My 2009 health care policy recommendations

8. Invest more in pandemic preparation.  By now it should be obvious how critical this is.  It’s fine to say “Obama is already working on this issue” but the fiscal constraint apparently binds and at the margin this should get more attention than jerry rigging all the subsidies and mandates and the like.

Here is the full post, much broader and mainly about best alternatives to Obamacare.  Also in 2009 I wrote this (pointer via Dave Pote):

I say think probabilistically…A one percent chance of one hundred million deaths is, in expected value terms, one million deaths and that is a big deal.  Probably the United States is less vulnerable than it was in 1918, but how many people would die in China, India and many other locales?  How much disruption to trade, travel, and the world economy would take place?  Even in the United States, our public health systems would break down quickly and render many modern medical advances useless (e.g., when would the Tamiflu run out?).  Having lots of living space is wonderful, but it pays off only if people stay home from work and that means dealing with massive absenteeism.  Not pretty.  Better safe than sorry.

Oddly Stephens never mentions that we are living in a raging epidemic now, namely AIDS, which has run for several decades.  For all the virtues of retrovirals, the modern world was quite slow in combating or even checking the disease and still many people, including U.S. citizens, engage in very risky behavior.  Our collective response was not terribly impressive.  Greater wealth does help, but greater wealth also means we should spend more to limit the problem…

The main thing we should do — invest in public health infrastructure — is in any case a good idea with many possible payoffs, whether a pandemic comes or not.  It is a better investment of money than pursuing the ideal of universal health insurance coverage.  I might add that one of the better arguments for universal coverage is simply that it could lead to better monitoring of some public health issues.

See also my text with Alex.  And here is me on pandemics and local public health infrastructure, November 2018.  And here are my earlier writings on avian flu.


TC for President.

I’m not joking.

Any adrenaline junkies here? Checkout this NYC inpatient care story on reddit:

"The hospital is receiving 3-4 extra non-COVID patients from another hospital that is already maxed out. Already."

"...he asked her age (88), flat out said she’d never get off the ventilator and then darkly implied that we’re close to a point where “decisions” would have to be made."

"But, in the back of my head, I was also thinking I saved the nurses from having to witness a pointless and traumatic CPR and I saved one likely-inevitable ICU bed and a ventilator."

'Even in the United States, our public health systems would break down quickly': I thought the use of "even" rather droll.

"Probably the United States is less vulnerable than it was in 1918, but how many people would die in China, India and many other locales?" - haha, TC got it wrong! ;-)

Speaking of 1918, it's odd that Tyler wrote this the other day on March 26:

"It should be noted, of course, that the Spanish flu did not give rise to a comparable economic stagnation."

There was a serious economic depression in 1920-1921 right after the Spanish flu pandemic of 1918-1920 [1]. A massive agricultural price collapse, a pandemic that killed 600k people, and the wartime subsidies and contracts were expired [2]. Add in labor unrest and tight monetary policy under the gold standard and you have the recipe for a shock to the US economy.


I think TC extrapolated to the Roaring Twenties, but otherwise good point. Stock markets still overvalued. Those kicking themselves for missing the March crash can still redeem themselves now. DJ-30 to 10k.

Angus Maddison U.S. GDP per capita data in 1990 dollars. It was a bumpy ride back then, not like the smooth sailing we are all used to...

1913 | 5301 | 1.92%
1914 | 4799 | -9.46%
1915 | 4864 | 1.35%
1916 | 5459 | 12.2%
1917 | 5248 | -3.86%
1918 | 5659 | 7.83%
1919 | 5680 | 0.37%

1920 | 5552 | -2.25% 11000
1921 | 5323 | -4.12%
1922 | 5540 | 4.07%
1923 | 6164 | 11.26%
1924 | 6233 | 1.11%
1925 | 6282 | 0.78%

If you took away 1923, the first half of the roaring 20s barely tread water.

(The "11000" is GDP per capita in 2018 dollars in 1920.)

No bad, the USA was pretty well off in the 1920s. I've lived in about $4-5k per capita countries today (Philippines) and it's not that bad, so $11k is like modern Mexico I think. Pretty good. You won't have 10 pairs of shoes to wear but you'll be fine.

