Ban, Subsidize, Mandate: Ethics and US Healthcare Policy

Tomorrow (Friday 12/2) I’ll be speaking at the Fall Ethics Forum at Sacramento State. The Center for Practical and Professional Ethics there does a forum every year on a different field of practical ethics, and this year they chose healthcare (some previous iterations look quite interesting, like Bryan Caplan on education and Lyman Stone on population). The event is open to the public if you happen to live near Sacramento, and I hope to be able to post a recording later. But for now, here’s a short preview of what I plan to say:

In many key respects, US health policy is about restricting the choices available to patients and health care providers: banning things the government doesn’t want, while mandating or subsidizing things they want. These restrictions on autonomy are typically justified by the idea that they lead to superior health or economic outcomes. In some cases this tradeoff between freedom and efficient utilitarian outcomes is real, but I highlight some policies such as Certificate of Need laws that appear to harm both freedom and efficiency. I argue that the overarching US approach to health policy is to subsidize demand while restricting supply, which together lead to exceptionally high prices but mediocre health outcomes.

I’ll also take on some classic questions like: when are free lunches truly free? And when is moral hazard really immoral?

Protests Erupt Across China Over COVID Policy But Lockdowns Continue: Why?

Headlines in today’s financial news include items like “Clashes in Shanghai as COVID protests flare across China“ from Yahoo Finance. There have been widespread protests this week, which are normally a rarity under the authoritarian regime, and are being suppressed by any means necessary. Apple stock is down about 4% in the past two trading days on fears that iPhone shortages will get worse due to worker unrest in the giant Foxconn factory in Zhengzhou. Wall Street keeps hoping the China will loosen up, since the lockdowns on the world’s second-largest economy are a drag on global markets.

China has pursued a “zero-COVID” policy, of strict mass lockdowns to halt any spread of the virus. Residents have been confined to their apartments for over 3 months in some cases. Whole cities with tens of millions of people have been locked down for months at a time whenever a number of cases are spotted. China’s economic growth has stagnated, and unemployment among young people has risen to 20%, which has helped fuel unrest.  Chinese people are aware that the rest of the world has moved on from mass lockdowns, and may be realizing the futility of thinking that lockdowns can stave off the virus indefinitely.

Given its discomfort with widespread discontent and protests, why does the Chinese government persist in this policy? An article in the Atlantic by Michael Shuman answers that question: “Zero COVID Has Outlived Its Usefulness. Here’s Why China Is Still Enforcing It. “  Back in 2020 when COVID first swept through the world, the strict lockdowns (readily enforced in an authoritarian regime) seemed like a big win for the Chinese leadership:

When the outbreak began in Wuhan in early 2020, the virus was unknown, vaccines were unavailable, and China’s poorly equipped health system could have quickly become overwhelmed by a sweeping pandemic. Yet the policy had a political element from the very beginning as well. The Communist Party is adept at sniffing out threats to its rule, and it quickly identified COVID as one of them. A major public-health crisis, with millions dying, would have raised serious doubts about the regime’s competence, which is, in effect, its sole claim to legitimacy.

Worse, the party could have faced a populace that directly blamed it for the outbreak—with good reason. The Chinese authorities at both the national and local levels botched their initial response to the novel coronavirus, suppressing information about its discovery by a Wuhan doctor and acting far too slowly to contain the initial spread. Sensing its potential vulnerability, the party shifted into anti-COVID overdrive, shutting down large swaths of the country, with the result that it did succeed in snuffing out an epidemic in a matter of weeks, even as it spread to the rest of the world.

That success allowed the Communist Party to transform a potential tragedy into a public-relations triumph. Within weeks of the Wuhan outbreak, China’s propaganda machine was touting the wonders of its virus-busting methods. And as the U.S. and other Western countries struggled to contain the disease, Beijing’s big win became even more valuable as evidence that its authoritarian system was more capable and caring than any democratic one. Beijing and its advocates pointed to rising case and death counts in the U.S. as proof of China’s superiority and American decline.

