Relevant and even prescient commentary on news, politics and the economy.

What do we want ? Hydroxychloroquine (update without Azithromycin) and Remdesivir. When do we want it ? Now

I will never forgive Donald Trump for saying something exceedingly controversial with which I agree. I hate to say this but I agree with Trump and disagree with Fauci on hydroxychloroquine and Remdesivir.

Update: But don’t mix the Hydroxychloroquine with Azithromycin
“Azithromycin: (Major) Avoid coadministration of hydroxychloroquine and azithromycin.”

Thanks Ted Lieu

I will discuss hydroxychloroquine here because there is no legal issue. It can be prescribed for Covid 19 under current law and regulation. As noted here, the FDA has no say in the matter — they regulate food, drugs, and advertising and do not regulate the practice of medicine.

Consider the different treatment of Remdesivir, Hydoxychloroquine, and sever control measures. Because it is not proven that hydroxychloroqine works, it is considered a Trump average level outrage to say it should be tried. The side effects have been known for decades (and are acceptable given the circumstances). It inhibits SARS Cov2 replication in vitro https://www.nature.com/articles/s41421-020-0156-0 . There is anecdotal evidence that it has saved lives.

This does not amount to proof. Therefore, it is argued (by many people I respect) that it is irresponsible to type the following: all Covid 19 patients should be given hydroxychloroqine now. There is no morally acceptable alternative to doing this now. Now.

In contrast, there is extremely limited evidence on extreme control measures. There is no control group. The sample size is maybe one or two. And yet, it is perfectly responsible to advocate extreme control measures. Indeed it is perfectly responsible to impose them by decree (I am in Rome and have been ordered by prime minister Conte not to leave this apartment without a good reason).

Note the contrast here
The NYTimes.com presents a model graphically on page 1. It shows estiamtes. It is, in fact, theory, forecast not fact. The effectiveness of “severe control measures” is assumed. The data on which the estimate is based isn’t presented (on page 1)

Consider this published the same day (no longer on page 1)

“Trump’s Embrace of Unproven Drugs to Treat Coronavirus Defies Science”

Notice there is no headline about how Cuomo’s, Newsome’s and Conte’s embrace of unproven public health measures defies science (and I absolutely don’t assert that — I think they are making reasonable policy choices given necessarily incomplete knowledge)

It is absolutely clear that there is no general rule for acting without proof or solid knowledge. Sometimes, the rule is to not do something new until there is proof that it works. Usually, the rule is entirely different.

I do not think that anyone can justify the current dichotomy. I don’t think anyone tries. It is just assumed that the FDA rules are laws of nature and must be accepted.

I am trying to understand why this is. There are many possible good explanations which I will try to consider over after the jump

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A Rehash, Stimuli Considered, And ACA Healthcare Insurance Assistance

I am sure by now many of you have read what the gov is and is not doing for us. The later is more prevalent as can be witnessed in the stimuli being offered. I am going to ask you to pay attention to the last item on ACA Healthcare Insurance. Whether you qualified or not in the past, you may be eligible for assistance now. I have broken this out into 4-points of which many of us might find ourselves. If you questions, PLEASE ASK, I will try to answer.

The Rundown

Goldman Sachs projects that after a 30% spike in jobless claims last week, to 281,000, new claims will hit 2.25 million this week — an unprecedented surge.

Treasury Secretary Steven Mnuchin warned Republican senators Tuesday morning that without action the coronavirus pandemic could drive up US unemployment to 20%, a Republican Senate source told CNN.

Mnuchin’s comments came as he urged Republican senators to act on economic stimulus measures totaling $1 trillion designed to avert that kind of worst case scenario. A 20% unemployment rate would be double the unemployment rate during the Great Recession, the highest in the US since the Great Depression, and it would leave more than 32 million Americans out of a job based on the current US labor force.

During the Great Recession of 2008 to 2009, approximately 9 million people lost their jobs. Losses this time around could far exceed that total if economic stimulus is not enacted.

I am not sure if it can get any worst than this; potentially lose your life, lose kin, lose your job, lose your healthcare, or lose whatever resource you might have.

Senate Republican Stimulus for People

– a direct payment to qualified Americans of up to $1,200. Married couples could get $2,400. Taxpayers who earn more than $75,000 annually will begin to see that payment reduced by $5 for every $100 they earn over the $75,000 threshold, with those who make more than $99,000 getting nothing. Families with children would get $500 per child.