Mexico's GDP per capita is $20,000. Anyone who plays chess as well
as you (and Tyler) can certainly learn PPP if you put your mind to it.

Committing to a large national stockpile of PPE after the "first wave" of coronavirus subsides would help the current crisis. Right now a company risks sinking a bunch of capital costs and losing big if the crisis evaporates in the meantime. Plus it is credible preparation for possible seasonality.

Nice to see familiar names from 11(!?) years ago. dearieme and Yancey Ward are still active these days. mulp leaves not one but two walls of text comments. I guess some things never change.

2009? I In that year people opposed to the US stimulus removed $870 million from pandemic preparation.

Maybe this becomes a question for someone older than me, but I think the American two-party system was once less adversarial than it has become in recent decades.

Sometimes an explicitly adversarial system works, as the least bad alternative. It underpins our theory of law and justice after all.

But I think reason (and pragmatism) really break down if we allow ourselves to fall into the mental model the Democrats are for spending, and Republicans must always adversarily be against it. (You can modify that a bit and say Democrats are for some spending, like welfare, and Republicans are for other spending, like warfare.)

Anyway, I think that's kind of what happened on pandemic preparation. Democrats were for it, because it was pro-social spending. Republicans were against it for the same reason.

Republicans "won" that one, but give them an inch and they'll blame the Democrats for not fixing things anyway.

I speak as a ruleful independent who is not either.

Since there seems to be an effort to rewrite history into a false narrative here, I'll point out that in 2009 the Democratic party was fully in control of the US government, even having a supermajority at times. They used that power for the goals they deemed important, enacting significant changes to the US healthcare system (changes which, ironically, Democrats of 2020 consider a failure). If they didn't enact some amount of unspecified pandemic spending, that's because they didn't care about it, and to say that "Democrats were for it" is simply wrong.

Put another way, if Democrats are entirely without power or moral agency even when completely in control of the levers of government, what's the point in ever voting for Democrats?

The classic way to "rewrite history" is to make claims in a comment section, sans links.

On the other hand ..

To drive this point home a little bit more, it might have been possible at one point for a Republican to say:

"I will oppose all spending, and the spending we really need will happen anyway."

But in fact that was only true until you got a bit too much political power.

Remember, anonymous is a pure partisan troll here to throw shit against the wall. He also doesn’t read anything but the headline of whatever his idiotic google search results give him.

his own links almost always say the exact opposite of his own argument

From his own f’ing link:

both Collins and Schumer "said publicly at the time that it should not be done in an emergency vehicle to save the nation's economy from collapse."

[instead they] voted for a bipartisan bill in support of pandemic preparation funding. According to the Center for Infectious Disease Research and Policy at the University of Minnesota, that bill was "$7.65 billion for battling pandemic influenza, more than three times what the House and Senate had earlier proposed."

Read your own links maybe? Moron

You just want to read into that something that isn't there.

The Democrats wanted a bill, and they accepted Collins' change to get the bill.

This is exactly the scenario I'm talking about. Republicans fight all spending, and when they remove that spending, they claim "it's your fault, you should have done it anyway."

Zero self-reflection or accountablity.

Also it was George W Bush that gave us the strategic mask stockpile in the first place as part of his pandemic plan.

“In 2005, the George W. Bush administration published the "National Strategy for Pandemic Influenza," which outlined a strategy for the federal government to assist state and local efforts in the event of a pandemic. A key part of the strategy was for the federal government to distribute medical supplies, such as N95 masks, from the Strategic National Stockpile.”

“The national stockpile used to be somewhat more robust. In 2006, Congress provided supplemental funds to add 104 million N95 masks and 52 million surgical masks in an effort to prepare for a flu pandemic. But after the H1N1 influenza outbreak in 2009, which triggered a nationwide shortage of masks and caused a 2- to 3-year backlog orders for the N95 variety, the stockpile distributed about three-quarters of its inventory and didn't build back the supply.”

This is as per usual a complete bipartisan failure. The one bright light being ironically the Bush administration.

