For thirteen years I worked as a medical director, chief medical officer and executive VP for medical affairs in the health insurance industry.  One of my responsibilities in those roles was to manage the cost of prescription drugs for health plan members.  I oversaw prescription drug formulary development and implementation, determined benefits for covered drugs, and for a time had responsibility for managing all pharmacy services from formulary management to network and rebate contracting.

After that time on the health insurance side, I spent about 18 years in the pharmaceutical industry, selling the benefits of pharmaceuticals to my old colleagues at the health plans.   I liked to say that one of the main reasons that the pharmaceutical industry hired me was to keep me from working against them on the health plan side.  This may actually have been true.  At the same time, I believe in the benefits of prescription drugs, and even today I would say that prescription drugs are the best value in healthcare.  This is particularly true if you consider the actual cost of prescription drugs paid by patients.  That being said, the cost of prescription drugs is certainly out of control, and may be reaching the limit of its exceptional value proposition.

Let’s go back to the beginning with the classification of prescription drugs.  Prescription drugs were defined by the Federal Food, Drug and Cosmetics Act (FDCA) of 1938, which in part was designed to ensure the effectiveness and safety of prescription drugs.  Prior to that time, doctors and just about anyone else could compound and sell just about anything without any proof of effectiveness or safety.   The FDCA may have had the effect of stimulating research and development of prescription drugs, as the first wave of new drugs came shortly after the Food and Drug Administration was established.  By that time, health insurance coverage was also booming led by Blue Cross and Blue Shield insurance plans.  As a way to differentiate themselves, some health insurance plans began covering prescription drugs as a benefit in the late 1950s.

In 1968 the first pharmacy benefit management company (PBM), Pharmaceutical Card System (PCS), Inc., provided a platform for health plans to administer prescription drug benefits at the pharmacy.  The development of the PBMs coincided with the development of the health maintenance organization health insurance model which almost always included a prescription drug benefit.  This growth in insurance coverage for prescription drugs provided incentive for the second great wave of pharmaceutical research and development that began in the 1970s. As a result of the Affordable Care Act of 2010, all qualified health plans now have a prescription drug benefit.

As with health care services covered under the medical benefit, the cost of prescription drugs has grown steadily for 50 years, and more recently, sharply.  Under the insurance model, there are limited marketplace constraints on prescription drug prices.  Pharmaceutical manufacturers can set prices and raise prices in the US without regulation.  As with most of healthcare costs, competition does not result in lower costs for prescription drugs.  In fact, the opposite is often true.  For example, between 2010 and 2015, prices for drugs to treat multiple sclerosis increased by almost 500% in anticipation of the launch of new drugs into the market.

The first PBMs simply provided the platform and software to administer health plan prescription drug benefits.  The development of the internet made it possible for almost anyone to create software to provide this service.  The PBMs responded by expanding their business model to include the development and implementation of prescription drug formularies, which offered drugs at different benefit levels.  The idea was to encourage the use of more cost-effective drugs by reducing the out-of-pocket cost of those drugs to the patient.  The way that the PBMs profited from formulary models was by contracting with pharmaceutical manufacturers for discounts and rebates on drugs that would be formulary preferred and less expensive for patients.  Unfortunately, because of this economic model, the most cost-effective drug was probably not be the preferred drug.

The Drug Price Competition and Patent Term Restoration Act of 1984 provided an incentive for the development and launch of generic drugs.  Because of the relationship between PBMs and pharmaceutical manufacturers, it took over 10 years for generic drugs to have a significant impact on prescription drug prices. Finally, by the turn of the century, PBMs were promoting generic drugs as part of prescription drug formularies.  By the second decade of the 21^st century, PBMs actually began curbing the prices of new prescription drugs through aggressive contracting.  Unfortunately, most of the savings went to the PBMs thru rebates from pharmaceutical manufacturers.   Patients saw little to no relief from out-of-pocket costs.

Just as generic drugs were beginning to impact the cost of prescription drugs, research and development in the pharmaceutical industry turned toward specialty drugs.  Specialty drugs are complex to manufacture and dispense, often indicated for rare diseases, and almost always high cost.  Many specialty drugs are biologics, meaning that they are derived from living cells, an expensive process.  Specialty drugs accounted for about 5% of all prescription drugs in 2020, but accounted for almost 50% of prescription drug costs.  While non-specialty drug inflation is basically zero (mostly due to the impact of generic drug launches), specialty drug inflation has been 15-20% per year for about a decade.   Specialty drugs may cost hundreds of thousands of dollars per year.  The most expensive specialty drug costs $2.125 million dollars for a single intravenous infusion.

Pharmaceutical manufacturers have focused research and development on the specialty drug market.  About 1/3 of drugs in the research and development pipeline are considered specialty drugs.  These drugs will provide significant benefit for patients who currently do not have good options for treatment, but the cost will be high.  PBMs and health plans have adjusted formulary benefits to cover specialty drugs, shifting a lot of cost to patients.  