While a Treasury Department outline circulated earlier in the week had called for two payments from the IRS — one each in April and May — the Senate GOP proposal only calls for one check at this time.

– The poorest families, those with no federal income tax liability, would see smaller benefits, though the minimum would be set at $600. About 22 million people earning under $40,000 a year would see no benefit under the GOP plan, according to an initial analysis by Ernie Tedeschi, a former Obama administration economist.

Business is the big winner under the Republican Senate Plan. I am waiting for a cohesive Democratic plan. Perhaps, I missed it?

ACA Healthcare Insurance

There are some things which will help people who lose their jobs and subsequently healthcare. Andrew Sprung at xpostfactoid also writes at Health Insurance Org. Today he wrote about “Uninsured in a pandemic? Seek help – it’s likely available.”

1. If you lose your job – and your employer-sponsored health insurance with it – you become eligible for a special enrollment period in the ACA marketplace. You can apply through HealthCare.gov if you’re in one of the 38 states that use the federal website. Twelve states and Washington D.C. run their own ACA exchanges. You can access those sites from this list. You can also get assistance from a licensed broker through this site.

2. If your estimated income for the year – including expected unemployment insurance – is below 400% of the federal poverty level ($49,960 for an individual, $67,640 for a couple, $103,000 for a family of four), you probably qualify for advanced premium tax credits – aka premium subsidies – a federal subsidy that picks up much or most of the monthly premium for plans offered on the exchange.

3. In the 36 states (and the District of Columbia) that have implemented the ACA Medicaid expansion, you should qualify for Medicaid if you lose your job – or you’re a freelancer who loses much of your income – and your monthly income going forward is below 138% of the federal poverty level ($1,468 for an individual, $3,013 for a family of four*). Apply through your state Medicaid office or website.

4. Important note for those whose income falls abruptly, e.g., to zero: While the ACA marketplace (HealthCare.gov for 38 states, state-based exchanges in 12 states and D.C.) calculates subsidy eligibility and Medicaid eligibility on the basis of yearly income, State Medicaid departments determine Medicaid eligibility on the basis of monthly income. Accordingly, if your earnings before layoff or loss of work were substantial, and your income going forward is zero or below the Medicaid threshold, you should apply for Medicaid through a state office or website, not through the ACA marketplace.

The main provider for healthcare insurance may be Medicaid. Pre-Medicaid expansion, rule of thumb was about 1 million Medicaid enrollment increase for every 1 point increase in unemployment rate. More than likely higher with many more parents and other adults potentially eligible in expansion states (Prof. Edwin Park, Georgetown).

Hopefully, the better souls and minds prevail in determining what stimuli is used to assist people. If you need some assistance in finding information, please ask and I will assist.

Sources of Information which will lead to other place:

Uninsured in a pandemic? Seek help – it’s likely available,” Health Insurance Org., Andrew Sprung, March 20, 2020

The ACA as recession insurance, revisited,” Xpostfactoid Blog, Andrew Sprung, March 20, 2020

CR’s Guide to the Coronavirus freebie informan

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Moscow Mitch was hoping the fever would break

The closing remarks of Moscow Mitch McConnell statement before the vote to spare Donald John Trump his presidency.

He was talking about “factional fever” that the “framers” referred to as a concern for majorities acting in a partisan manor.  And yet, here we are.

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Bailouts

Given the Coronavirus crisis, there will be bailouts. Should there be bailouts ? If so how should firms be bailed out ?

I think it is useful to look at the last round of bailouts from 2008-9 for lessons learned. First with the benefit of hindsight, does it seem that bailing out firms was a mistake ? On the one hand one can argue that it was necessary to prevent the Great Depression. It is hard to discuss whether it was worth the cost, because there was no cost. Instead, the US Federal Goverment obtained the highest profits recorded in human history by accident when focused on saving the financial system (and GM and Chrystler).

The many brilliant economists who argued that we should stick to laissez faire and that, in particular, socialism for bankers and ruthless capitalism for everyone else is no good, have not examined the outcomes. I think this is because the evidence is overwhelmingly damaging to their case.

OK so let’s bail out again. Looking back, can we decide on a better way to do it ? It is challenging. Preventing the second great depression while making hundreds of billions in profits is a good year’s work by any standard.

If things worked out rather well (and the bailouts did even if aggregate demand management was distorted by austerians) what can we learn ?