The Strategic National Stockpile was actually Bill Clinton's idea. Got it from reading a novel about bioterrorism "The Cobra Effect". He signed a bill in 1998 that created the stockpile for civilian use.

H1N1 under Obama had ~3500 deaths with ~116000 confirmed cases (going with confirmed numbers not CDC estimates)

COVID-19 under Trump so far has ~1700 deaths with 104000 confirmed cases.

The race is on.

The practice of quoting numbers without growth rates or first derivatives needs to stop. Just a few days ago, someone made a very similar remark, only that time deaths stood at 1,000. All of these, "oh, yeah, how about..." remarks become obsolete in a matter of days because all the evidence points to the U.S. doing an unusually poor job of containment. The U.S.'s future is almost certainly that of Spain and Italy unless something miraculous happens over next couple of days.

Asking for me anything but time - a former emperor of France who was noted for winning battles in the face of daunting odds. And losing them too.

For weeks, some people have done their pitiful best to say it was time to prepare America for a pandemic. And a few hundred thousand decided it was time for spring break. The virus won that round too.

The connection between events like an international women's day march in Madrid or Mardi Gras in New Orleans is directly causal for the quick spread of covid19 in each city as measured by confirmed cases and deaths.

Florida is closing the barn door now - police are controlling the border to keep out anyone from areas where covid19 is currently spreading rapidly. Which has been the basic story of this virus in everywhere in the West. Carnival/fasnach/Mardi Gras is not a single event, but it is the background of the spread in northern Italy. Germany, and also in Switzerland and the Alsace, both of which have fairly strong regional carnival traditions.

Trump's numbers will very likely surpass Obama's and we're only in the 2nd inning. NYC is out of beds in certain neighborhoods and out of supplies. Atlanta and New Orleans are up and coming hotspots and supplies are running low. LA and Orange counties are hitting frequent doubles. 100,000 active cases nationally, with 2,500 in serious condition. Expect a good fraction there to die. California 'only' has less than 5,000 cases while NJ has 8,800. Expect CA to surpass NJ. Louisiana already has more deaths than CA and NJ, Mardi Gras the likely culprit. I'm also expecting more under-60 deaths because the healthiest age groups these days have all kinds of chronic conditions like obesity, diabetes, high blood pressure, heart conditions, asthma, smoking/vaping, etc.

Hard to see how Fla escapes w/ seniors and travel to/from NYC/Boston during months of Feb/March... school break spring training MLB So much absurd talk about baseball re starting in FLA/AZ as if they're going to out run this

"The U.S.'s future is almost certainly that of Spain and Italy unless something miraculous happens over next couple of days."

Given the exponential curve of US confirmed cases, the relatively flattening curves in other countries with significant number of cases, and the lag between confirmed cases and deaths, we already know what happens. The US case rate soon approximates the total cases in the rest of the world, and US deaths surpass those of Italy and Spain combined in a couple of weeks, and continues to rise and next states face their trials.

There are no miracles here. There was a time for thoughtful, prudent actions in previous years, and thoughtful, aggressive action in previous weeks and months. But those ships have sailed.

The fate of the world was decided by two incompetent fascists: Xi Jinping and Donald Trump.

outside of the 2-3 places that have seemed to contain CV through test and trace, it's hard to imagine any place in the world stopping the original outbreak, had it happened somewhere else. China seems to have done a decent job, all thing considered. They at least appear to have their situation under control. China had no heads up. They had to figure out what was happening in real time, with little context or understanding. Every other country has had a heads up about this, and they are almost all doing worse than China. If this had originated in the US...

There are plenty of reasons to criticize Xi and DT, even [especially] on CV. But some things are bigger than the incompetencies of those involved, and their actions are mere vectors pointing in the same direction as general mayhem.

Spain just picked up another 832 dead. The numbers keep climbing.

But the rate of increase of deaths keeps dropping:

Coronavirus deaths in Spain:

Mar 19.... 861
Mar 20.... 1,093.... 27%
Mar 21.... 1,381.... 26%....27%
Mar 22.... 1,772.... 28%....
Mar 23.... 2,331.... 32%....30%
Mar 24.... 2,991.... 28%....
Mar 25.... 3,647.... 23%....26%
Mar 26.... 4,365.... 20%....
Mar 27.... 5,138.... 18%....19%

The percentage increase in coronavirus cases has continued to decline and is now at 15% a day.

