to ignore this level.) 11.3 million prescriptions at $4,000/year comes to $45 billion, but Morgan Stanley expects that not everyone will fill their prescriptions consistently or stay on the medication the same amount of time, leading to their $31 billion figure. Towards The Glorious Post-Obesity Transhuman Future The Morgan Stanley report shows that even the greediest pharma investors, openly plotting to medicalize obesity, can’t bring themselves to believe in more than 11 million US semaglutide patients by 2030. That’s less than 10% of the US obese population. Isn’t that kind of disappointing? We’ve got > 100 million people dealing with a condition that not only makes them unhealthy, but also causes them psychological distress, and makes lots of people low-grade disappointed in and repulsed by our society. And we’ve got an effective drug that treats the condition. And we’re going to use it on less than 10% of the people involved? In 2032, semaglutide goes off-patent. It will probably take a few years to sort out legal issues and ramp up generic production, but by the mid-2030s, its price will go way down. I don’t think there are technical barriers to getting it down as low as $10 - $100 per month. By then, maybe there will be even more exciting branded weight loss drugs for wealthy people to choose from. But at the very least, semaglutide itself should become much more widely available even to poor or uninsured patients. I’m not sure what will happen. Will there be an inflection point, where so many people use semaglutide that obesity becomes unusual again, and then the remaining obese people start using it just to fit in? Will obesity become an optional fashion statement, like shaving your head or getting a tattoo? Or will semaglutide end up disappointing us in some way, like so many promising drugs have before? I come at semaglutide from a transhumanist perspective. I want to hack genetics and biology until everyone is as tall as they want, as strong as they want, as smart as they want, and whatever gender they want. If you want wings, you should be able to have wings. And yes, part of this vision is everyone having the weight they want. I’m not sure this will happen, but for the first time I can see a clear path to how it might. Postscript 1: Should You Take Semaglutide? I can’t answer this, please ask your doctor. But I do want to add that there are potential side effects I haven’t mentioned in this post, including nausea, gastrointestinal problems, pancreatitis, and kidney problems. Semaglutide has been accused of slightly increasing risk of pancreatic and thyroid cancers. Studies have found trends in this direction, but these conditions are so rare that even over thousands of patients over many years, the increase hasn’t yet reached clear statistical significance. The current consensus position is that it may increase thyroid cancer by a tiny amount not relevant to most patients, and that it probably doesn’t increase pancreatic cancer. I think my father has looked over these data more and is less sure than other people about the lack of pancreatic cancer risk, but he can’t get the resources he needs to prove anything, and I can’t remember his exact argument. More broadly: like all medications, semaglutide has benefits and risks, and you shouldn’t blindly take it after reading one blog article. Postscript 2: Is There A Way To Cheat The System To Get Semaglutide For Lower Cost? Health care is much like airline tickets: everyone pays a different price for everything and there’s usually a secret way to get what you want for much less money. Is this true of semaglutide? Pharma company Novo Nordisk offers a Savings Card that they say brings the price down to as low as $25 per month. I’m a little suspicious of this - pharma company offers are rarely as good as they sound - but I don’t notice any obvious tricks in this one and it should probably be your first bet. This startup claims that they can get insured people semaglutide for a $25/month copay “after their deductible is met” by negotiating with the insurance company very effectively. I can’t imagine how that works or what they have to negotiate with, but they seem pretty convinced, so I would welcome more information. Otherwise, you don’t have many great options. Although there are two older forms of semaglutide not FDA-approved for weight loss - Ozempic and Rybelsus - these are both more expensive, milligram per milligram, than Wegovy itself. Canada is also of no help. The usual Canadian pharmacies don’t seem to carry Wegovy, and charge about the same amount for Ozempic as American pharmacies do. This article in Drug Discovery Trends says that compounding pharmacies have been selling semaglutide for $300/month, less than a quarter of the sticker price. This is a bit confusing: compounding pharmacies are small local operations permitted to dispense unusual medications by mixing existing ones together in nonstandard ways. They’re arguing that they can legally dispense the semaglutide because they’re mixing it with vitamins, which, fine, but how are they getting it in the first place? Everyone else seems as confused as I am: "Nobody knows how [compounding pharmacies are] getting it," said Karl Nadolsky, an endocrinologist at Spectrum Health. "Who's making it? [The pharma company that makes it] Novo [Nordisk]'s not giving it to them. They're the ones with the rights to the molecule, so how is anybody getting semaglutide?" Has nobody asked compounding pharmacists about this? Do they have a conspiracy of silence? Does the FDA sometimes send their goons in to extract the