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If I could quadruple plus this comment I would
Minor quibble on your use of the term "regulation." Since this was being discussed in Congress, this would actually be about proposed statute, not regulations. Statutes are laws enacted by legislative bodies. Regulations are promulgated by executive agencies, to provide the details of how statutes should be implemented (they tend to be saner than statutes, because they're limited by real world constraints; they're also easier to tweak). Lastly, case law is issued by court cases that are considered to be "binding authority." All of these are considered to be "sources of law."
I think of laws in practical terms as machines for managing human conflict. My redux of the various branches of government is as follows:
- Legislative branch - manufactures laws
- Executive branch - operates laws
- Judicial branch - troubleshoots/fixes laws
Hot take - we've been in denial for several decades now about a deep, nagging epistemological crisis. If the "AI disaster" was your pipes breaking, and you filed a claim with your insurance company about it, they'd deny it as being the result of wear and tear.
Human knowledge long ago passed the point where it was possible for a single person to understand significant pieces of it, operationally. The level of trust that's required to function is terrifying. Ai does all that - faster.
I suspect that some sort of regular recommended boosting schedule will evolve, but it won't be something noticeable to a layperson. You'll go to annual checkups, as you should, and doctor will tell you to get a bunch o' shots and/or blood tests.
Adding - does anyone else wish there was a seamless, streamlined way of recruiting more people into clinical trials so we could bring new treatments to market faster, and while we're at it at least give half the people in the trial an effective treatment?
Like, how about sn annual general consent form, directly sent to clinicaltrials.gov in exchange for a modest tax break?
What's sorely needed is an international drug approval reciprocity treaty. A single organization, say, part of the WHO, would be tasked with periodically vetting national level food and drug approval agencies of signator countries. In exchange for this service, drugs would be instantly approved when just one country approves it.
ETA: It looks like bilateral "agreements" are a thing:
But of course that falls well short of an international treaty. And lots of bilateral agreements strikes me as o(n^2) more complicated than a hub-and-spoke framework.
And I should also add that my general vision for federalism kind of goes in both directions. Namely, I'd like it if each state could be allowed to form its own mini-FDA but the federal government's role would be to "approve the approvers"
Weirdly, with the collapse of any externally imposed controls (lockdowns, mask mandates, vaccination requirements) and just general fatigue in the population at large, it's become easier than ever to buy one's way out of getting covid than it's ever been. For instance, N95 masks are way cheaper - enough that I can switch them daily. With so few people getting the bivalent shot, I'm seriously considering going back for seconds.
Just dropping in to plant the idea of "parametric insurance indexed to wastewater surveillance."
Munich Re, Lloyd's, are you listening?
Re medical bills (or any bills, for that matter):
A major change from the TCJA in 2017 was allowing more businesses, including some health care providers and third party debt collectors, to use cash accounting rather than accrual accounting for the purpose of computing taxable income. The upshot is that treatment plus a printed and mailed bill no longer counts as revenue for a lot more businesses. That's precisely what allows for the "aspirational" bills you're describing. Repealing this provision would go a long way to taming this particular aspect, I believe.
The news about Evusheld is indeed disappointing. Why mAb's aren't updated in lockstep with vaccines is baffling: they could be harvesting mAb's at the same time that they're testing vaccines using the same mice
One thing I don't see talked about very much is that attempting to predict who's at risk of long covid, as a function of severity of the initial infection is very much playing to an inside straight: the illness has to be severe enough to cripple you but not kill you. It's related to the reason that long term disability insurance I'd tricky for even the best actuaries and underwriters.
I think it depends on the externality. Widespread destitution is itself a "public bad" when it impacts crime, public health, noise, etc
That's income tax. Sales tax is a different story. In fact since wealthier people benefit from bulk discounts, I'd go so far as to guess that the poor pay proportionally more per, say, toilet paper roll.
I can't begin to tell you how much I appreciate this. The reality that novids like me need to accept is "learning to take yes for an answer." We've reached the point where we are no longer under any compelling legal or moral obligation to know if we have Covid at any given time. Meet the new normal, same as the old normal.
From the article, here's a description of the strategy:
As an example, consider a hypothetical community of 5 households labeled A through E, with 5 individuals in household A, 4 in household B, 3 in C, 2 in D, and 1 in E. This gives a total of 15 individuals, none of which are previously immune. Suppose that we only have the capacity to fully vaccinate 5 individuals. In line with the reasoning above, EHR gives the following vaccination strategy:
- The largest household by effective size is A, with 5 individuals. The first vaccine is therefore allocated to the eldest member of A.
- A and B are now tied in terms of effective size, with 4 susceptible individuals each. We therefore vaccinate one person each from both A and B.