A number of other countries including Australia and New Zealand also implemented strict (stricter than in the U.S.) lockdown measures in 2020, and, like China, experienced far less impact from the virus in that timeframe than seen in the U.S. However, most of these measures were lifted in 2021. The widespread application of mRNA vaccines like those from Pfizer and Moderna in the West has served to mitigate the severity of the viral infection. Also, some measure of herd immunity has been achieved by the widespread exposure to COVID in the population; antibodies persist for at least eight months after contracting the disease. So, what’s up with China?

China has resisted using Western vaccines, relying instead on homegrown vaccines which are less effective, though they do give some measure of protection.  Also, “The additional layers of high-tech surveillance adopted in the name of pandemic prevention can be used to enhance the tracking and monitoring of the populace more generally,” which is another win for the government. However, the major factor is that the Party, and especially President Xi, cannot afford to loosen up now and risk an embarrassing explosion of cases that would overburden the healthcare system and probably lead to millions of deaths:

The victory of zero COVID was claimed not just as the party’s but as Xi Jinping’s in particular. The State Council, China’s highest governing body, declared in a 2020 white paper that Xi had “taken personal command, planned the response, overseen the general situation and acted decisively, pointing the way forward in the fight against the epidemic.”

This narrative became entrenched. If Beijing loosened up and allowed COVID to run amok, the Chinese system would appear no better than those of loser democracies, and Xi would seem like another failing politician, a mere mortal, not the virus-fighting superhero he was painted as. Zero COVID’s failure would be a disaster for the Communist Party’s veneer of infallibility.

So the leadership insists on zero COVID and damn the consequences.

What’s Killing Men Ages 18-39?

The all-cause mortality rate in 2021 for men in the US ages 18-39 was about 40% higher than the average of 2018 and 2019. That’s a huge increase, especially for a group that is not in the high-risk category for COVID-19. What’s causing it?

Some have suggested that heart disease deaths, perhaps induced by the COVID vaccines, is the cause. This is not just a fringe internet theory by anonymous Twitter accounts. The Surgeon General of Florida has said this is true.

What do the data say? The first thing we can look at is heart disease deaths for men ages 18-39.

The data I’m using is from the CDC WONDER database. This database aggregates data from US states, using a standardized system of reporting deaths. The most important thing to know is that in this database, each death can one have one underlying cause, and this is indicated on the death certificate. Deaths can also have multiple contributing causes (and most deaths do), and the database allows you to search for those too. But for this analysis, I’m only looking at the underlying cause.

Here’s the heart disease death data for men ages 18-39, presented two different ways. First the trailing 12-month average. Don’t focus too much on that dip at the end, since the most recent data is incomplete. Instead, notice three things. First, there was a clear increase in heart disease deaths. Second, that rise began in mid-2020, well before the introduction of vaccines. Third, once vaccines started being administered to this age group in Spring 2021, the number of deaths leveled off (though it didn’t return to pre-pandemic levels).

Here’s another way of looking at the data: 12-month time periods, rather than a trailing average. I created 12-month time periods starting in March and ending in February of the following year. I’ve also truncated the y-axis to show more detail, not to trick you. But don’t be tricked! The deaths are up 2-3%, not a more than doubling as the chart appears to show.

We can see in the chart above that the rise in heart disease deaths for young males completely preceded the vaccination period. Something changed, for sure, but the change wasn’t the introduction of vaccines. Heart disease deaths (by underlying cause) are only up 2-3%, while overall deaths are up around 40%.

So, to repeat the title question, what is killing these young men?

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Can You Use an Expired Home COVID Test?

Using a COVID test is a fairly serious matter – the results of such tests drive decisions on staying home and isolating or not, which in turn affect the spread of the virus in the population. I am known to use medicines that maybe expired six months earlier, figuring that the med will still be say 80% effective, but for a COVID test I want it to be as accurate as possible.

We all have on our shelves boxes of rapid COVID tests which were send out by the government in the first half of 2022. Most of these tests had nominal six-month lives, so according to what is stamped on the box, they are expiring right about now.

But wait – – that six-month life was just a (conservative) estimate from back when the tests were manufactured. For about a dozen out of the original 22 approved tests, subsequent data has shown that the tests remain accurate for longer than six months. Typically, the approved life is extended an additional six months or more. So before using or throwing out a box whose stamped expiration date has passed, go to this FDA link. You can quickly find your brand of test. The instructions for using this site are:

To see if the expiration date for your at-home OTC COVID-19 test has been extended, first find the row in the below table that matches the manufacturer and test name shown on the box label of your test.   