information, but the compounding pharmacists compound sleeping gas / smoke grenades and vanish into the night? Anyway, the usual authorities warn you not to take compounded semaglutide under any circumstances, but they’re the same people who tell you never to buy drugs from a Canadian pharmacy because they might be adulterated. You can decide how much you want to trust them. Postscript 3: What About Europe And The Rest Of The World? Countries that are not the US usually negotiate with pharmaceutical companies over price. Because of some combination of “negotiation works” and “they are free-riding off Americans’ hard work”, they usually get much lower prices. What does semaglutide cost elsewhere? This is hard to find out because government health agencies sometimes keep their prices secret, plus Wegovy mostly isn’t available in other countries yet. The only information I could find was from Britain, which is in the process of making Wegovy available to patients. It looks like NHS will “restrict the expensive drug’s availability to very obese people attending specialist weight-loss clinics”, but that it might be possible to get it from private clinics for £199/month = £2400/year. Wegovy has been approved in the EU but doesn’t seem to have made it there yet. I can’t find any information about any other country. Non-weight-loss-indicated versions of semaglutide are available in many countries, but I wouldn’t expect their health care systems to be flexible about redirecting it for weight. Canadian regulators have approved Wegovy, but it doesn’t seem to be available there yet. I haven’t seen any evidence that Ozempic costs less in Canada than it does in the US, and I’m not sure why. Maybe the pharma companies have figured out that anything that happens in Canada gets imported into the US, and they’re playing hardball this time. I don’t know whether Canadians will be able to get it for cheaper than Americans or not. Postscript 4: Predictions (all predictions are conditional on no singularity or global catastrophe) 10 million Americans on semaglutide (or yet-to-be-approved equally good or superior alternatives) by 2030: 75%
Inline links: modeled the economic future of obesity medications over the next decade, https://substackcdn.com/image/fetch/$s_!zSOS!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2F0906b28a-1ad4-421d-a055-87ed95db59ce_918x261.png, https://substackcdn.com/image/fetch/$s_!QJj9!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fb966f730-6b24-48e1-98b1-e710cda9264c_903x656.png, this is mysteriously not how things work in health care, https://substackcdn.com/image/fetch/$s_!5poy!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fc201f05a-7d1f-4738-911f-11d0d051adf9_2880x1562.png, Institute for Clinical and Economic Review, don’t think there are technical barriers, offers a Savings Card, This startup, about the same amount for Ozempic, This article in Drug Discovery Trends, Everyone else seems as confused as I am, NHS will, private clinics
Tech PACs Are Closing In On The Almonds
October 21, 2025 · Original source
During the 2018 election, Americans - candidates, parties, PACs, and small donors like you - spent a combined $5 billion pushing their preferred candidates. Although that sounds like a lot of money, Americans spent $12 billion on almonds that same year. Why the imbalance? The oil industry has strong political opinions, and they make $500 billion per year. Do they really think electing oil-friendly politicians isn’t worth 2% of revenue?
Everyone else The partisan groups have lots of money but little distortionary effect. Democratic machines try to elect Democrats, Republican machines try to elect Republicans, but they don't push their chosen candidates towards any specific position besides the ones that play well with voters. They are, so to speak, priced in. AIPAC is a single-issue PAC aimed at supporting Israel. They are orders of magnitude more effective than any comparable political organization. Their advantage stems from the nature of political donations, which come in two types. "Hard money" is money given directly to candidates; strict campaign finance limits it to $7000 per donor. "Soft money" comes from SuperPACs and can evade most campaign finance laws; it can pay for ads but can't fund candidates directly. Candidates prefer hard money to soft money, but it's harder to get; a single billionaire can provide unlimited soft money, but you need a wide donor base to acquire hard money. But not too wide! When millions of waitresses and bartenders gave Bernie Sanders $25 each, that was impressive grassroots support - but each of those $25 checks only went 1/280th as far as one person giving the $7000 max, and all of these waitresses are hard to corral and coordinate for downballot causes. AIPAC's natural constituency, (((Middle Eastern democracy supporters))), are at the exact sweet spot of moderately numerous, moderately well-off, and very committed. This gives AIPAC unparalleled access to hard money, compared to other groups that are more reliant on single billionaires or masses of poor people. But also, AIPAC fights hard. If some random Congressman is anti-Israel, AIPAC will swoop down on their race in Middle Of Nowhere, Missouri and pour $10 million into electing their opponent. By now everyone knows this, and the mere threat of AIPAC action is enough to keep most politicians in line. Everyone else includes other industry groups, labor groups, and activist cadres. Probably on aggregate these people are destroying America, but as individual organizations they're miniscule compared to the first