- A, B, and C are now tied in terms of effective size, with 3 individuals each. With enough capacity left to vaccinate only two people, we therefore randomly choose two of the three households, and vaccinate one individual in each of the randomly chosen households.
I found this:
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0263155
"Further investigating herd immunity thresholds for a range of values for R0 we find that for most parameter choices, EHR achieves herd immunity with fewer vaccinated individuals than the other presented strategies (and universally, dramatically earlier than age-based strategies). At the most extreme, assuming a 90% effective vaccine and R0 = 2, EHR achieves herd immunity at just 48% of the population vaccinated, compared to thresholds of 61% and 89% for random and eldest-first strategies. At 100% efficiency, the relative herd immunity thresholds are 44% and 55%, for the EHR and random strategies, respectively."
I doubt it would cost very much. Epidemiologists have software they can use to model it. Moreover, an easy way to do controlled experiments would be dorm assignments on college campuses.
At any rate, my unabashedly Bayesian gut feeling is that it's obviously a good idea to do it. See above for my priors.
To the extent that this kind of thing is hard, I'd put it squarely in the "hard but worth it" bucket, along the lines of JFK's speech at Rice University. I'm calling for us to stop meekly accepting case surges as inevitable, and I don't think it's unreasonable to speculate that by leading with mass vaccination, we've unwittingly created a kind of "bang bang control system" with similar issues to overworked thermostats - a public health analog of metal fatigue, if you will.
I'm gonna throw this idea out there: might it be a good idea to stagger booster shots within a household? We never know for sure when the next surge will occur, but we do know that (1) immunity against infection wanes and (2) household transmission is a big factor during surges. Careful timing boosters within a household (or social bubble) might be a good way to take more control of what can be controlled.
Just spitballing, as they say.
In the specific case of Moderna vs Pfizer, maybe an equitable trade secret swap? Pfizer could simply agree to let Moderna produce its own version of Paxlovid.
In the long run, we really need to revisit the Bayh-Dole Act. It's not unreasonable for the government to retain some rights to intellectual property that's the result of federally funded research, whether it's from grants or because the government agrees ahead of time to purchase the finished product.
Yeah, you'd have to prove that the costs are somehow shifted. That's not at all clear. A dollar in accounts receivable is something of a legal fiction. It exists on a probability distribution according to how likely it is that the debt is going to be collected. Before credit cards, it was standard practice for businesses to "age" their AR over the course of months, ultimately writing off the most intractable debts. In many ways, that's all that's going on here. Credit cards are simply a way for businesses to sell their AR (at a modest discount). Interest rates partially offset this, but only to a point. If $200,000 isn't collectable neither is $2,000,000 - interest theater, if you will.
The fundamental problem with student loans is that education is an intangible asset. Unlike a loan to buy a home or a car, there's nothing that the lender can repossess if things go sideways. Financing education, both at the individual level and societal level, is always going to be a difficult problem, contentious and fraught. That being said, there's some low hanging fruit.
1. Streamline the collection of student debt by creating a system of payroll deductions - maybe even add it to W4's. It's all going to the U.S. Treasury anyway.
2. Cap payments at a fixed percentage of the borrower's federal tax liability, say 20%. Thus if you pay $10 in taxes in a given pay period, at most $2 would go toward your loan.
3. Prorate PSLF instead of making it all-or-nothing - if you work half a year for a qualifying employer, you'd get 5% of your principal written off.
4. Federal student loans are unique compared to other loans in that they're completely forgiven when the borrower dies. That's nice, but it also means that a significant portion of the high interest rates is likely due to default risk. Borrowers should be allowed to get a reduced rate if they buy credit life insurance, making the government (that is, the lender) the beneficiary.
Killing pets was a bit brutal, don't you think?
I think part of the problem is in the fog of a contentious election, we never had a rational, nuanced discussion of how mask mandates should be enforced. The CDC had some constructive suggestions early on, that struck a reasonable middle ground.
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Is it at all possible that the bill could promote greater honesty towards investors? After all, if you're taxed on book income you're that much less likely to make it appear to investors that your company is more profitable than it really is. Not saying thus will necessarily happen, but certainly worth watching and keeping an open mind.
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I'm not sure how much different taxing book income is from reversing a key provision in the TCJA from 2017 - namely, the TCJA raised the income threshold where companies are required to use an accrual basis to report income.
I think the reality at this point is that while Covid is certainly endemic and will be a permanent fixture of our lives, it is also in every way that matters, deterministically avoidable.
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N95 respirators are cheaper than they've ever been ($25 for 50 Kimberly Clarke pouch style masks - I can switch out my single use masks daily)
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It's really not that hard to get boosted every 3-4 months if your D&D alignment is "neutral-good". The only person stopping you from getting an extra booster right now is...you.