The percentage increase in coronavirus cases has continued to decline and is now at 15% a day.

Isn't that astonishing? As the absolute numbers of cases increase, further increases constitute a smaller percentage of the whole. How remarkable! What's really remarkable is the amount of numerical gymnastics apparently being indulged in by sequestered individuals with internet access. The numbers being pasted all over the MR comments really don't mean much of anything at all. They don't actually indicate who will become infected, when, or how seriously. Those posting these meaningless numbers should find other, more productive things to do.

You really shouldn't have stopped taking math in the 4th grade.

March 21 increase in cases- 232 27%

March 27 increase in cases- 773 18%

Absolute numbers unimportant, it's percentages that count.

>Spain just picked up another 832 dead. The numbers keep climbing.

Well, there's a mulp-quality comment.

Did you think that number would start dropping? Zombies, coming back to life, maybe?

And this certainly also among the 2010 health care policy recommendations, and the 2011 health care policy recommendations, and the 2012 ... to 2019.

Just as it was among the 2008 health care policy recommendations, and the 1995 health care policy recommendations, and the 1980 ... back to at least 1918. But the US is not a nation interested in long term planning and preparation for low-frequency, high-impact events (unless that planning and preparation helps drive the economy, like preparing for fighting in foreign wars).

Gary Becker and Posner posted much the same in 2005. They argued that investment to prevent pandemics was needed because serious pandemics occur about every 50 years. They argued about the horrible costs of such rare events. But private firms couldn't find a way to profitably provide such research. And politicians don't have such long time horizons because voters don't care about the issue.

"Preserve current HSAs ... They also keep open some path of getting to the Singapore system in the future."

" It is a better investment of money than pursuing the ideal of universal health insurance coverage."

These lines contradict each other because Singapore has universal healthcare.

I remember those days. Conservatives and libertarians were praising the Singapore system but with no understanding of the fact that the state is the main provider of both health insurance and hospital care there.

Yes, and even the private components of Singapore's system are much more heavily regulated (e.g. price controls) than here. I'd be happy switching to such a system but a libertarian or conservative alternative to what we have now it is not.

"I will oppose universal healthcare, and everyone will get healthcare anyway."

("Because you know, it will be required by the laws I oppose.")

Why weren't the hospitals warehousing this equipment? They knew what the risks were and still sat on their hands. Instead of blaming the government, hospital administrators and board of directors should have to explain why their facilities were not sufficiently prepared. Is there a hospital regulatory aspect to this that was not enforced or missed?

Which hospitals under which charters? Considering just of the nonprofits and public interest corporations .. they had a trade-off in terms of costs and preparedness.

Basically all of us hated "rising healthcare costs" a year ago. Now we want idle and available ICUs ..

I was talking about equipment and consumables. So you are saying we are to blame for them not investing in this equipment? They have no responsibility towards being prepared for a crisis?

There’s a lot of construction around hospitals these days. They are flush with cash.

Saying “I told you so” is never a good look.

Na, Tyler has earned it, especially in the face of such criminal negligence on the part of the federal government and many state governments.

Contra his troll post a few days ago about the end of modern progressivism, Cowen was simply repeating elite consensus when warning about the threat of pandemics and was correct. It turns out there are worse things than simply giving a fair hearing to expert opinion.

Bill Gates gave a TED talk a few years ago on pandemics so hat tip to him too.

Tyler trying to win back some points after that idiotic Harvard take.

The prescience here is impressive.

Bill Gates' 2015 TED talk is similar

Interesting that the UK Civil Service also identified the threat, but didn't recommend stockpiles of PPE and Respirators, and underestimated the economic disruption, assuming herd-immunity/let-it-rip similar to 1957 pandemic.

What other tail-risk events should we be worried about? Power-supply viruses/glitches?

Boloids. Been saying this since 1988. MR agrees.