two categories. The biggest of these is a real estate group 25-50% the size of AIPAC that nobody's ever heard of. The average PAC strategy is this: when the incumbent will obviously win, donate money to the incumbent. When there's a tight race, donate money to both sides. Why does the first prong of this strategy work? If the incumbent will definitely win, why are they selling out for more cash? Safe-seat Congressmen want more hard money for a pretty good reason: they can transfer it to other politicians or the party apparatus in exchange for goodwill that can be cashed in later for leadership positions. Safe-seat Congressmen want more soft money because . . . the consultants I talked to didn’t have a great answer here. One ventured that he had seen Democrats in D + 30 states with 0.000% chance of losing run themselves ragged raising more and more money. Just as Substack bloggers may reload their browser again and again watching the likes and restacks come in, so politicians will reload their campaign metrics panel watching the flow of donations. Any politician who’s survived long enough to matter is a little bit paranoid and will never truly accept that their safe seat is safe. These people aren't corrupt. They're not spending the money on campaign Lamborghinis. They don't even necessarily have some future campaign they're saving it for. They're just addicted to fundraising. And why does the second prong work? Why does donating to a Congressman buy their goodwill if you also donated an equal amount to their opponent? Part of the answer is the same as above: it can buy leadership positions, it can satisfy an irrational addiction to money. But another part is that politicians don’t like thinking of donations as a corrupt quid pro quo. The AIPAC strategy, where you know the PAC will fund your opponent if you don't do what they want, is something of an exception. Usually it's just - you have a random bill on toilet regulation or something in front of you. A bunch of randos want to call you and give their advice. But you see that Americans For Innovative Toilets donated $3295 during your last campaign (and maybe also gave something to your opponent, but whatever, everyone does it). This catches your attention. So you make sure to take their call first, and listen the longest. This still doesn't entirely make sense to me. But it's how all PACs (except AIPAC and the machines) operated until 2024. III. In 2024, the crypto industry raised the stakes. Let's put numbers on all of this. In that year, AIPAC raised $87 million. The real estate group that usually plays runner-up raised $20 million. Marc Andreessen’s new crypto PAC, Fairshake, raised $260 million. Just a totally unheard-of amount of money for a single industry. How did they do it? In some sense, this isn't surprising. In case you haven't heard, Bitcoin did very well. Many people in the industry got rich. A16Z, Marc Andreessen's crypto-heavy venture capital firm, says they invested $8 billion into crypto. Coinbase, the biggest US crypto company, is valued at $85 billion. The richest crypto billionaires have 10-to-11 digit net worths. And government regulation is potentially an existential threat to crypto. So in some sense, it's the least surprising thing in the world that they could scrounge up $260 million to save their multi-hundred-billion-dollar industry. The only reason it's remarkable is that, for some reason which I still haven't figured out, nobody else - not the oil industry, not the firearms industry, not the defense industry - ever tried this before. How exactly did the industry pull this together? Andreessen personally donated $40 - $50 million (remember, the second-biggest industry PAC, real estate, raised only $20 million total from all donors, personal and business). Again, this isn't a crazy proportion of his net worth: he has $2 billion, so a $50 million expense hardly forces him back to ramen. It's just that no other billionaire of his stature is even in the game. Then his cofounder Ben Horowitz donated another $40 million. Then two big crypto companies (Coinbase and Ripple, both with A16Z links) donated another $40 - 50 million each. As the saying goes, sooner or later it all adds up to real money. Anyway, they won overwhelmingly. They combined the business-as-usual strategy of donating to safe incumbents and both sides of close races, with the AIPAC strategy of picking a few big opponents of their cause and airdropping massive sums on their rivals. For example, Representative Katie Porter (D-California) was an Elizabeth Warren ally and cryptocurrency critic. When she ran for Senate, Fairshake dropped $10 million into attack ads against her in the primaries - more than most candidates' total spending. The attack ads didn't say she was bad on crypto - something that approximately no voters care about. They were just normal attack ads on whatever aspect of her policy and personality focus groups said she was most vulnerable on (in practice, an accusation that she mistreated her Congressional staff). She lost badly, coming in third place. Although nobody can prove she wouldn't have lost anyway, conventional wisdom was that crypto had successfully made its point. According to SFGate: An unnamed political operative told the magazine: “Porter was a perfect choice because she let crypto declare, ‘If you are even slightly critical of us, we won’t just kill you—we’ll kill your f—king family, we’ll end your career.’ From a political perspective, it was a masterpiece.” The scare campaign appears to have worked. The House of Representatives passed a pro-crypto bill, with bipartisan support, in May. Candidates with Fairshake’s support won their primaries in 85% of cases, the New Yorker wrote. Now, neither presidential candidate wants to run astray of the industry: Donald Trump spoke at a crypto conference, and Kamala Harris signaled her support. And Porter is forced out of Congress. These are all important signs that crypto’s bet is paying off, but I think I know what metric the crypto barons themselves are watching, and if anything it’s even more bullish: Red arrow represents the 2024 election. Crypto titans had many valid complaints. The Biden administration’s crypto regulation policy was arbitrary and punitive, and occasionally skirted the border of illegality. It genuinely harmed innovation and held back important industries like remittances, digital payments, and (of course) prediction markets. As a crypto bag-holder myself, I can’t complain about all the beautiful verdant green on the chart above. Still, winning this hard is maybe a little humiliating. Does the government really need a strategic Bitcoin reserve? Should it really release economic data on three different blockchains? Must we really have a twelve foot high golden statue of Trump holding a Bitcoin in front of the US Capitol? We’re exploring bold new territory here. Give me your degens, your risk-seeking. Your huddled masses, yearning to bet free. IV. …and we’ll be exploring it a whole lot more, very soon. Last month, the AI industry announced a new SuperPAC called “Leading The Future” (a dumb name, but, in their defense, “AIPAC” was already taken). They start with $200 million in seed funding, led by a $50 million donation by Andreessen Horowitz, and another $50 million from OpenAI co-founder Greg Brockman. (Why Brockman and not Altman, or OpenAI as a corporation? Because most people don’t know who Brockman is, so this keeps OpenAI’s hands clean. I imagine Altman going into a meeting, pointing at Brockman, and saying “I’m famous, you’re not, please cough up $50 million of your own money for the cause.”) On the same day, Meta announced their own SuperPAC, Mobilizing Economic Transformation Across (META) California. Why two PACs? Opinions differ; one person told me that it lets the general PAC avoid the negative associations that Facebook has gathered over the years, but the Verge thinks that maybe everyone else in tech hates Zuckerberg too much to work with him. Meta has committed to spending “tens of millions”. Most likely, the new PAC will use the playbook pioneered by crypto: destroy any candidate who dares support regulations on AI, by funding attack ads that don’t mention AI in any way and, at best, briefly mention the name “Leading The Future”. Just the Andreessen/Brockman SuperPAC, without any help from Meta, is already twice as rich as AIPAC. Their existence sends a clear message: we are going to crush any politician who tries to regulate AI. V. …unless someone stops them. Leading The Future still only has 2% as much money as the almond industry. The tiny scale of US political spending is dangerous insofar as it means that one or two billionaires willing to go all-in can distort the national landscape. But it also makes it possible to oppose them. Certainly if you can get one or two billionaires of your own - but it might even be within the range of a committed group of ordinary people. Not waiters and bartenders, maybe. But if safe AI supporters were as committed as Israel supporters, they could probably make something happen. For a long time, the AI safety movement has underperformed politically. Effective altruism includes thousands of well-off people committed to spending 10% of their income on improving the world. If a thousand of them gave $7K each to political candidates, that would be $7 million of campaign-finance-compliant hard money - about as much as anyone can gather for anything. Hard money buys more influence per dollar than soft money, so this could be a big deal. All you’d need is the right people to coordinate it. So far, this has been slow going. Partly it’s because in the early 2020s, people affiliated with FTX took point on this effort; when FTX imploded, it not only took its incipient political infrastructure with it, but poisoned the well for future efforts. And partly it’s because EAs overlearned the lesson of the early 2010s, when we spoke out against AI capabilities efforts so “effectively” that a bunch of people thought “wow, AI capabilities companies must be a really big deal, maybe I should found one!”; the resulting institutional scar tissue biased us towards staying quiet about our concerns. Still, I wouldn’t be writing this if the consultants and activists weren’t gearing up for a bigger fight. They asked me to include some action items for readers who want to participate: Email aisafetypolitics@gmail.com to connect to the people organizing this effort and talk with them about what you can do, including potential future donation opportunities.
Inline links: According to SFGate, https://substackcdn.com/image/fetch/$s_!bWaN!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2F13d918d0-5918-4bf6-9dee-0a798c76ae82_706x499.png, strategic Bitcoin reserve?, release economic data on three different blockchains?, a twelve foot high golden statue of Trump holding a Bitcoin in front of the US Capitol?, https://substackcdn.com/image/fetch/$s_!eZlq!,f_auto,q_auto:good,fl_progressive:steep/https%3A%2F%2Fsubstack-post-media.s3.amazonaws.com%2Fpublic%2Fimages%2Faa435a03-c505-4414-8be8-4a3b76dfad12_738x612.png, announced a new SuperPAC, Mobilizing Economic Transformation Across, the Verge thinks