  • If the Expiration Date column says that the shelf-life is “extended,” there is a link to “updated expiration dates” where you can find a list of the original expiration dates and the new expiration dates.  Find the original expiration date on the box label of your test and then look for the new expiration date in the “updated expiration dates” table for your test.   
  • If the Expiration Date column does not say the shelf-life is extended, that means the expiration date on the box label of your test is still correct.  The table will say “See box label” instead of having a link to updated expiration dates.  

A couple more notes re COVID Tests:

( 1 ) The tests do detect the omicron BA.5 subvariant, which has driven much of the infections lately. However, if you have been exposed to COVID, the new recommendation is to take three (instead of just two) tests, at least 48 hours apart. (If you take the test too early, not enough antigen has built up to detect, so you might get a false negative).

( 2 ) Although the initial federal program for free tests has expired, there are several ways to still get free tests. Any health insurer will pay for them, as will Medicare. And there are other venues for uninsured or low-income people. See this article.

Should Virologists Regulate Themselves?

Last Friday a group of researchers mostly from Boston University posted a paper which revealed they had created a new chimeric coronavirus and used it to infect mice.

We generated chimeric recombinant SARS-CoV-2 encoding the S gene of Omicron in the backbone of an ancestral SARS-CoV-2 isolate and compared this virus with the naturally circulating Omicron variant. The Omicron S-bearing virus robustly escapes vaccine-induced humoral immunity, mainly due to mutations in the receptor-binding motif (RBM), yet unlike naturally occurring Omicron, efficiently replicates in cell lines and primary-like distal lung cells. In K18-hACE2 mice, while Omicron causes mild, non-fatal infection, the Omicron S-carrying virus inflicts severe disease with a mortality rate of 80%. 

Many people who heard about this expressed concern that the risk of creating more contagious and/or deadly versions of Covid that could escape from a lab outweigh any potential benefits of what we could learn from this research.

Several researchers have responded to these concerns with variants of “trust virologists to weigh the risks here, they know more than you.”

Don’t tell us virologists how to do our jobs; tell farmers, hunters, and veterinarians how to do theirs

Here’s the thing: the virologists do know the risks better than the public or potential regulators- but they also have different incentives. What I want to point out today is that virology isn’t special; this is true of just about every field. A nuclear engineer knows much more about what’s happening at their plant than voters do, or distant bureaucrats at the Nuclear Regulatory Commission. Should we leave it to the engineers on site to decide how much risk to take? Should federal regulators leave it to the financial experts at Bear Sterns and AIG to decide how much risk they can take?

To some extent I actually sympathize with these critiques; industry practitioners really do tend to have the best information, and voters often push regulatory agencies to be insanely risk-averse. With any profession this information problem is a reason to regulate less than you otherwise would, and/or pay to hire expert regulators.

But externalities are real- the practitioners who have the best information use it to promote their own interests, which tend to differ from the interests of the public. In finance this means moral hazard at best and fraud at worst (who are you to say Bernie Madoff is a fraud? You know more about finance than him?). In medicine it means doctors who get paid more for doing more; they gave the guy who invented lobotomies a Nobel Prize in Medicine. In research that involves creating new viruses, researchers get the private benefits of prestige publications for themselves, but the increased pandemic risk is shared with the whole world. In this case its not just outsiders who are concerned, some subject-matter experts are too (and not just “usual suspects” Alina Chan and Richard Ebright; see also Marc Lipsitch).

The main current check on research like this is supposed to be Institutional Review Boards. The chimeric Covid paper notes “All procedures were performed in a biosafety level 3 (BSL3) facility at the National Emerging Infectious Diseases Laboratories of the Boston University using biosafety protocols approved by the institutional biosafety committee (IBC)”. But there are many problems with this approach. The IRB is run by employees of the same institution as the researcher, the institution that also claims a disproportionate share of the benefits of the research.