The Food and Drug Administration is only authorized to review the safety and effectiveness of pharmaceutical products.  While there are independent organizations that make assessments of the value and reasonable pricing of prescription drugs, the pricing of prescription drugs remains unregulated.  The current pricing trends are unsustainable, so something will have to give.  The question is what. 

Stay tuned for a proposed solution. 

I wrote this essay one day after the unbelievable assault on the US Capitol.  The news for almost 48 hours was completely focused on this event.  In the meantime, each day saw a new record for deaths caused by Covid-19 in the United States.  4,051 Americans died from Covid-19 infection on January 7.

Not only is the pandemic continuing to surge with no real attempt to control spread of the virus, but the immunization strategy which has been promoted to be the cure for the pandemic has been a complete failure.  The reason for the failure is the absence of a clear national strategy for immunizing the population.  The lack of this strategy is then compounded by a confusing and muddled plan for vaccine distribution.  As a result, after 4 weeks, only 25% of available vaccine had been administered, and in many cases it was not going to the population at greatest risk.  There was a report of a pharmacist in a free-standing pharmacy who pulled two young men off the street to get two vaccine doses, because the pharmacy was closing and they had not used all of the prepared vaccine.  News reports in Austin documented that patients who were not in the Texas priority groups were receiving the vaccine for the same reason – the vaccine doses were not where they need to be. The response in Texas is to open up vaccination to everyone. This has created confusion, long lines, shortages of vaccine in specific locations, and worst of all, leaves vulnerable populations at risk.

The reason that the management of the pandemic is such a mess is first due to the lack of a coherent national strategy.  Unfortunately, politicians have taken the lead on the state level strategy in Texas, resulting in nothing less than chaos.  It is time for public health officials and physician leaders to take over the management of the pandemic in Texas.  The governor and the attorney general should stay out of the way.

We had an opportunity to “flatten the curve” of the pandemic over the recent holiday (see the last Pandemic Update).   Our political leaders continue to argue that the effect of a non-essential shut-down would be too devasting to the economy.  Is that more important than thousands of lives?  

With regard to the control of viral transmission in the community, the last CDC guidance issued the end of October 2020 was primarily focused on strategies to reopen communities after achieving control of community transmission.  I can find nothing explicitly outlining the recommended strategies for managing substantial, uncontrolled community transmission – except for a recommendation to “shelter in place”.  The decision to go to a shut-down should be based on the rates of community transmission, rates of hospitalization, and the availability of healthcare resources to treat patients.  Maximizing the response to these metrics would certainly reduce severe infections and deaths.  I would say that we are in the red zone in Texas across all of these metrics.

We need for state and local public health professionals to do the right thing and take control of the Texas strategy for managing the pandemic.  Politics has no place in public health decisions during a pandemic.

Here is what I would recommend from the public health perspective.  First thing is to stop interstate and international mass transit.  This is not about the travel – which on its own is generally non-essential.  The purpose of this restriction is to keep people from doing things during travel that they would not be doing if they stayed home – traveling thru airports, riding trains, eating in restaurants, staying in hotels, and attending in-person meetings and events.  Second, we should shut down all in-door non-essential activities and outdoor activities that attract large crowds.  This includes schools, gyms and fitness facilities, churches, bars, restaurants, theaters, sports venues, amusement parks and other outdoor events.  These are all high-risk activities.  I will argue that it is not possible to significantly reduce the risk of these activities, even if you implement strong hygiene protocols.  The reason is that most of these activities involve in-person interactions in the travel to and from these activities.  A great example is the bars that have received restaurant certification in downtown Austin.  These bars are following the recommended guidelines for infection control in their facilities, but at most locations you find lines of people waiting to get in with no social distancing or mask-wearing.

What about the immunization strategy?  In this case, the CDC has recommendations for vaccine prioritization, that for some reason, the state of Texas has chosen to ignore.  The first CDC priority (phase 1a) is healthcare personnel and long-term care facility residents.  This should mean all healthcare personnel, including private clinics and facilities.  In this phase, vaccination should be mandatory.  We must remember that you are taking the vaccine not only to protect yourself, but also to protect others.   This cannot be accomplished completely in these high-risk settings if individuals opt-out of vaccination.  The second CDC priority is frontline essential workers and individuals over age 75 (phase 1b).  In this group, the vaccine should be mandatory for individuals who have significant inter-person interactions: EMS workers, firefighters, police, daycare workers, and public transit workers.  The vaccine can be voluntary for groups who do not have regular inter-person interactions. Vaccine should be distributed to healthcare facilities with the capacity to store, prepare and administer the immunization to large populations referred to that facility. 

The state of Texas initially opened vaccination to the CDC phase 1c population, individuals over age 65 and over age 16 with underlying medical conditions.  The problem with this strategy is that vaccine is being delivered to private clinics and pharmacies that apparently do not have the logistic systems in place for effectively prioritizing vaccine administration.  You also are seeing that patients who meet criteria for vaccination cannot get the vaccine because they do not have a relationship with the private clinic or pharmacy that has vaccine supply.  It would be better at this phase and for subsequent vaccination of the full population to establish an independent network of vaccine centers.  This would include health department clinics and pharmacies like CVS and Walgreens that have in-store clinics and pharmacists.  The fact is that most physician offices have not been vaccine providers for several years – they are referring their patients to the pharmacy chains. There may be some large private clinics who have the capability to immunize large populations, but they should not restrict vaccine to their patients only.  

