B4 EZ BD THE WASHINGTON POST.SUNDAY, JUNE 12 , 2022
On this last point, it is hard to disagree. Our
treatment of undocumented children is a stain
on our nation.
In the end, the authors offer an optimistic
message: “Immigration contributes to a flour-
ishing American society.” In a rapidly evolving
world, Abramitzky and Boustan urge us to take
“the long view, acknowledging that upward
mobility takes time, and is sometimes mea-
sured at the pace of generations, rather than
years.”
“Streets of Gold” led me to reflect on my own
family’s journey. I thought about my great-
grandparents Carmelo and Vincenza, who
moved from Sicily to New York in the 1910s. As
a recent immigrant, my great-grandfather
didn’t speak English and — according to the
census — worked as a “laborer.” “Scrivilo”
(Write it down), he would say when looking for
work. His employers would write down the
address, and he would go there for the day. He
and my great-grandmother spent the rest of
their lives in a railroad-style apartment on
Manhattan’s Upper East Side, where they
raised four children, including my grandmoth-
er. In my grandmother’s telling, her parents
left Sicily in search of opportunity for their
family. My grandmother lived her entire life in
those same few blocks of Manhattan, worked
as a nanny and had a culture that was distinct-
ly Italian American (from her cooking to herextent to which the economy relies on people
vs. machines in the decades to come.
Immigration is, of course, about more than
economic activity. Part of its beauty is the
cultural richness and diversity that it brings. A
multicultural society is greater than the sum of
its parts. Miami is exciting not because of
assimilation but because of the culture that its
diverse population has created. It’s a city
where you can find croquettes and Cuban
coffees as easily as pizza and burgers. There is a
rich history of immigrants bringing new cui-
sines, which are then adopted and adapted
throughout the United States, a journey that
can be seen in the evolution of Italian Ameri-
can food.
Drawing on the research, Abramitzky and
Boustan weigh in on a number of hot-button
policy issues: For instance, should the United
States focus on encouraging high-education
immigration? They conclude that “policies
designed to deter less-educated immigrants
from entering the United States are misguid-
ed.” Discussing the border wall, they argue that
“no one wins from the border fencing policies.”
And on the 1.5 million undocumented immi-
grants who arrived as children, they make a
full-throated argument in favor of “providing
work permits and a path to citizenship,” noting
that “the barriers that undocumented children
face are stumbling blocks of our own making.”driven account of the history of American
immigration. Second, to provide guidance into
what research suggests about the design of
immigration policy.
The book reflects an ongoing renaissance in
the field of economic history fueled by techno-
logical advances — an increase in digitized
records, new techniques to analyze them and
the launch of platforms such as Ancestry —
that are breathing new life into a range of
long-standing questions about immigration.
Abramitzky and Boustan are masters of this
craft, and they creatively leverage the evolving
data landscape to deepen our understanding
of the past and present.
In contrast with the rags-to-riches mythol-
ogy, a more systematic look at the data shows
that low-income immigrants do not tend to
catch up to nonimmigrant income levels in
their lifetimes. Instead, financially successful
immigrants tend to come from more privi-
leged backgrounds. To name a few: the authors
point out that the father of Tesla chief execu-
tive Elon Musk “co-owned an emerald mine.”
EBay founder Pierre Omidyar’s “father is a
surgeon who worked at Johns Hopkins Uni-
versity,” and his “mother has a PhD in linguis-
tics.” Google co-founder Sergey Brin’s “father is
a professor of mathematics,” and his “mother
is a NASA scientist.” Looking at how many
companies have been led by high-skilled immi-
grants, I wonder how much more innovation
we are missing out on by not further opening
our doors to the world’s talent. Yet these are
hardly tales of huddled masses.
The case that lower-income and lower-
education immigrants also meet with success
rests on assessing not only the fates of immi-
grants themselves but also those of their
children and their children’s children. As it
turns out, Abramitzky and Boustan write,
“children of poor immigrants from nearly
every country in the world make it to the
middle of the income distribution.” Immi-
grants from mainland China, Hong Kong and
India do especially well.
The book debunks myths that immigrants
dramatically increase crime and displace
U.S.-born workers. Much of this work focuses
on natural experiments in which sudden
shocks to immigration levels have allowed for
a better understanding of cause and effect. For
instance, the authors point to the 1980 Mariel
boatlift, which brought an influx of Cuban
immigrants to the United States, especially to
Miami, virtually overnight. The surge of low-
income immigrants did not lead to large spikes
in unemployment for U.S.-born workers. Low-
skill immigrants have a history of taking jobs
that would otherwise be unfilled or filled by
machines. As companies around America were
rushing to automate operations, the influx of
Cuban immigrants to the Miami area slowed
this process, and jobs went to people rather
than to machines. Compared with the rest of
the country, businesses in high-immigration
areas have access to more workers and hence
less incentive to invest in further automation.