Don't worry, the killer asteroid comes in late April.

Terrorists discover the brown note.

A solar storm creating prolonged outages of electrical grids, for weeks or maybe even a couple of years. A "Carrington event" most likely recurs with roughly the same frequency as killer epidemics.

My recommendation on Obamacare was to incentivized home triage. If ot then mass congestion in hospital rooms resulted.

I used abstract tree to find the congestion points, treating hospitals as a value chain. Worked fine and most pros who studied this agreed with me.

The recommendations were sensible, but it was odd to pose them as alternatives to ACA. ACA is primarily a re-distributional measure not an investment in increasing QALY in a model with strong externalities on behavior.

In making their case for X within the bureaucracy [in real life I suppose that such investments get make because some entity is arguing for a larger budget to do X] I wonder if they include in their cost - benefit analysis the costs of alternative prevention measures. A better public health response to the pandemic wold have saved not only lives but incomes lost to lock downs.

Serious question: Suppose you were prepared to concede that in a polity such as the United States, it's impossible to adequately invest in pandemic preparation—structural political considerations simply won't allow it no matter how many well-meaning fingers we wag.

What then would be the second-best policy recommendation that a clever, somewhat Machiavellian policy entrepreneur could make? Can we disguise "pandemic preparation" as something else?

My initial idea would be to advocate increasing defense appropriations for "cutting-edge military logistics capabilities." This would be an easier sell politically, and could serve as pandemic preparation in disguise.

At some point we are just going to have to become a better polity.

Let's hope we do that before the socialists take over. Because face it, in a solutions vacuum they will. They have a plan.

TC - amazingly accurate foresight in 2009.

Calling for unspecified pandemic preparation during a pandemic may be good policy, but it's hardly prescient.

"It’s fine to say 'Obama is already working on this issue.'”

Or rather, it would have been fine if true.

Official COVID-19 cases in the US aren't much more than twice that of Australia's per capita, but per capita the official death rate in the US is 9 times higher than in Australia. This is very bad news.

Australians have health coverage for all their citizens. Americans don't see the doctor until it's too late.

Obviously no correlation, when you compare the death rates in western Europe.

Covid-19 arrived in Australia during its hot summer months.

I'm not sure if and when per capita statistics are relevant for something like this.

If you seed the same number of infections in two different places with different size populations, and assume they grow at a similar rate. The smaller population will inherently have higher per capita rates. If the population is the same size, per capita would tell you something about extent of outbreak, but otherwise, I'm not sure what you can glean from the statistic.

After rereading crikey's comment, comparing those per capita statistics does offer some info, and indeed, bad news.

In Australia today the mortality rate is about 3% above average. In the US it's around 37% above average. Definitely not looking good.

What would “investing in pandemic preparation have meant though?” In 2019 John’s Hopkins ranked the US as #1 in such categories, based largely on infrastructure, equipment, having lots of doctors and medical researchers, etc.

In 2020 though it turns out that if leadership does nothing until it’s too late and people aren’t willing to change their lifestyles, and the healthcare system is more apt to punish prevention than reward it, then all the equipment and medical degrees no really make a difference.

I asked about specifics the last time this came up, and the trolls all jumped on me.

A more complete picture is here:

This 2016 post's opening sentence is "I hope we always will have non-vindictive Presidents in this country. "

And welcome to 2020 - “When they’re not appreciative to me, they’re not appreciative to the Army Corps, they’re not appreciative to FEMA, it’s not right,” Trump said.

He then added: “I say, ‘Mike, don’t call the governor of Washington; you’re wasting your time with him. Don’t call the woman in Michigan. It doesn’t make any difference what happens.’ You know what I say: ‘If they don’t treat you right, I don’t call.’ He’s a different type of person; he’ll call quietly anyway.”

We were that close to having President Pence being in charge of America's pandemic response. Instead, we missed it by 20 Republican senators deciding Trump was the right man for the job.

Heckuva job, Republican senators.

My 2009 proposal
Elimination of all US health sector discrimination in price, access or quality, between insured and uninsured
As is all get the short end of the stick of non-transparent deals between insurance companies and health sectors

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