It would have been ideal to have a national strategy for management of the pandemic and vaccine administration prior to the vaccine roll-out.   It may not be too late to reorganize and get it right.  I call on public health professionals and physician leaders to step up and get the politics out of this pandemic.

As 2020 has finally come to an end, certainly everyone must be frustrated with our federal elected representatives.  After Congress finally passed a bill in late December to provide relief for the economic effects of the Covid-19 pandemic and to fund the federal government for the 2021 fiscal year, President Trump refused to sign the bill for almost a week.

There was bipartisan condemnation for the President’s refusal to sign the bill into law.  But we would not have been put in that situation if the Congress had passed the bill when it was needed months earlier.  So, it is primarily the fault of Congress that Covid-19 economic relief was late and that the federal government was on the brink of shut down yet again.

The fact of the matter is that our representatives in Congress have failed to do the work they were elected to do for many years.   Consider job number one of the Congress – pass appropriations to fund the federal government.  The last time that the Congress passed a complete appropriations bill on time (before October 1) was 1996.   Since 1974, when Congress took primary responsibility for passing federal appropriations, appropriations for all segments of government have been passed before October 1 only four times.  In recent years, we have had multiple threats of government shut-downs and actual shut-downs, remedied only with temporary budget extension resolutions.

The Congressional approval rating over the past 50 years has generally been in the 20% range, except in periods of national crisis, when we seem to give them a break.  Yet 90% of Congressional incumbents are re-elected.  Do we need to review Einstein’s definition of insanity?   When we get really frustrated, we call for term limits.  But if members of the House of Representatives must face re-election every two years, and Senators every six years, don’t we already have term limits?  We simply must choose not to send incumbents back to Congress.

For 20 years beginning in 1988, I chose to vote against every incumbent who represented me at any level, including Congress.  If the incumbent was not running for re-election, I voted against the candidate from their party.   Occasionally, I voted for independent candidates (I voted for Kinky Friedman for Texas governor in 2006).   Back in the 1980s, incumbents were usually identified on ballots, so it was fairly simple.  The political parties apparently got wind of this strategy and now incumbents are not identified on ballots.  It takes some research to identify the incumbents for re-election from local to federal elections.   That is research we should probably be doing anyway.

I already knew by 2006 that my strategy to oust incumbents was not very effective, and Kinky Friedman’s sound defeat in the Texas gubernatorial election made me rethink that strategy.  By that time, the platform of the Republican party had been pulled to the far right by evangelicals and wealthy conservative activists.  Recently, I have found myself voting mostly for Democrats – a frustrating exercise in Texas.  Like most Texans I would describe myself as fiscally conservative, socially moderate and individual rights liberal.  Republicans and Democrats have become so polarized that neither party aligns to these values.  In my view, Republicans have become the party most responsible for dysfunction and division, thus my vote for Democrats.

That is not to say that I believe that Democrats can be trusted, or are more capable of governing.   Money has corrupted politics on both sides of the political spectrum (see the blog post on Money in Politics).   Plus, I do not think that I will convince a lot of people who typically vote Republican to start voting for Democratic candidates, even if I thought that was the solution.   The real solution is to take the influence of money out of politics by imposing term limits through the re-election process.

I will admit that I have not always participated in the primary election process, and I did not often take the time to educate myself about the candidates standing for primary election within the parties.  When I voted against incumbents, it did not matter to me if I voted for the Republican or the Democrat in the general election.  But recognizing that most voters will prefer candidates of one party over another, the primary election process is where we can all get involved.  By voting against the incumbent in the primary election, we can support our political party while imposing term limits on our elected representatives.

I understand that this is a simplistic view of politics and candidate selection.  We may want to return some incumbents to office if they are doing a good job.  At the same time, we should remove incumbents who are not doing what they were elected to do.  They should not get credit for taking uncompromising positions (whether those positions are popular or not) if nothing actually gets done.  It will be useful to have objective measures of effectiveness to evaluate incumbents, and for that matter, challengers.  In order to replace incumbents, we will need qualified candidates to run against them.  As long as we have a two-party system in the US, support for third party candidates is probably futile.  However, if we begin to unseat incumbents who are not doing a good job, we may be able to get qualified independent candidates to challenge incumbents within one of the two parties.  Some of us will need to become more active in helping to recruit candidates to represent us, or to consider running for office ourselves.  If we don’t take on this responsibility, we deserve the representatives that we get.

2020 was historic for the number of citizens who voted in the general election.  In order to make our elected representatives more responsive to citizen voters, we will need to take that same commitment to the primary election process.  