IRBs are also incredibly opaque. The paper claims it was approved by Boston University’s institutional biosafety committee, but these committees don’t maintain public lists of approved projects; I e-mailed them Sunday to ask if they actually approved this project and they have yet to respond. There is also no public list of the members of these committees, although in BU’s case you can get a good idea of who they are by reading the meeting minutes. This chimeric Covid proposal appears to have been reviewed as the second proposal of their January 2022 meeting, reviewed by Robert Davey and Shannon Benjamin and approved by a 16-0 vote of the committee. During the January meeting the committee approved all 6 projects they considered unanimously, after hearing 6 reports of lab workers at BU being exposed to lab pathogens in the previous month, e.g.:

MD/PhD student reported experiencing low grade temperatures and other symptoms after he accidentally injured his thumb percutaneously on 12-6-21 while cleaning forceps that he had used to remove infected lungs from mice injected with NL63 virus

IRBs are supposed to protect research subjects from harm, but in practice largely serve to protect their institutions from lawsuits and PR disasters (part of why they’re often too strict). The fact that this did get institutional approval provides one silver lining here; if this chimeric Covid ever did escape and cause an outbreak, those infected by it could potentially sue for damages not only the individual researchers, but Boston University and its $3.4 billion endowment. Being able to internalize externalities in this way is one of many good reasons to be testing those infected with Covid to see what variant they have.

I think we should at least consider stronger national regulations against research like this, rather than leaving each decision to local institutional review boards (ask any researcher how much they trust IRBs). At the very least we should stop subsidizing it; NIH claims they don’t fund “gain of function” research like this, but the researchers who made a new version of Covid conclude their paper:

This work was supported by Boston University startup funds (to MS and FD), National Institutes of Health, NIAID grants R01 AI159945 (to SB and MS) and R37 AI087846 (to MUG), NIH SIG grants S10- OD026983 and SS10-OD030269 (to NAC)

6 Tips for Taming Your Inner Spock

The younger, high school and undergrad version of me was not the best person. My sense of humor was too dark and I didn’t much care about the experience of other people. When I went to grad school, I was so excited. I would finally be around other economists and I would be able to drop all of the niceties, empty social signals, and fuzziness that I thought non-economists employed. And I was oh so very wrong.

It turned out that economists are also human beings and that no amount of self-congratulatory Spock-praising would stop that from being the case. Indeed, with some candid feedback, I became convinced that I was in desperate need of the kind of prosocial norms that could help me to better produce social capital. In other words, I needed to figure out how to get along. Below is some advice that I’ve found pivotal. Maybe you can share it with another person who might be well-served by reading it too.

Below are six norms that are good to employ in order to improve social cohesion, agreeableness, and, frankly, better mental health. And these aren’t just for economists. I suspect that there are plenty of people (maybe young men) who can benefit from what took me too long to learn. So here we go!

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Doobies over Butts: More Americans Now Smoke Marijuana Than Cigarettes

Gallup has polled Americans for many decades about their smoking habits. About 40-45% of adults smoked cigarettes from about 1945-1975, but the percentage has dropped steadily since then. A 2022 poll showed a new low of 11% being smokers. Roughly three in 10 nonsmokers say they used to smoke.

On the other hand, marijuana usage has climbed steadily since Gallup first asked about it in 1969. Some 16% of Americans say they currently smoke marijuana, while a total of 48% say they have tried it at some point in their lifetime:

Younger adults (18-34) are much more likely to be current users, but the 55+ crowd tried it nearly as much (44%) as the younger cohorts:

Among all adults, opinion is about evenly split on whether marijuana has a positive or negative effect on society and on people who use it. However, opinion is skewed very positive among those who have actually tried it, and negative among those who have not:

(I can’t resist inserting a consistent anecdotal observation by reliable people I know or know of, that habitual smoking of MJ tends to be highly correlated with passivity / lack of initiative, especially among young men. When one young man I know of told his counselor, “Nothing happens [when I smoke weed]”, the response was, “That’s the problem, nothing happens [because with weed you just chill and don’t do the stuff you need to do].” Of course, correlation says nothing about the direction of causation here).

The big gorilla of substance usage is still alcohol. About 45% of Americans have had an alcoholic drink within the past week, while another 23% say they use it occasionally. Alcohol use has remained relatively constant over the years. The average percentage of Americans who have said they are drinkers since 1939 is 63%, which is close to Gallup’s most recent reading of 67%.

