Me – Talk: Recent article on Health Affairs I tapped into and decided to present here at AB. The topic? As expressed in the title, return Medicaid to its former self and improved upon by the new Biden Administration. I also have been working on additional posts touching upon the history of the opioid epidemic by the numbers, single payer, and a comparison to the a European healthcare model.

“In Its First 100 Days, The Biden Administration Must Restore The Soul Of Medicaid, Health Affairs,” Nicole Hubereld, Paul Shafer

Some Purpose . . .

The new administration needs to turn things around quickly and fix the damage trump, his administration, and the Republicans sponsored. This is as vital as getting stimulus money to people.

With the pandemic and many out of work, one of the top priorities for President Biden in his first 100 days should be: repeal the changes to Medicaid over the last 4 years by Republicans driving the Trump administration – bus. Medicaid provides a safety-net covering nearly one-quarter of the population today and will also cover those who have recently lost income and insurance. Nothing could be more vital during a pandemic than people needing healthcare.

The PPACA is not perfect but with the implementation of it, the expansion of Medicaid in 38 states and Washington D.C. came to be. It was “only” Republican opposition which stymied it in the other 12 states.

Coronavirus dashboard for January 6, 2021: new infections vastly outpacing vaccinations

Total confirmed COVID-19 infections: 21,046,195*

Infections last 7 days average: 219,253

Total deaths: 357,258

Deaths last 7 days average: 2,670

Total vaccinations: 4,836,489

*A study just released, based on random blood samples, suggests that as many as 50,000,000 Americans may have already been infected. Because some of the positive tests may be based on exposure to other coronaviruses, I do not think the number is that high. But my own guess is that the “true” number might be about 30,000,000, or 1 in every 11 Americans.

Today I want to focus on comparing this winter’s breakout with last spring’s and summer’s, by comparing the top and bottom 25 States with the “poster children” for each of the past breakouts.

Seven day average of new infectionsBottom 25

Top 25

Not only do *all* of the top 25 now exceed the infection rate of the 2 poster children for the previous breakouts, but many of the bottom 25 are in the same ballpark as well. Among the 50 States, only Vermont and Hawaii have some semblance of control.

Wear Your Masks Around Others, Socially Distance If You Are Out and About, And Stay Home As Much As You Can!

Eric, Dan, and Me

Coronavirus dashboard for December 29: a final look back at the pandemic disaster in 2020

US confirmed cases: 19,132,726*
Average cases last 7 days: 184,005
Total US deaths: 333,118
Average deaths last 7 days: 2,207 

Total vaccinated: 2,127,143 (per CDC via Bloomberg)

*Because many asymptomatic people probably never get tests, actual cases are probably more like 26 million, or about 8% of the US population

Source: COVID Tracking Project

The good news is, we finally have started the process of vaccination, and 1% of the population should be vaccinated by the end of this week. The bad news is, at the current rate, it would take over 4 years to vaccinate everyone in the US. I do expect this to ramp up, both as more States get more efficient at administering the vaccine, and because the Biden Administration will be much more activist and competent at ramping up production and improving the supply chain.

As we end 2020, let’s take a look at total infections and deaths per capita so far.

While everyone is social distancing (?), wearing masks when out, and staying at home (mostly); there has been an uptick in women and men not getting along together well when confined to apartments or homes. No place to go and the heart may not grow fonder of your-other when confined due to the COVID-19 pandemic.  

Domestic violence surges during mandatory lockdowns

USA Today: The National Domestic Violence Hotline reported a 9% increase from 2019 in calls between May 16 in 2020. During that period many states declared lockdowns.

The San Antonio Police Department received 18% more calls related to family violence March 2020 compared to March 2019, the New York City Police Department experienced a 10% increase in domestic violence reports over the same period, and the Portland Police recorded a 22% increase in arrests YOY in March related to domestic violence.  

Review of Act History

Here is a simple thought experiment on the use of scarce vaccine supplies.

Suppose that we had tested the Pfizer/Moderna vaccines with one dose per person and discovered that they were 85% effective at preventing covid-19. However, due to an administrative error, we gave some people two doses, and when we analyzed the data it turned out that a two-dose regimen was 95% effective at preventing covid-19.

Only 200 million doses of vaccine will be available over the next six months.

Under these circumstances, the idea that we should switch from our initial vaccination plan of one dose per person to two doses would be regarded as insane. It is clearly better to give 200 million people 85% protection than it is to give 100 million people 95% protection.

Yet today, many people believe that we should vaccinate half as many people using two doses per person, simply because this was our initial plan. This certainly seems like an irrational framing effect, or a status quo bias of some kind, or hidebound, bureaucratic thinking, and it seems likely to lead to thousands of unnecessary deaths and prolong our social and economic misery by months.