When Austin Mayor Steve Adler cancelled the South by Southwest Conference and Festivals on March 6, 2020, I was surprised.  Honestly, I am not sure that I could have made that decision at that time.  It was one of the first major events in the world to be cancelled or postponed.  It wasn’t until three weeks later that most organizations began to announce changes in event schedules.  Cancelling SXSW was clearly the right decision.  But it had to be done with the understanding of the economic impact to the City of Austin, and with no indication of financial support from the state or federal government.   I applaud the Mayor and the City Council for doing the right thing at the right time.

Now, after a complete failure of government at all levels to manage the pandemic, we are at a point where a difficult decision has to be made again.  Yes, there is a vaccine on the horizon.  But the effects of vaccination will not impact the pandemic for months.  

First, consider the population to receive the first doses of the vaccine.  This will be the high-risk population, the elderly, healthcare workers and nursing facility residents.  These populations are already on lockdown and are using personal protective equipment, so we will not see a great impact in the number of new cases by vaccinating this population.  25% of the US population under age 65 have underlying health conditions like diabetes, immune disorders, and heart and lung disease. They will still be at risk until the second stage of vaccine roll-out.

Second, the Pfizer vaccine is a two-dose vaccine with doses given 3 weeks apart.  Although there will be some protection to vaccinated persons within a week or so after vaccination, it will take six weeks for the full immune response to develop in vaccinated individuals.  In the meantime, they are still at risk, could become infected, and could transmit infection to others.  The Moderna vaccine which may be approved soon is also a two-dose immunization, given four weeks apart.  It will take two to three months at least to vaccinate the high-risk population.  So those receiving vaccine in February or March will not be fully protected until March or April. 

Finally, it does not seem likely that we will have a single-dose vaccine (Johnson and Johnson) until late spring.   Immunity with a single-dose vaccine probably still takes 3-4 weeks, but single-dose administration will speed up the process for vaccinating the entire US and world population. We may see the result of immunization in the high-risk population by March or April, with a decline in mortality rates.  That is several months away.  Even then, unless something else is done, we will continue to see high rates of community transmission through the middle of next year.  And we know that low-risk adults and children will die from complications of coronavirus infection. 

Here is what I recommend.  We should have a national shutdown of all non-essential services beginning December 24, 2020 and lasting for two weeks.  This is a period where economic activity slows significantly, so the economic impact will be decreased.  Many non-essential organizations have holiday shutdowns.  Children and other students will mostly be on holiday break, so we don’t need to worry about going to school.   Everyone fretted about the impact of Thanksgiving holiday travel, so let’s make it easy not to fret.  Interstate and international commercial travel should be prohibited.  Hotels should close except to essential workers.

For the two-week period, everyone who can should work remotely.  We have information about the activities and places that are associated with the highest risk of coronavirus transmission (https://www.texmed.org/TexasMedicineDetail.aspx?id=53977).  These are all non-essential and need to close for at least two weeks:

• Indoor dining
• Bars and clubs
• Coffee shops and cafes
• Religious gatherings (including weddings)
• Gyms and fitness centers
• Indoor movie theaters and entertainment facilities
• Concerts, sports, and festivals with a large number of people (even outside)
• Non-essential manufacturing and processing
• Non-essential industrial and construction activity

Yes, we have to continue all of the other stuff, wearing masks, social-distancing and staying home.  And wash your hands.  As a physician, I took care of contagious people, including kids, almost every day.  I virtually never got sick.  I did not wear a face mask or a protective gown.  I did wash my hands diligently.  It works. One more thing about washing hands.  Bacteria and viruses live in the oil on your skin.  What do you use to remove oil?  Soap.  Save the disinfectant for hard surfaces.

We need support from the state and federal government to implement the shutdown and to protect small businesses from the economic consequences.  The federal government must take the lead, because it is generally the only governmental entity that can spend at a deficit.  The federal government also has the data to make payments to employers who have to shut down for two weeks (employers file employment taxes with the federal government).  I am also in favor of grants to the states so that they can customize economic support at the local level.  We do not need stimulus checks.  The majority of Americans are able to work in essential jobs or remotely for now, and we may need this kind of economic stimulus later.  

If we value human life (this should resonate with Republicans), we will do what needs to be done to try and get control of this pandemic.  A two-week shutdown will take us in the right direction.  Let’s hope it will be enough.

7.8.2025

You may have noticed that Comic Con Austin is at the Cedar Park HEB Center this year. Or maybe you didn’t. You may also not have noticed that the Austin Convention Center is closed for a $1.6 billion renovation that is expected to take at least 4 years. Will anybody actually notice that it is closed – except for the local traffic detours?

It is reasonable and probably necessary for a commercial building to undergo renovation every 20 years or so.  The Austin Convention Center was last renovated and expanded in 2002.  The question remains – does it make sense for Austin to operate a convention center?

Municipal convention centers across the country are generally money-losers. Convention facilities were just recovering from the pandemic as of last year. This year booking and revenues are down, likely due to economic uncertainty. Municipal convention facilities claim that they generate a profit for the community through tourism revenue. Many have also learned to claim a profit by showing local hotel taxes as revenue. Currently 70% of Austin hotel taxes go to the convention center. Independent consultants have estimated that the cost of renovating and maintaining the Austin Convention Center over the next 30 years will be $5.6 billion. Revenue from bookings are expected to bring in $1.6 billion during that time.