A Theory of Certificate of Need Laws and Health Care Spending

I just published a paper on CON laws and spending in Contemporary Economic Policy. As frequent readers of this blog will know, CON laws in 34 states require healthcare providers in 34 US states to get permission from a state board before opening or expanding, and one goal of the laws is to reduce health care spending. The contribution we aim for in this paper is to lay out a theoretical framework for how these laws affect spending.

There have been many empirical papers on this, typically finding that CON laws increase spending, but the only theory explaining why has been simple supply and demand. Health care markets are hard to model for a few reasons, but one big one is that most spending is done through insurers, so the price consumers pay is typically quite a bit lower than the price producers receive. This leads to “moral hazard”- i.e. overuse and overspending by consumers. Normally economists hate monopolies because they lead to underproduction, so in a market with overuse its fair to ask (as Hotelling did about nonrenewable resources)- could two market failures (moral hazard overuse and monopoly underuse) cancel each other out?

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On the Spreading of Monkeypox

New York City has become the second major U.S. city after San  Francisco to declare a state of emergency due to the rise of monkeypox cases: “New York City is currently the epicenter of the outbreak, and we estimate that approximately 150,000 New Yorkers may currently be at risk for monkeypox exposure.”

With the country and the world still feeling the economic/social/personal effects of one pandemic, is there another one on the way? I don’t know, having no special training in epidemiology, but have tried to peruse some reliable sources to find out what I could, and share this information for your examination. I will paste in a general page from a UC Davis article, then conclude with a CDC snip on transmission details.

It seems that monkeypox typically takes pretty close physical contact (especially with skin, body fluids, or e.g. towels/clothing)  to spread, with having multiple romantic partners being a high risk factor. This is the opposite of COVID transmission, where just being in the same room puts you at high risk. However, as with COVID, someone can be contagious in the early stages before they show obvious symptoms. Based on all this, my guess is that monkeypox will not spread in the general population very much, but it will spread significantly in some groups and locales. But that is just my guess.


From UC Davis “Monkeypox: What you need to know about this rare virus:

What are the signs and symptoms of monkeypox? At what point is it infectious?

Monkeypox starts with fever, then general body aches, malaise, and muscle aches. with the first symptoms are similar to influenza. Those usually precede the development of a rash. You have probably seen photos of the rash. It’s really hard to miss. It starts as macules, which are flat lesions. Then it forms a firm nodule. From there, it becomes a blister, then a pustule (a blister containing pus) and then it scabs over.

According to the Centers for Disease Control and Prevention (CDC), the incubation period (The time from infection to symptoms) for monkeypox is usually 7 to 14 days, but it can range from 5 to 21 days.

People may be contagious at the early signs of fever and stay infectious through the rash until the skin scabs and heals over.

How is it transmitted?

Monkeypox is transmitted through close person-to-person contact with lesions, body fluids and respiratory droplets, and through contaminated materials such as clothing or bedding.  [[ see more on transmission below]]

Can you die from monkeypox? 

Most people with monkeypox will recover on their own. But 5% of people with monkeypox die. It appears that the current strain causes less severe disease. The mortality rate is about 1% with the current strain….

What are the treatments for monkeypox? Is there a vaccine for monkeypox?

The smallpox vaccine has some cross protection against monkeypox. The vaccine is being made available through public health for people who have had contact with confirmed or suspected cases of monkeypox. If the vaccine is given within four days of exposure, it protects about 85% of the time. Even if the vaccine is given up to two weeks after exposure, it may modify the disease, making it less severe. 

In addition, there are some antivirals and immunoglobulins that are available to treat monkeypox.

Is there a way to test for monkeypox?

If a health care provider suspects that a patient has been exposed to monkeypox, they can get a sample of a lesion and send it to the state for testing. If it turns out positive, the result will be confirmed at the CDC.


From CDC “How It Spreads”:

Monkeypox spreads in a few ways.