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Labcorp is now offering spike antibody tests that go up to 25,000 u/mL. You can take a few, spaced a few months apart, to get a good sense of your half life. If you're able to hold at, say, 7000 u/mL for 8 or 9 months, you're probably all set for a couple years.
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Rapid tests are easier to get
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Higher levels of population immunity
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Heterologous immunity, from vaccines against other diseases, is a thing
Basically, I'm living my best life at this point.
Just a reminder that this paper provides a cute way to estimate the "true" prevalence of Covid (or indeed any pathogen) in a community: geometric mean of case rate and positivity rate.
Thus for instance based on today's numbers for the NYC metro area on covidactnow.org
50.4 per 100K = .000504 13.7% positivity rate = 0.137
True prevalence = 0.831%
Thing is....our public health infrastructure is pretty well buggered at this point, and we don't have the resources to do adequate contact tracing. So is it spreading beyond sexual networks? Can't be sure, but it also seems like that's the only place we seem to be looking.
I'm probably a bit more concerned about monkeypox than you are, mainly because it has an alarmingly long incubation period (up to 14 days) and then a punishingly long infectious period (3-4 weeks). That's a lot of time to infect a lot of people in a lot of places. Plus it seems like it's pretty hardy on surfaces. In places like NYC, monkeypox + covid could easily overwhelm public health systems.
The public health messaging is awful, and you couldn't think of a better way to create distrust and homophobia.
As with Covid, the clunky system for prioritizing who gets vaccinated "first" is transparently stupid. The idea that any male with a good internet connection isn't going to set up an alert to monitor changes to a website and just get a jab regardless of their sexual proclivities is just plain laughable. You might as well auction off doses to the highest bidder.
What's needed is a "virtual" line. Let everyone go ahead and schedule their shot. Ask for a modest non-refundable copay. There are three possible contingencies to consider:
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Someone with a higher priority comes along and wants your spot, more than 48 hours before your appointment. Then you automatically get moved or rescheduled and possibly offered a different vaccine you're due for anyway.
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Out of stock. Offer a different vaccine. Reschedule
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No show - retain the deposit. Jab anyone
For #10, I'd replace it by a more agnostic "allow price gouging OR enforce nationwide rationing" - however you feel about free market vs government control, the idea that there's a conflict-free middle ground where we ban price gouging but don't go all in with rationing is pure fantasy.
"those few people can be well-compensated in money and also honor and status and would happily volunteer and so on, all the usual arguments. Worth noting."
I'm so glad you made this point. The resistance to challenge trials as being somehow unethical always struck me as odd - lots of people put their lives on the line for the public good, and we don't see that as an earth shattering moral dilemma.
What's needed is state level counterparts that can approve manufacturing facilities within their borders. The FDA can simply distribute funds and periodically "approve the approvers" and thereby ensure that states give one another full faith and credit.
Are we going to talk about the coincidence that Abbott is also the leading supplier of rapid Covid tests???
Appalling, since it's pretty easy to verify obesity on the spot. Most pharmacies sell calculators, scales, and tape measures.
What's not within our power is making sure that well-fitting respirators (full or not) are available to everyone. In order to make this happen, at the very least, we need to make sure that public or private insurance covers qualified fit-testing services (and we need some sort of infrastructure for certifying who offers such services - this appears to be a thing in some other countries).
And I'd also remove the word "covid" from the initial part of the sentence, and have it read "If people actually took risk seriously", since big part of our failure is not balancing covid risk with other risks, like the risk that flight attendants and store clerks assume (physical violence, mainly) when they're tasked with enforcing mandates.
Part of the Covid endgame we should probably be considering right now - and feel free to down vote me until I add links (if you hate me) or add links for me (if you love me) should probably be - underlying genetic resistance (or susceptibility). There are tantalizing clues that this might be relevant:
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the UK challenge study - about half of the participants stubbornly refused to catch Covid
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actual progress in identifying genes for susceptibility, lots of data
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experience with other viruses, often with tradeoffs (e.g. HIV vs West Nile virus - weird, right?)
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waves often don't go past about 60%
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lots of breakthroughs and re-infections and lots of people not getting it (consistent with my own social circle)
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household secondary attack rates surprisingly low
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myxomatosis in rabbits and virus/host co-evolution. As with humans and covid, interferons seem to be the key to understanding innate resistance/susceptibility to novel pathogens
At this point, I'm really starting to think I'm one of the lucky ones, since I've been plenty exposed and I test myself fairly frequently. Just like if I were to flip a coin and get 10,000 heads, at some point I start to wonder if it's biased. I don't feel too guilty about this, since swine flu got me pretty bad in 2009 and I'm old enough to have had chickenpox pre-vaccine (fun fact - everybody who gets chickenpox has "long chickenpox" - the body never clears it)
For my own personal closure on all this mishuggass I recently sent my spit to 23andme to get a sense of where I fall on the innate susceptibility spectrum. Don't try this at home, dear reader. It's pretty safe for me to do this, since I've got no plans to buy life insurance (no kids!) and I have a stable unionized government job with a great benefits.