Why does a city operate a convention center in the first place?  There are usually two goals:  revitalize a downtown area and generate tax revenue thru tourism.  Most cities are willing to operate convention centers at a loss in order to accomplish these two goals – including the city of Austin.  Multiple cities have renovated their convention centers in the past 10 years (see the UT Austin report Frameworks for Placemaking: Alternative Futures for the Austin Convention District – https://issuu.com/utsoa/docs/frameworks_for_placemaking_utsoacsd).   Virtually none have met the booking and attendance targets boasted by consultants and developers, and many are at booking and attendance levels of the pre-2009 recession level.  Yet consultants and developers continue to insist that “if you build it, they will come.”  And they continue to operate at a loss, just a bigger loss.

Does Austin need to use the Convention Center to revitalize the downtown area and generate tax revenue thru tourism?  I would say that the answer to that is no.  Austin has such a tremendous building boom downtown that infrastructure is not able to keep up, resulting in gridlock traffic, streets destroyed by construction trucks, and parking that is a problem even during non-peak times.   As far as tourism, prior to the pandemic, hotel occupancy rates for Austin were nearly 75% – the highest rate in the state for major cities.  The occupancy rate downtown was even higher, about 85%, with 98% occupancy during the Formula 1 race week when room rates average $477/night.   Current Austin hotel occupancy rates are still strong, averaging 69% overall and 78% downtown.

The convention center industry has been in decline for over 20 years despite the renovations and expansions.  Actually, the decline is partly because of these renovations and expansions.  The convention business has become ultra-competitive, leading to heavy discounting.  A good part of the competition comes from the hotel industry.

Take Las Vegas as the best example.  While the Las Vegas Convention Center has struggled to maintain about 1.3 million visitors per year over the last 10 years, hotel-based conventions have boomed.  Of the 20,000 meetings and conventions held in Las Vegas each year, the Las Vegas Convention Center books about 60.  Las Vegas hosts about 60 of the largest conventions in the US each year, but only about half of those go to the Convention Center, even though it is the largest venue.  The hotels have better facilities, better food, and they have the convenience of the hotel rooms.  Hotels like the Venetian-Palazzo and Mandalay Bay compete directly with the convention center because they have enormous convention facilities.  And yet the Las Vegas Convention Center is currently expanding again, after an update in 2012.

The same thing is happening in Austin.  Austin attracts over 1000 meetings and conventions each year, and about 100 use the Convention Center (pre-pandemic).  But competition is steep with hotels (Fairmont Hotel and the Marriott) next door, together boasting as much meeting space as the convention center itself.  And if you consider the Downtown Hilton and the JW Marriott, these four hotels have almost twice the capacity of the Convention Center.  They all have upscale facilities, better food and yes, hotel rooms in the building.

What is the answer for the future of the Austin Convention Center?  It would be hard to say that it did not contribute to the boom in Downtown Austin and the tax revenue that comes with the boom.  The Convention Center provides a unique venue for local exhibitions like the auto, boat and RV shows.  We do need additional meeting space in Austin, even with the opening of the newest hotels.  In a normal year, it is almost impossible to book space for a small to medium size meeting in Austin during the last three months of the year.  

The Convention Center will probably never compete with hotels for the small and medium size meetings and conventions, which are the great majority of all meetings booked.  What is needed is a public-private partnership with the current and future hotels to build and maintain space that they don’t have (the massive exhibit hall), and combine that with the facilities, amenities and conveniences that the hotels can provide.  There are already state tax rebate incentives available for this kind of partnership.  What we don’t need is an expanded convention center trying to compete with hotels next door.  

Will the Austin Convention Center ever operate at a profit? No. But we can stop the ever increasing losses. Last year, the Austin City Council voted to drop a planned hotel joint venture from the renovation plan. Even with that, the budget from the renovation has already increased from $1.26 billion to $1.6 billion. But that is at least a move in the direction of reality. We will probably need more of those decisions before the renovation is complete – in 2028, or 2029 or maybe 2030.

Crime in Downtown Austin – APD CrimeViewer

The Austin Police Department has an application on-line called CrimeViewer where you can review crimes reported in Austin.  You can review at the city level, by Council District, by APD district, by zip code and by several other filters.  Crimes are segregated into two FBI reporting categories, Part 1 Crimes and Part 2 Crimes.   Part 1 Crimes include homicide, aggravated assault, robbery, arson, burglary, auto theft and theft. These are categories that the FBI collects detailed information on and reports at the national level.  Part 2 Crimes are everything else, mostly misdemeanor crimes or non-violent crimes which are reported by top-line numbers only.

For the last few months, I have been running a CrimeViewer report on City Council District 9, where I live.  This is Kathie Tovo’s district, which is the east side of downtown Austin, from just south of the river to 51^st street, and mostly west of the interstate.  I have also compared District 9 statistics to District 4, which is north of District 9 and includes the St. John’s neighborhood, and District 10 which is west Austin north of Lake Austin Blvd., including the Tarrytown, Northwest Hills, Great Hills and Jollyville neighborhoods.