  • Monkeypox can spread to anyone through close, personal, often skin-to-skin contact, including:
    • Direct contact with monkeypox rash, scabs, or body fluids from a person with monkeypox.
    • Touching objects, fabrics (clothing, bedding, or towels), and surfaces that have been used by someone with monkeypox.
    • Contact with respiratory secretions.
  • This direct contact can happen during intimate contact, including:
    • Oral, anal, and vaginal sex or touching the genitals  or anus of a person with monkeypox.
    • Hugging, massage, and kissing.
    • Prolonged face-to-face contact.
    • Touching fabrics and objects during sex that were used by a person with monkeypox and that have not been disinfected, such as bedding, towels, fetish gear, and sex toys.
  • A pregnant person can spread the virus to their fetus through the placenta.

A person with monkeypox can spread it to others from the time symptoms start until the rash has fully healed and a fresh layer of skin has formed. The illness typically lasts 2-4 weeks.

Trial Updates: Novavax Approved, Potatoes Work

I’m usually the one writing the papers, but I recently did two studies as a participant / guinea pig. Both just released major positive updates.

I joined the Novavax trial in late 2020 to have the chance to get a Covid vaccine sooner; at the time Pfizer had just got emergency approval but wasn’t available to the general public. The smart bio people on Twitter also seemed to think it was likely to be safer, and perhaps more effective, than other Covid vaccines (it delivers relevant proteins directly, rather than using mRNA or a viral vector). The trial results were published over a year ago now, and were in fact excellent:

Results from a Phase 3 clinical trial enrolling 29,960 adult volunteers in the United States and Mexico show that the investigational vaccine known as NVX-CoV2373 demonstrated 90.4% efficacy in preventing symptomatic COVID-19 disease. The candidate showed 100% protection against moderate and severe disease

As usual the FDA dragged its feet, even as other agencies around the world like the European Medical Agency and the World Health Organization approved the US-made Novavax. But last week it finally gave emergency authorization, and yesterday the CDC recommended Novavax. Of course, by now almost everyone who wants a Covid vaccine has one, and this approval is only for adults. But this will be a great option for boosters, as well as for anyone who was genuinely just concerned with the new technologies in the other vaccines (rather than just afraid of needles, or preferring to cut off their nose to spite authority’s face). As the CDC put it:

Protein subunit vaccines package harmless proteins of the COVID-19 virus alongside another ingredient called an adjuvant that helps the immune system respond to the virus in the future. Vaccines using protein subunits have been used for more than 30 years in the United States, beginning with the first licensed hepatitis B vaccine. Other protein subunit vaccines used in the United States today include those to protect against influenza and whooping cough….

Today, we have expanded the options available to adults in the U.S. by recommending another safe and effective COVID-19 vaccine. If you have been waiting for a COVID-19 vaccine built on a different technology than those previously available, now is the time to join the millions of Americans who have been vaccinated

I’m glad I was in this trial- I got a Covid vaccine several months before I otherwise could have, I made a few hundred dollars, and I learned a lot. But it would have been much better if they found a way to do fewer blood draws, and if FDA approval had come quicker. I’ve been in a weird gray area with respect to vaccine mandates for the last year; almost everyone ended up accepting my vaccine card, but I never knew if they were going to say “no, you need an FDA approved one”. I ended up getting Pfizer for a booster even though I think it’s a worse vaccine, partly for this reason, and partly because Novavax said they’d only give me the booster if I did another blood draw and I was tired of that.

The all-potato diet trial I wrote about here also released its results this week. This trial was much less formal, much smaller, and had no control group, so the results aren’t a slam-dunk the way Novavax is. But I think they’re still impressive. I lost 8 pounds in the 4-week trial, but it turns out the average participant who did all 4 weeks did even better:

Of the participants who made it four weeks, one lost 0 lbs…. Everyone else lost more than that. The mean amount lost was 10.6 lbs, and the median was 10.0 lbs.

Their summary also explains other costs and benefits of the diet, showing lots of data as well as many quotes from participants, including two from me. They conclude with some fascinating speculation about potential mechanisms from the boring (literally, lower variety makes eating boring so you eat less) to the speculative (low lithium? high potassium? weird lithium-potassium interactions), check it out if you’re interested in why obesity rates keep rising or if you’re considering doing the potato diet.

I’m glad I was in these two trials- what to try next?