So far most of Trump’s appointments have been ordinary conservative hardliners or ethically-compromised rich people. But there’s a chance that some of his health care picks could be really interesting.

I’m not talking about Health and Human Services nominee Tom Price. As far as I can tell he’s an ordinary conservative hardliner (not to mention an orthopaedic surgeon), and pretty par for the course.

But I’ve seen three names mentioned as top candidates for FDA commissioner – Scott Gottleib, Jim O’Neill, and Balaji Srinavasan. I don’t know much about Gottleib, besides that he writes for Forbes about how Obamacare is bad. But either of the latter two would be shocking breaks with tradition and potentially among the highest-value political experiments of all time.

Jim O’Neill is a director at Mithril Capital and a former deputy deputy (sic) HHS secretary. He’s a (former?) board member of the Seasteading Institute, which hopes to create a libertarian utopia on a floating platform in international waters, and which recently signed a preliminary agreement with French Polynesia to begin pre-construction planning. He’s also a director of SENS, Aubrey De Grey’s collaboration to fight aging, and has proposed increasing the organ supply by paying donors. Also, I see him commenting on Eliezer’s Facebook feed sometimes, and he seems to be Facebook friends with Eliezer, Julia Galef, and, uh, me. Maybe he reads this blog? Hi, Jim!

Balaji Srinivasan describes himself as “a computer scientist, investor, entrepreneur, and academic”, and previously founded a very successful genetic testing startup; now he holds various Bitcoin-related positions. He’s famous (infamous?) for a piece called Silicon Valley’s Ultimate Exit, where he promotes “exit” over “voice”; he suggests Silicon Valley find ways to create an alternate society that escapes the dysfunction of the federal government and the rest of the country – both figuratively via new institutions like Bitcoin and eventually literally through possibilities like seasteading. He called the FDA “the man to beat – or escape, via exit – whether you want a new drug or to get to transhumanism”. And, uh, he also follows me on social media, which is definitely not a characteristic I expected multiple candidates for FDA director to have in common.

I worry that my more liberal friends won’t be sufficiently impressed. They’re thinking “Oh, more libertarians, like all those small-government people from the Bush and Reagan administrations”. My own view is that “libertarian” gets used to pick out at least two different clusters of people. One is rich crony capitalists who want a convenient excuse to cut their own taxes and roll back workers’ rights, but who fight tooth and nail against any decreased subsidies or increased competition that might threaten their own comfortable position. The other is people who are actually interested in using the power of competition to kindle innovation, improve access, bring down entrenched interests, and ultimately help regular people. The first cluster of libertarians has been around forever. O’Neill and Srinivasan seem to be part of the second. A principled, intelligent cluster-two libertarian getting the top job at one of the country’s worst bureaucracies would be practically unprecedented.

(and lest I try to weasel out of this one later, let me state for the record that if O’Neill or Srinivasan get chosen and are able to implement their preferred policies, but the US pharmaceutical industry doesn’t improve dramatically, I should accept it as a defeat for one or another hypothesis of mine. Either free markets don’t work in medicine, or I am so terrible at identifying principled intelligent libertarians that I might as well give up.)

Some important policies that an FDA commissioner like O’Neill or Srinivasan might be able to implement with high benefit and little cost:

1. Medical reciprocity with Europe and other First World countries (The Atlantic, Health Affairs, Marginal Revolution). Right now, Europe has a licensing agency about as strict as the FDA approving medications invented in Europe. Any pharma company that wants their medication approved in both the US and Europe has to spend a billion or so dollars getting it approved by the FDA, and then another billion or so dollars getting it approved by the Europeans. A lot of pharma companies don’t want to bother, with the end result that Europe has many good medications that America doesn’t, and vice versa. Just in my own field, amisulpride, one of the antipsychotics with the best safety/efficacy balance, has been used successfully in Europe for twenty years and is totally unavailable here despite a real need for better antipsychotic drugs. If the FDA agreed to approve any medication already approved by Europe (or to give it a very expedited review process), we could get an immediate windfall of dozens of drugs with unimpeachable records for almost no cost. Instead, in the real world, we’re cracking down on imported Canadian pharmaceuticals because the Canadians don’t have exactly our same FDA which means that for all we know they might be adding thalidomide to every pill or something. This is exactly the sort of silly anti-competitive cronyist practice that a principled intelligent libertarian could do away with.