This has implications for today’s immigra-
tion debates: The United States is expected to
face a dramatic labor market shortage as baby
boomers retire and lower birthrates over time
result in fewer young people to replace them.
Increased immigration is one approach to
avoiding the crunch. Notably, the other way to
avert this crisis is through further automation,
enabled by rapid advances in artificial intelli-
gence. Immigration policy will help shape the
IMMIGRATION FROM B1
Two economists conclude that immigrants are more a benefit than a burden
SALWAN GEORGES/THE WASHINGTON POST
Migrant families from Nicaragua and Honduras walk alongside the border wall after crossing into the United States near Sasabe, Ariz., in January.STREETS
OF GOLD
America’s
Untold Story
of Immigrant
Success
By Ran
Abramitzky and
Leah Boustan
PublicAffairs.
237 pp. $29mixing of languages) and distinctly New York
(her love of the Yankees and H&H bagels). My
parents taught elementary school in Upstate
New York.
And a century after my family moved to this
country, I moved to Boston and became a
professor. I still cook my grandmother’s reci-
pes (such as a pasta dish with sardines, raisins
and fennel); I still root for the Yankees (despite
living in Boston!); and I don’t speak a word of
Italian.
Shortly after my grandmother passed away
a few years ago, I was chatting with one of her
friends. She shared stories about my grand-
mother and reminisced about her love of
children and of cooking. She told me how
happy my grandmother was to see her chil-
dren and grandchildren as adults, enjoying
their lives and contributing to society.
As we parted ways, she said something that
has stuck with me and echoes the main
message of “Streets of Gold.” Commenting on
the struggles, the successes, the sorrows and
the joys that families face across generations,
she said: “That is the American Dream.”Michael Luca is the Lee J. Styslinger III associate
professor of business administration at Harvard
Business School and a co-author of “The Power of
Experiments: Decision Making in a Data-Driven
World.”packaging, pressure mounted for regulators to
deliver on food labeling reform. With policy-
making gusto, Congress and the Food and
Drug Administration, led by David Kessler,
simultaneously crafted nutritional labeling
policies in a race to regulate. These efforts
culminated when President George H.W. Bush
signed the Nutrition Labeling and Education
Act in 1990.
Acting on this law, the FDA debuted the
Nutrition Facts panel in 1993, a consistent
tabulation of nutrients and their amounts that
is displayed regardless of the food or beverage.
This standardized format lets shoppers easily
compare different products, helping inform
their buying decisions.
Prescription medicine needs its own ver-
sion of Nutrition Facts — a simple summary of
specific information accessible by everyone in
the decision chain, from physicians to phar-
macists.
As a starting point, such a guide should
include a patient’s out-of-pocket cost for the
medication under that patient’s insurance, the
cash price without insurance, whether a ge-
neric or biosimilar version is available, the
generic or biosimilar cost under the patient’s
insurance, and whether the insurance impos-
es any restriction such as prior authorization.
Ideally, the guide would also display alterna-
tive dosage or delivery versions or other simi-
lar drug options, sorted by cost. In theory, thisof different models or shop around? Sorry,
that’s not possible. Or imagine if, at a restau-
rant, the waiter lets you know the price of a
dish only after the food arrives. Even when the
lobster has “Market Price” where a dollar
amount would normally appear on the menu,
buyers generally have a good idea of the cost
before placing their order.
The federal government has stepped in to
facilitate simple, readable consumer informa-
tion in the past. Consider the “Nutrition Facts”
panel on food packaging. Although shoppers
today can easily compare the nutritional con-
tent of different foods, such information was
not always available. For much of the 20th
century, with Americans preparing most
meals at home from fresh ingredients, de-
mand for detailed nutrition information was
limited. As processed foods became common-
place, however, consumers became more in-
terested in the contents of their food.
The case for nutrition labeling strength-
ened as scientific research in the 1970s and
1980s uncovered stronger connections be-
tween diet and health. Understanding the
harms caused by excess sodium, saturated fat
and cholesterol encouraged the publication of
their respective amounts in various foods. At
the same time, food companies sought to
promote the positive health effects associated
with other nutrients in their products. As
questionable health claims began to appear oninformation could be incorporated in existing
electronic health record systems, which are
accessed by patients and their doctors.