The first thing that stands out for those of us in Downtown Austin is that the crime rate in District 9 is three times higher than in District 10.   The crime rate in District 9 is comparable to the rate in District 4, which has long been known as the highest crime area in Austin.  74% of the District 9 Part 1 crimes are theft, and if you look at the detail, it is mostly vehicle break-ins.   Burglary makes up 10% of Part 1 crimes in District 9 (mostly burglary of a vehicle) and auto theft is also 10%.  Burglary of a residence reported under Part 2 is about 4% of reported crimes in District 9, similar to Districts 4 and 10.  If you look at all property crimes, they make up about 54% of all crimes in District 9, 48% in District 4 and 66% in District 10.  

With regard to violent crime (including robbery), 18% of crimes in District 9 are in this category, 20% in District 4 and 10% in District 10.  Drug and alcohol related arrests account for 9% of crimes reported in District 9, 7% in District 4 and only 5% in District 10.

In summary, in District 9, the crime rate is 3 times higher than in west Austin, and violent crime is twice as high.  The largest cluster of crimes reported is in the east Downtown Austin area between Cesar Chavez and 11^th street south and north, and from Interstate 35 to Lamar Blvd. east and west – zip code 78701.

My question is, why are we tolerating this crime rate in District 9, and what should we do about it?   If the crime rate went up in west Austin by 300%, don’t you think something would change pretty quickly?  And I bet that they are complaining about the property crime rate in their neighborhoods.  I do not want to hear that crime is just higher downtown, so live with it.  The Austin City Council has promoted residential development in the downtown area and encouraged us to move here.  We have the right to safety and security anywhere we live in the city of Austin.

I have some ideas about what we should do, but I would like to leave this as an open forum.  Please provide your comments and ideas.  Encourage others to visit this post and provide comments. Be polite and constructive.

Find CrimeViewer here: http://www.austintexas.gov/GIS/CrimeViewer/

Money and Politics – Political Campaigns

Now that the 2020 election is over, it is a good time to think about solutions to the broken system that we have for electing our public servants.  I think everyone of any political persuasion would agree that the main problem with politics today is the influence of money.   

There are a lot of ways that money can buy political influence, but a lot of money today comes from political campaigns that run 24 hours a day, 7 days a week, 365 days a year, forever.   Most state and federal office-holders raise funds continuously, and their campaign organizations remain mostly intact after an election.  This naturally leads to a couple of conflicts of interest.  First, we elect office-holders to do a job or represent us in government.  In most cases this is a full-time job (you might even consider being a member of the Texas legislature as a full-time responsibility), that should not have the constant distraction of political fundraising.  In addition, there is the conflict of interest between the politics of a campaign and the responsibility of public office.  Without clear separation you have to be concerned about the unbalanced influence of political campaign donors.  

It has gotten to be that a political candidate’s potential to be elected is based on how much money they can raise.   You will notice that I did not say on how much a candidate can spend.  Most political campaigns raise more money than they spend.  While politicians cannot use campaign funds for personal expenses, they can spend it on almost anything else, and they do.  One of the most common ways to spend campaign money is to donate to another politician’s campaign or to a political party committee, which then spreads the money around.   This can have the effect of overcoming limits on campaign donations, and supporting candidates who are not able to generate public support for their own campaigns.   Texas governor Greg Abbott for example has a considerable campaign surplus, and donated generously to Texas republican campaigns in 2020 to ensure that he has a republican legislature to work with.  Texas legislators routinely use campaign funds to supplement staff salaries, again blurring the lines between campaign and legislative staff.  And Texas legislators are notorious for exchanging gifts with each other using campaign funds, a practice that for some reason is not illegal.

In Texas and some other states, there are no limits to the amount of individual donations to political campaigns (Texas politicians cannot accept corporate contributions).   This has led to massive contributions by wealthy donors.  Studies have clearly shown that campaign donors have better access to office-holders than non-donors, and there are many examples of corrupt influence by political campaign donors.   There are limits to political campaign contributions at the federal level, but these limits have become irrelevant due to the explosion of political actions committees (PACs) and joint party committees that can accept much higher contribution levels.  As a result, individuals can contribute about $500,000 to a federal political candidate using various committee organizations.  You can also defeat the intent of contribution limits by donating thru a charitable organization that subsequently donates to a PAC.  Since charitable organizations do not have to report who donates to them, the money ultimately going to a PAC is from anonymous donors and can’t be tracked.  Again, you see the potential influence of mega-donors.

What can be done about the influence of campaign contributions in politics?  First thing is to stop the continuous campaign cycles.  Interestingly, the City of Austin has a template – campaigns for city office can only operate beginning 365 days before an election.   We should carry this limit on campaign activities to the state and federal level.  Where there is a primary election, the 365 day rule should relate to a general election.  I would actually like to see challengers to an office have an advantage to overcome incumbency.  I would propose that active campaigning begin for a challenger 90 days before an incumbent.   That would level the fund-raising playing field somewhat and help to ensure that an incumbent stays focused on the business of government.   