A possible reason for being cautious about prescribing Paxlovid to just anyone (regardless of underlying risk factors and severity) from a public health standpoint is the issue of rebounds. The Paxlovid might hold the infection at bay for a while, and then people could start testing positive again a few days later, so quarantine protocols become a bit more complex.
This NYT article is a bit closer to deserving the "stop being poor" criticism:
https://www.nytimes.com/2022/03/30/well/live/ba2-omicron-covid.html
In our current landscape we've got an insurance/banking regulator in every state, plus DC and Puerto Rico. Then there's the US DOL, that regulates self-funded employer plans (ERISA). Then there are local, state, and federal employee/retiree plans. Then Medicare and Medicaid, which fall under CMS. Finally there's the wild west of plans offered by religious employers, which aren't under the jurisdiction of any administrative agency (if you exhaust your internal appeals your only recourse is the courts). This state of affairs is largely due to the McCarran-Ferguson Act, which asserted that insurance was the exclusive jurisdiction of the states (in response to a SCOTUS decision that said otherwise). So we're left with an insanely inefficient patchwork in which large insurance companies shop for jurisdictions that make it as easy as possible for them, and as opaque as possible for customers. I think if we simplified regulation of insurance, we'd have less of a pressing need for single payer.
To me the most compelling reason to let people go ahead and get all the boosters they want, at this point (as long as they're reasonably safe) involves going back to the basic function of government: managing human conflict. For over half a year now, the principal axis of conflict has been between people who won't get vaccinated and people who will (and want more protection from those thar won't get their shots). At this point, the best way to settle this would be to move towards a boosting-free-for-all, with clear communication that (1) You should really get your first shot if you haven't already, and if you haven't yet, that's a you problem (2) If you're worried about being beset on all sides by inadequately vaccinated people, that's also a you problem, help yourself to a shot (3) If there's a need for any sort of prioritization, make it "virtual" - if you book an appointment and someone in a higher priority score wants your slot with a 48 hour notice, you get bumped
My suspicion is that vaccine doses are way more fungible than we think they are, and the focus should always have been matching willing arms with doses. What was a hard public health problem is mostly a banal manufacturing problem - rapidly creating covid-hardy humans.
Every time I hear someone start preaching to be about single payer, I want to say "Good idea, but maybe we can start with single regulator?"
Which is why insurance companies should be encouraged to start underwriting the cost of quarantines. With a discount for people who get vaccinated.
Fascinating stuff about possible beneficial effect of MMR and TDAP boosters - they could help mitigate the risk of getting Covid:
https://www.sciencedaily.com/releases/2021/08/210831142423.htm
"The sense in which you have to ‘beat the market’ is the danger that everyone might be trying to get the booster at the same time when things are about to get bad, and fighting for limited appointment slots. That is potentially a concern, but given people’s reluctance to boost, I do not anticipate there being enough additional demand to cause much of an issue. Even if there is, you’ll have ample warning."
That, and it's not a zero sum game. If there's a mad rush to get boosted right before a wave, that's going to have the aggregate effect of making that wave into more of a ripple.
Right. There's definitely some sort of bias in the testing.
One area in which I've run out of patience is the "Home tests are keeping case counts down" trope. In order for that to be true, you need to make a lot of assumptions about what those home-testers would be doing if there weren't any home tests available. Would they be running out to get PCR tests? Somehow I doubt it.
Thanks for this thoughtful analysis. Concrete example: there have been house fires in which loss of smell from Covid was a contributing factor.
Also people who are "hard of smelling" often develop cardiac issues because they tend to over-salt their food. My aunt has struggled with this for several decades now after a chemical accident, and recently had a heart attack.
I'm assuming insurance companies will pay for it. The government will still be paying indirectly to the extent that insurance premiums are pre-tax.
I'm also predicting that Paxlovid will probably end up being used for way more viruses than just Covid. If that happens, it could obviate the need for testing.
I'd counter with the theory that there's been a marked shift in why people are testing. If you're mostly testing for the purpose of controlling the spread (e.g. contact tracing) then the CFR will be lower than if you're focused on treating people who are acutely ill (with the goal of getting antivirals ASAP)
I do broadly agree with you that there are perverse incentives for people to avoid going on record as having Covid, especially with what we're finding out about possible long term cardiovascular issues (if you ever want to buy life insurance, don't get a PCR test). That could have the effect you're describing.
The photo of the anti-vax sign has only reinforced my belief that anything printed in comic sans is inherently dubious