It seems to me that we learn that Treasuries should bear risk. Bearing risk is highly rewarded in expected value. Bearing risk is highly rewarded on long term average. This is what matters to Treasuries who are concerned about long term debt sustainability. Bearing risk is very very highly rewarded during crises, when it is buying at fire sale prices.

In general the riskier the positions taken by the US Federal Government in 2008/9 the more it helped the private sector and the more it profited.

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Let’s get real about coronavirus testing . . .

We do not know how severe the covid-19 epidemic will be or how much economic and social pain it will cause, but it clearly has the potential to kill hundreds of thousands or even millions of Americans, and the economic consequences could include a deep recession and even a financial crisis that will cause misery to tens of millions of people.

Testing is key to getting the epidemic under control, and it is not clear to me that policymakers are being nearly as aggressive about expanding testing capacity as they should be.  Think of two alternative testing strategies.  One strategy is to selectively test people who have symptoms or who may have been exposed to someone with the disease.  The alternative strategy is to develop the ability to do mass screenings for the virus among the general population.  (There are various intermediate strategies one can imagine, such as doing mass screenings in local areas with a high incidence of disease.)  Of course, selective testing is the place to start, but the ability to do mass screenings would allow us to pro-actively identify and isolate almost all carriers and would thus avoid the need for widespread social isolation which is wreaking havoc on the economy.  Selective screenings, in contrast, may or may not be able to contain the epidemic sufficiently to allow normal economic activity to resume.

I am not sure what is being done to expand our testing capacity, but if we want to develop the ability to do mass screenings, we need to make it a priority nowThe government will need to contract with equipment manufacturers and other suppliers (of reagents, swabs, protective gear, etc.) for large capacity commitments on a short timeline.  I have no idea what this would cost or even if it is feasible, but if there is even a small chance that the epidemic will last for six months or return next winter, it seems that a $10 or $20 billion investment in testing capacity would be short money.

The Democrats should jump on this as they take up the next coronavirus response bill.  Not only is it good policy, it will give them an opportunity to highlight the fumbling, timid response of the Trump administration to the crisis.

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Remdesivir II

This is, in fact, another post on Coronavirus, but it will take me a while to get to the point. To put the conclusion here, I think that it is important to get the FDA out of the way (by executive order if necessary).

The Food and Drug Act, as currently interpreted, requires the assumption that people should (generally) not be treated with pharmaceuticals which haven’t been proven to be safe and effective. The rule is first do no harm, second do no harm. This only makes sense if results with current standard of care are acceptable. In this case, they aren’t. I think there should be mass production and use of Remdesivir starting on the 5th of March, based on one case where it seems to have cured a patient overnight.

To be honest, I think it should have been approved based on evidence that it is safe (from failed efforts to treat Ebola) and evidence that it inhibits the RNA dependent RNA polymerase of the MERS Coronavirus

Obviously one case is not proof. Still more obviously a pre-clinical study of a related organism isn’t strong evidence about the novel coronavirus.

So ?

It isn’t as if the current approach is working so well, that we should stick with it until there is proof that a new approach works better.

I think the trace of information is enough that, given almost no knowledge and a very diffuse posterior, one can conclude that the expected welfare of a patient treated with Remdesivir is higher than of one not treated with Remdesivir.

At this point, the standard ethical rule that decisions should be made in the patients’ intererests would mandate use of Remdesivir
(I personally do not accept that rule)

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CORONA VIRUS AND SOCIAL SECURITY, ANOTHER GRAND BARGAIN?

by Dale CoberlyCORONA VIRUS AND SOCIAL SECURITY, ANOTHER GRAND BARGAIN?

Republicans are showing what they are made of. After claiming that the Corona Virus was not serious, or was well contained, or was Democrat fake news; they are now admitting it is serious and calling it a Chinese virus.

Fox News explained to a reporter they don’t expect “turning the ship around” to cause any problem with their viewers. They did not say that is because their viewers will believe anything they tell them to believe. Nor did they tell the reason for their turnaround of their seeing how to make money out of the pandemic. Even more so, they have seen how to use it to destroy Social Security.

These guys are akin to inviting your boss to dinner and noticing he couldn’t take his eyes off of your teenage daughter. Well, you think, at least he has kept his hands off her. Then your daughter comes over and says, ”Dad, Mr Peterson has been telling me about his house on the beach. It sounds so cool. And guess what, he said I could come and spend the weekend there if I want to. Can I? Can I? Please.”