Ending the continuous campaign cycle will do a lot to stop the influence of campaign politics on office-holder decision-making.  But we also need to prohibit the use of campaign funds to finance activities of public office, including staff salaries.  Campaign activities should be clearly distinct from public office activities and campaign staff should always be separate from office staff, in work and travel.

Contributions from one campaign to another should be prohibited, and there should be clear limits on political party spending on specific campaigns.  

Charitable organizations that contribute to PACs, and maybe even to political campaigns, should be required to disclose their individual donors and allocate donations, so that individual donor contributions can be tracked consistent with regulatory limits. 

The rules for PACs and joint committees are so complex that I would have to spend time that I don’t want to spend to try and understand how it all works.  Let’s just say that there should be limits on donations from a single entity, whether individual or corporate.  We need to get to a place where politicians serve their constituents, are accountable thru election to those constituents, and are not influenced by political contributions.

Homelessness in Downtown Austin

From 2008 to my retirement in July of 2020, I worked for a company based in San Francisco and traveled there frequently.  San Francisco has been a haven for the homeless forever, but the change in the 13 years that I traveled there regularly was remarkable.    About 18 months ago on a trip where I stayed in downtown San Francisco, I had the experience of stepping over human feces on a sidewalk storm grate, and then the next morning in a cab on the way to the airport, I watched a man drop his trousers, squat and defecate into a curbside storm drain.  I wrote a letter to San Francisco Mayor London Breed, and copied it with a note to Austin Mayor Steve Adler.  I communicated my experience to Mayor Breed and implored Mayor Adler not to follow what San Francisco had done.  I got a response from Mayor Breed, nothing from Mayor Adler.   A few months later, Austin City Council changed the ordinance on camping and loitering, moving exactly in the direction that San Francisco and other large cities on the west coast have gone.   

I was born and grew up in Austin, and I have been back in the Austin area since 1989.  In 2017, my wife and I moved to downtown Austin.   Since we moved downtown, the homeless problem has exploded, largely driven by the vagrancy ordinance change in June 2019.  While the problem is acute in the downtown area, it has spread all over Austin from East Riverside Drive to North US 183.  It is obvious that the change in the ordinance in 2019 has worsened the problems of drug use, property damage and trash accumulation, aggressive panhandling and crime in areas where the homeless have congregated.  In the fall of 2019, I met a colleague at the outdoor bistro at the JW Marriott.  We were approached while in the bistro by an individual asking for money, and then later as I walked from there east on 2^nd street, I was approached three more times, once aggressively.   I have called 911 three times due to incidents involving homeless individuals in our neighborhood since 2017.    I also called 311 several times, but I don’t do that anymore – calling 311 (or using the app) is useless.  

So why did the Austin City Council change the vagrancy ordinance?  Austin and other cities are aware of a handful of cases (e.g. Martin v. City of Boise) where courts have decided that you cannot prohibit lying, sitting or camping in public places if homeless individuals have no other place to go.   That has also driven the Austin City Council to look for alternatives to shelter homeless individuals.  In the meantime, Austin spends about $60 million dollars a year on support for the homeless through multiple intermediaries from Front Steps (manages the Austin Resource Center for the Homeless) to Mobile Loaves and Fishes (manages Community First! Village).   A very few people have been moved into temporary and permanent housing, while the homeless problem continues to grow.  This is because the City of Austin is not addressing the causes of homelessness. I also would argue that current policies attract homeless individuals from other areas.  This has been an obvious result of similar policies in places like San Francisco.

Various advocacy groups who have surveyed the homeless population say that there are three primary causes for homelessness:  lack of affordable housing, substance addiction and mental illness.  I would argue that there is a fourth reason driving the current crisis – habitual criminal behavior.   Over 25 years ago, the State of Texas embarked on prison reform, allowing courts to reduce sentences for state jail felonies and increased probation and community supervision.  Many people arrested for drug and property crimes serve their sentences waiting for disposition of their cases, and then are released.  They serve just long enough to lose their jobs and their qualification for jobs, and then end up back out on the streets.  Without a job or income, affordable housing is hard to come by.  And for this population the re-arrest rate is over 60%, and that is based on the ones who get caught.  That is why I categorize them as habitual criminals.

Mayor Adler has cited a survey that stated that only about 30% of the homeless population suffered from substance addiction or mental illness.  The number is likely much higher.  Consider that no one in their right mind would live under the 6^th Street IH 35 overpass.   Then you have the population of habitual criminals.  Finally, you have a minority population who is temporarily displaced, certainly made worse by the 2020 pandemic.  All of these have the issue of lack of affordable housing, generally compounded by lack of family support.

How is crime associated with homelessness?  Unfortunately, mental illness (including intellectual disability) and substance addiction are intertwined.  Mental illness and substance addiction are also highly prevalent in the habitual criminal population.  The need to access illegal drugs drives property crime, property crime needs organized criminals to move merchandise, and of course drug dealers prey on the homeless population.  Austin has always had an illegal drug problem, primarily because of Interstate 35.  The homeless problem has just made it worse.  