Come on people! Let’s think outside the box.

Rolling Out the Vaccine

 This morning’s (Dec. 25) New York Times offers a panel discussion on the question of who should get vaccinated against Covid first.  Broadly speaking, they take a utilitarian position: it’s interesting that none disagreed with the positions taken by panelist Peter Singer, the world’s most prominent utilitarian philosopher.  And I wouldn’t either, except for one thing.

The vaccines approved by the FDA, along with those approved by other countries like China and Russia, have gone through the fastest possible testing.  Tens of thousands of individuals have been placed in control and treatment groups in order to determine two things: to what extent do the vaccines reduce the likelihood of getting infected (efficiency) and how common and severe are the side effects (safety)?  Meeting both criteria is sufficient for approval, which is how it should be.

But there is another crucial question, to what extent do the vaccines reduce transmission of the virus to others?  The answer does not affect whether these vaccines should be employed, but they do have large consequences for other policies during this phase of the pandemic, such as rules for separation and masking, restrictions on activities and events, resumption of in-person schooling, and how much should be spent on interventions like ventilation overhauls. To the extent that vaccination reduces transmission, other restrictions and investments can be modified as the vaccinated portion of the population increases.  Unfortunately, our knowledge of this issue is minimal.  We don’t have any published lab results at all, and we are at least months away from meaningful epidemiological data.

I am very sympathetic to Robert Waldmann’s argument that we should give twice as many people one dose of the new Pfizer/Moderna vaccines, at least until supply constraints are eased, instead of following the FDA approved vaccination protocol and giving everyone two doses right from the beginning. What follows is a rough way of thinking about the logic and perhaps the magnitudes involved. Let me emphasize that this is just a finger exercise and I am not an epidemiologist, but with those important caveats I will share my work.

Here are my assumptions. The reproduction number of the virus is currently 1. This means that if behavior, transmissibility, and natural and vaccine acquired immunity are all unchanged, the number of people getting infected each day will remain the same. I assume that there are 300 million people in the United States, 40 million of whom are currently immune due to prior infection, and 260 of whom are susceptible. There are 400,000 new actual infections each day (two times the reported number of cases). These infections lead to 3,000 deaths per day (roughly the current number).

I am going to write more on the topic of Covid 19 vaccines. I will argue that it would be better to give second (booster) shots only when vaccine supplies are plentiful. I think that so long as the vaccine is in short supply, people should be given one dose. I criticise the current policy of withholding vaccine to make sure that everyone who gets a first dose gets the scheduled booster either 3 weeks later (for the Pfizer vaccine) or 4 weeks later (for the Moderna vaccine). I argue that more lives will be saved with the one dose until supplies are plentiful strategy (even if many people don’t show up for the booster when supplies are plentiful). I think that the current policy will lead to tens of thousands of un-necessary deaths in the US alone with worse consequences for countries further back in line for vaccine supplies.

The post will have two sections. One will be an attempt to analyse the published data, which are mostly Kaplan and Meier plots with numbers read off by eyeballing. I will conclude that the best (poor) estimate of the reduction of infections from the first dose is more than 18 times the reduction due to the second dose. This calculation requires the key unproven assumption that the effect of one shot is weaker than but as durable as the effect of two shots.

This would mean that efficient deployment is one dose for as many as possible as soon as possible and second doses when giving them doesn’t interfere with this. I will go on to bore people with some p-values. I think that the null that it is as efficient to give second doses on schedule is rejected at at the 5% level (given published data). I note that benefits probably include the (unproven) prevention of transmission as well as benefits for the vaccinated people. I also note that giving two to some and zero to others is unfair especially given the difficulty of deciding who gets vaccinated first and the necessarily partly arbitrary decisions. The second section will come back to arguing about public policy and ethics as I just did.

While briefly discussing (accessible link below for addition information) this decision, keep in mind this is a big deal in lowering the costs of pharmaceuticals as it goes right to the source of some of the excess takings involved in the distribution of drugs from manufacturer to drug stores.

December 10, 2020: the Supreme Court handed a win to states and broadened the path for state health care cost control efforts. In Rutledge v. Pharmaceutical Care Management Association, the Court ruled 8-0 that the Employee Retirement Income Security Act (ERISA) did not preempt Arkansas’s law regulating pharmacy benefit managers (PBMs), the intermediaries that administer prescription drug benefits for health plans.

Speaking for an unanimous Court, Justice Sonia Sotomayor, held that “state laws requiring PBMs to pay pharmacies no less than their acquisition costs for prescription drugs was not preempted by ERISA (the federal statute governing employee benefits). ERISA does not pre-empt state rate regulations that merely increase costs or alter incentives for ERISA plans without forcing plans to adopt any particular scheme of substantive coverage.”