The federal government is best positioned
to bring about the creation of a patient price
guide. Health information is complex, and a
standardized system that looks the same for
everyone would have the best chance of pro-
viding useful information while reducing the
incentives for the strategic games that drug
companies play to obscure pricing informa-
tion. A market solution, moreover, is unlikely
to emerge without a governmental nudge.
Current reimbursement systems contain per-
verse incentives — for pharmaceutical compa-
nies, insurers and the middle players that
negotiate drug prices between them — to drive
patients toward higher-priced medications in
certain circumstances. Companies are unlike-
ly to voluntarily provide information against
their own interests.
Much of this patient-specific price informa-
tion already exists electronically. Pharmacy
systems contain much of the relevant, patient-
specific information for that pharmacy, in-
cluding the patient’s insurance plan and
whether the patient has met the plan’s deduct-
ible requirements. And although prices do
vary from pharmacy to pharmacy, many physi-
cian-facing electronic systems contain the
patient’s choice of pharmacy.
Given all of this, the FDA could push things
ahead and require electronic publication of
standardized, patient-specific information.
Physicians would be able to see this informa-
tion when writing a prescription, pharmacists
could read the information when the patient is
at the pharmacy counter, and patients could
access it alongside these medical profession-
als or on their own.
Physicians and pharmacists strive mightily
to recommend the best medication regimen
for their patients in light of many variables,
including the patient’s budget. And modern
medicine has labored so that patients can be
active and informed participants in their own
care. A price guide for prescription medicine
would go a long way toward injecting a dose of
sanity into the process.A
doctor prescribes one 450 mg pill of the
antidepressant Wellbutrin once a day
for a patient. The patient returns a
month later, having not taken the medication
and now more depressed. When the doctor
asks why, the patient replies that is it not
covered by insurance. The doctor writes an-
other prescription for this patient, this time
trying three 150 mg pills a day. That prescrip-
tion is fully covered. But for another patient,
the reverse may be true.
As we explained in the Annals of Internal
Medicine earlier this year, prescription drug
purchases rarely mirror reasonable expecta-
tions, partly because the information gaps are
extraordinary. With many patients, there is
just no way to know up front what will be
covered by that patient’s insurance and what
the cost will be. In most industries, consumers
make informed choices that include cost con-
siderations. With prescription drugs, the doc-
tor doesn’t know the cost to the patient, and
the patient may discover the out-of-pocket
cost only upon checking out at the pharmacy.
We propose, however, a simple solution: a
standardized pricing guide, akin to the nutri-
tional information panel on most food prod-
ucts, that generates definite information
about the costs for a given drug to a given
patient with a given insurance plan.
As prices for prescription drugs continue to
rise, clear information about out-of-pocket
costs for patients matters. A 2019 study pub-
lished in JAMA Network Open that examined
private insurance claims, for example, found
that for 78 percent of the most popular brand-
name drugs available since 2012, insurer and
out-of-pocket costs increased more than than
50 percent. Another study found that older
adults in the United States were six times more
likely to say they didn’t use their medications
because of cost, compared with older adults in
Britain.
The roots of irrational drug pricing are
complex and varied. They include rebate deals
and incentives in the patent and regulatory
systems that encourage marginal changes in a
drug’s dosage or delivery system to extend
intellectual property protection. These and
other factors subvert normal pricing expecta-
tions. Under some health plans, for example,
the generic may be more expensive than the
brand-name drug.
The opacity and illogic of prescription drug
prices find few parallels in other industries.
Imagine if the military operated this way:
Need to order a tank? We’ll tell you the cost
when we deliver it. Want to compare the prices
We need a labeling system for pharmaceutical prices
Making costs
transparent
would help
ensure that
patients get the
treatment they
need, say
Robin
Feldman ,
Natalie
Feldman
a nd Enrique
Seoane-
VazquezELISE AMENDOLA/ASSOCIATED PRESSBecause of patent
laws, insurers’
policies and other
factors, d octors
often don’t know
what prescription
drugs will cost their
patients, and
patients may
discover the out-of-
pocket price only
when they check
out at the
pharmacy.Robin Feldman is the author of “Drugs, Money, &
Secret Handshakes: The Unstoppable Growth of
Prescription Drug Prices” and the article “The
Cancer Curse: Regulatory Failure by Success.”
Natalie Feldman is a resident at Harvard Medical
School’s Brigham and Women’s Hospital. Enrique
Seoane-Vazquez is a professor at Chapman
University School of Pharmacy.