You can’t address the homeless problem without addressing the root causes.  You also can’t wait for someone with a serious mental illness or substance addiction to ask for help.  More than likely they will not.  Providing the homeless with tents, sleeping bags, camping equipment and bicycles does not address the root causes, it only prolongs the problems.  Austin will have to provide intervention for mental illness and substance addiction.  For these interventions to be successful, Austin will need to move the homeless away from access to drugs, basically away from the highway underpasses where many of them live.   This also means moving the Austin Resource Center for the Homeless from downtown.

Housing the homeless population requires a combination of temporary and permanent housing.  Temporarily displaced individuals may only need temporary financial support, others may need a place to stay, like the ARCH.  On the other end of the spectrum, about 30% of people with serious mental illness and intellectual disability may not be able to live independently and will need permanent housing and support.  This should be addressed by the state and federal government, not cities like Austin.  Everyone else may need temporary housing while they receive mental health and substance abuse treatment, or participate in job training and placement programs.

So, let me be honest.  The reason for this blog topic is not to improve the quality of life for the Austin homeless population.  The reason for this essay is to offer solutions to improve the quality of life and safety for people who live in Downtown Austin.  If we are going to do that, we have to be aggressive in our approach to the homeless problem.  Location and activities would be restricted, intervention would be mandatory, and compliance with case management necessary to continue access to services.  You are not going to find affordable housing in Downtown Austin, so why would you attempt to support the homeless there?   We cannot indefinitely support people with substance addiction and serious mental illness waiting for them to ask for help.   And we must require that they participate in treatment programs in order to continue to receive housing and economic support.  Here is an outline of how it might work.

1. Create safe, drug-free and solicitation free zones in entertainment, hotel and high-density residential areas of Austin.
   • Downtown Austin
   • South Congress from downtown to Ben White Boulevard
   • The Arboretum
   • The Domain
   • The University of Texas campus (including major event facilities)
   • City of Austin parks and hike and bike trails
   • Major event facilities (Circuit of the Americas, MLS stadium, etc.)
2. Prohibit panhandling, camping, loitering, and solicitation within ¼ mile of solicitation free zones.  Exceptions to prohibition of solicitation should require permits under the Right of Way ordinance.  Permits should not be required for musicians, performance artists or other artistic talents who do not directly solicit payment for their activities.
3. Move the ARCH from downtown and relocate outside of any solicitation free zone.
4. Require 911 operators to allow the caller to decide whether they require immediate assistance on any call relating to prohibited solicitation activities.
5. Provide a first-offense warning for panhandling, camping, loitering and solicitation offenses in prohibited zones.
6. Second offense in a prohibited zone should result in mandatory detention, drug and mental health screening – these are drug-free zones.
7. If drug testing reveals proximate use of Schedule 1 drugs (except marijuana), charges of public intoxication and/or diversion of a controlled substance should be filed.
8. If drug testing reveals proximate use of Schedule 2, 3 or 4 drugs and a valid prescription cannot be provided, charges should be filed (it should be illegal to buy, possess or consume Schedule 2, 3 and 4 drugs without a prescription in the city of Austin – diversion of a controlled substance is a state jail felony).
9. Drug related offenses in the prohibited zones should result in mandatory substance abuse treatment referral.
10. Individuals who are found to have untreated serious mental illness after detention for offenses in prohibited zones should be referred for mental health treatment.
11. Individuals who fail to comply with referrals for substance abuse or mental health treatment should be barred from receiving City of Austin social services.
12. Create a plan for managing the homeless population
13. The City of Austin should discontinue funding any services for homeless individuals that do not include case management.
14. There should be a reasonable annual budget or cap on provision of services under case management.
15. The City of Austin should discontinue funding for any programs which assist individuals to remain homeless, including tents, mattresses, camping supplies, or sleeping bags.  Blankets, clothing and personal items should be provided as part of short-term case management or included in temporary housing arrangements.
16. There should be a reasonable annual budget or cap on the provision of temporary* housing services.
17. Case management should place a priority on finding temporary housing with relatives, whether in Austin or elsewhere. 
18. Temporary housing arrangements should prohibit unlawful activities (including illegal drug use) and should mandate alcohol or substance abuse treatment, and/or mental health treatment if recommended by case management. 
19. Temporary housing arrangements should require full compliance with any correctional system probation conditions (including drug testing).
20. Individuals who violate requirements for temporary housing arrangements should be discharged from temporary housing and barred from receiving social services from the City of Austin.
21. Individuals who receive disability payments or have other sources of income should pay on a sliding scale for temporary housing arrangements.

*Permanent housing for homeless individuals should be the responsibility of the state and/or federal government.

Implementation of an aggressive program to reduce the homeless population will make Austin safer for everyone, including those who start out homeless.  It may also discourage migration to Austin of individuals who are not looking for resolution of their homelessness.  It will require the City of Austin to spend money on treatment programs, job training and real temporary housing.