2. Burdensome approval process for generic medications (SSC, more SSC). How come Martin Shkreli can hike the dose of an off-patent toxoplasma drug 5000%, and everyone just has to take it lying down even though the drug itself is so easy to produce that high school chemistry classes make it just to show they can? The reason is that every new company that makes a drug, even a widely-used generic drug that’s already been proven safe, has to go through a separate approval process that costs millions of dollars and takes two to three years – and which other companies in the market constantly try to sabotage through legal action. Shkreli can get away with his price hike because he knows that by the time the FDA gives anyone permission to compete with him, he’ll have made his fortune and moved on to his next nefarious scheme. If the FDA allowed reputable pharmaceutical companies in good standing to produce whatever generic drugs they wanted, the same as every other company is allowed to make whatever products they want, scandals like Daraprim and EpiPens would be a thing of the past, and the price of many medications could decrease by an order of magnitude.

3. Stop having that thing allowing companies to “steal” popular and effective drugs that have been in the public domain for years, claim them as their private property, shut down all competitors, and jack up the price 10x just by bringing them up to date with modern FDA bureaucracy.

4. Stop having that thing where drug companies can legally bribe other companies not to compete with them. I like this one because it sounds anti-libertarian (we’re imposing a new regulation on what companies can do!) but I think it’s exactly the sort of thing that the crony capitalists would never touch but which principled intelligent libertarians like O’Neill and Srinivasan might be open to, in order to bring more actors into the marketplace.

5. Stop thwarting consumer diagnostic products and genetic tests (SSC, more SSC). Srinivasan comes from the genetic testing world himself, so he’s likely to be extra sympathetic to this.

I notice that Jim O’Neill had (in 2014) a much more radical proposal than any of these: that the FDA should approve drugs based on safety but not efficacy; that is, drug companies have to prove that their drug isn’t dangerous, but they don’t have to do the long-term super-expensive studies proving that it works. This isn’t quite as crazy as it sounds – it just means we’d need to use academic studies and good judgment to figure out what works. We do this already in many cases – with drugs that were grandfathered in before the FDA existed (eg penicillin), or with drugs that the FDA approved for one indication but we use off-label but which we use for another indication (eg Prozac for anxiety). The best-case scenario is that a safety-but-not-efficacy regime would replicate that kind of careful skepticism across the board. The worst-case scenario is that we end up with a lot of ineffective drugs being used for a decade or so until science can catch up and prove them ineffective – something which is arguably already happening. Honestly this kind of policy is probably too revolutionary even for me – but in a world full of stupid regressive fear-driven bad ideas, it’s a bold revolutionary high-variance bad idea, and I respect that (see part 3 here for another problem with this idea).

The pharmaceutical industry stock index hasn’t moved much since some of these names started being floated. I’m not sure what to make of this; I wouldn’t have been able to predict which direction it would go, but I would have expected some direction.

One more really interesting potential appointment. Nature.com: Surprising Contenders Emerge For Trump’s NIH Chief. Most of the contenders aren’t that surprising: Collins is the current NIH chief, and Harris is a Republican congressman with an MD and a strong interest in health policy. One interesting idea of Harris’ is a pledge to lower the age at which researchers get their first grant, which would address a widely shared concern that we’re losing out on creative ideas because people have to spend decades learning to conform and playing academic politics before anyone pays attention to them. I guess this could be good (though see here, apparently the current NIH director supports this as well).

But one name stands out: Stanford statistician John Ioannidis, famous for promoting high quality studies and raising the standard of medical research. I don’t know what his administrative credentials are or what talents you need to run the NIH, but along with the Cochrane people he sets the gold standard for trustworthy bioscience, and having him in a high scientific position would do more to raise my confidence in the standard of US medical research than almost anything else I can think of.