So Trump has said he will spend some money fighting the epidemic, but he wants to get the money from Social Security. He wants a “payroll tax holiday.” The government won’t collect the payroll tax, and people can keep the money and spend it to help stimulate the economy.

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Reporting from Germany: “Welt am Sonntag”

Welt am Sonntag is reporting our honorable President is attempting to bribe lure a German company CureVac to develop a vaccine  to be used only in the US.

Germany’s Health Ministry confirmed a report in the newspaper “Welt am Sonntag”, which said President Donald Trump had offered bribes funds to lure the German company CureVac to the United States, and the German government was making counter-offers to tempt it to stay.

Welt am Sonntag quoted an unidentified German government source as saying Trump was trying to secure the scientists’ work exclusively, and would do anything to get a vaccine for the United States, “but only for the United States.”

CureVac’s chief production officer and co-founder Florian von der Muelbe told Reuters the company had started with multitude coronavirus vaccine candidates and was now selecting the best two to send into clinical trials.

The privately-held company based in Tübingen, Germany hopes to have an experimental vaccine ready by June or July to then seek the go-ahead from regulators for testing on humans.

Earlier this month CureVac CEO Daniel Menichella met Trump, Pence, members of the White House Coronavirus Task Force, and senior representatives of pharmaceutical and biotech companies to discuss a vaccine.

Professor of Health Economics and Epidemiology Karl Lauterbach, a senior lawmaker with the Social Democrats and a junior partner in Chancellor Angela Merkel’s coalition stated:

“The exclusive sale of a possible vaccine to the USA must be prevented by all means. Capitalism has limits.”

Germany tries to stop US from luring away firm seeking coronavirus vaccine, CNBC, March 15, 2020

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Coronavirus Treatment Case Report

“First Case of 2019 Novel Coronavirus in the United States” Holshue et al 2020

I quote

Treatment with intravenous remdesivir (a novel nucleotide analogue prodrug in development10,11) was initiated on the evening of day 7, and no adverse events were observed in association with the infusion. Vancomycin was discontinued on the evening of day 7, and cefepime was discontinued on the following day, after serial negative procalcitonin levels and negative nasal PCR testing for methicillin-resistant Staphylococcus aureus.

On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.

This suggests that Remdesivir is an effective treatment for Covid 19. I told you so. A guess in Angry Bear March 2 2020 a Case in the New England Journal of Medicine March 5 2020.

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Life in Rome

I am in a city with a curfew (enforced ?) where only pharmacies, supermarkets and those stores where someone from China sells all sorts of household stuff are open. Rome hasn’t reached the dread levels of Wuhan and Milan, but the Italian government is trying to get ahead of the curve.

It is strange and alarming that there is little traffic (it is also impressive that Romans don’t obey the traffic code even when there is little traffic). People are really trying to stay home all the time (I was semi home bound before it was cool).

I have learned about the activities which people consider absolutely necessary. A large fraction of people walking around are walking dogs. Many people are wearing masks (absolutely sold out everywhere) and gloves. I discover there are some things I have to touch. These include an ATM (alarmingly often) and cash.

One striking thing is that people wait outside of the supermarkets and pharmacies. This is a rule that does not have to be enforced — people are scared. Good thing it’s not cold in Rome during March (or February or actually ever at all in the globally warmed year of our lord 2019/2020). This makes me notice the high rates of infection in Iceland and Norway. I guess up there (where I have been in July with a rain coat) the choice is risk of Covid 19 or of frostbite.

The extreme measures (not just ordered but orders which are actually obeyed, by Romans) are impressive because as of the day before yesterday there were only 200 cases in Lazio (region which includes Rome). The fact that one of the cases was governor Zingaretti (also head of the Italian Democratic Party) might have made a difference.

The news spreads even faster than the virus. Down here the health care system is under strain but not overwhelmed (yet) but people read about (and see on TV) reports on how in Lombardy Triage has reaquired it’s original meaning. During World War I, It was red = critical, yellow = serious monitor but not critical, black = doomed. In normal times black now means deceased.

In Lois Armstrong Airport New Orleans during Katrina there were living people with black tags (for will not survive a flight and so will die here). I was appalled. Now in parts of Northern Italy there aren’t enough respirators for patients who would die without one. This is part of why the Italian case fatality rate is high. It is also important that Italians have had low fertility for decades and are old on average.

I guess I haven’t written anything that people don’t know already. I will update when the wave of contagion overwhelms us. I fear that I will be giving readers a hint of future action in their home town.

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