Category: Medicine

The *Love Letter* has a P.S.

As people start reacting to Covid-19, they are looking mostly to the larger businesses for assistance. Costco and Walmart are packed. Amazon and UPS are delivering our packages. For entertainment at home, Americans are relying on Netflix and the cable companies. For information on Covid-19, Twitter is a very useful stop. As hospitals become overcrowded, CVS and Rite Aid may become important as local health centers and sources of community information.

It turns out that the larger, more profitable businesses are the ones that have the talent, the command of public attention and the financial resources to adjust to these changing conditions.

Big business also has been ahead of the curve when it comes to prediction and adjustment. The NBA postponed its season before most politicians, including the president, realized the gravity of the situation.

Only a month ago, there were headlines mocking Silicon Valley for being overly concerned with Covid-19 and for avoiding handshakes. The tech community had a high degree of advance awareness of Covid-19 problems, and it was ready with telework and other adjustments when the time came. The tech world’s penchant for carrying what seemed to be absurdly large surpluses of cash — last year Apple had over $100 billion in cash reserves — now also seems prescient. Apple’s stores are currently closed in most parts of the world.

And this:

Larger businesses are also easier to assist if necessary. Whatever you think of the forthcoming bailout of the major U.S. airlines, logistically it will not be very difficult to pull off, since the targets are large and obvious and relatively easy to monitor. Banks are willing to lend to them, because they know the government does not contemplate a world without major airlines.

It is much more difficult to bail out the millions of small and medium-sized enterprises around the world that will demand assistance. How do you find and track them? How can you tell which have no chance of bouncing back? Government bureaucracies cannot easily deal with those problems, and in turn private banks do not perceive governments to be making credible commitments to these small businesses. By contrast, there are numerous precedents for governmental aid or loans to airlines or other major businesses.

That is all from my latest Bloomberg column, much more at the link.  One problem Italy has, of course, is a fairly high reliance on small business.

Bill Dupor of the St. Louis Fed on fiscal remedies

The entire piece is interesting, here are two highlights:

Subsidize COBRA Continuation Coverage Employer -provided health insurance is commonplacein the United States. Laid off (or furloughed) workers, even if they receive higher UI replacement rates, would (or at least could) lose their health insurance. The federal government already has the COBRA program to allow for continuation of coverage for workers losing their jobs. This program, however, requires worker-paid premiums. These premiums increase the relative cost of engaging in nonmarket activities. To reduce that cost, the federal government might temporarily cover 70 percent of the COBRA premiums for the unemployed or furloughed. Calculating an appropriate size of such a program, even in a rough sense, is difficult at this stage. For a baseline, suppose the allocation were $25 billion, which was the value of a similar program implemented under the 2009 Recovery Act.

And here is another way to get cash into people’s hands quickly:

Penalty-Free Withdrawals from Individual Retirement Accounts

Many Americans hold tax-deferred individual retirement accounts. Individuals can withdraw funds on retirement (and a few other special situations) or any time they wish if they pay a 10 percent penalty. This 10 percent penalty is in addition to the taxes that are due on the withdrawal. In the event of a severe viral outbreak, the federal government could temporarily remove this 10 percent penalty up to a certain dollar amount and for a preset length of time. Since the initial contribution to the retirement fund was tax deferred, taxes would need to be paid on the withdrawal even if the additional penalty was waived.

Recommended.

The best economic plan against the coronavirus

I have produced a 7 pp. document, mostly micro- rather than macroeconomics, leaving the pure health and health care issues aside, you will find it here (link is now corrected).  Intended for policymakers.  Here is the opening bit:

“We need a series of policies to achieve some rather complex ends, and in conjunction. Other than the obvious goals (“minimize human suffering”), these ends are:

  1. Scale down economic activity in a rapid way to keep people at home, but without devastating the physical, cultural, or organizational capital that will be needed to restore growth and normality.

  2. Boost the confidence of markets — both retail and financial markets — by showing progress in limiting the spread of the disease. (But note that merely slowing the spread of the disease may not help the economy, as uncertainty would linger for longer periods of time.)

  3. Keep business in a position to rebound.

  4. Create incentives for production to bounce back once that is appropriate.

You will notice a tension between #1 and #2-4, which is what makes this policy issue so difficult. The ideal policy mix should both lower and raise output, and at just the right speed. No one ever taught us how to do that.

Furthermore, policymakers need to figure out which sectors a) we wish to keep up and running (food, health care), b) which sectors we want to contract rapidly but bounce back rapidly as well (education), and c) which sectors we do not want to protect at all and would be willing to see perish (e.g., cruise ships, note that most operate under foreign flags and employ mainly non-Americans). 

Those classes of sector may require very different economic policies, most of all we should not waste aid on the latter class of sectors. Be nervous of general proposals for “the economy.”

Again, here is the link, please do leave your suggestions in the comments section of this blog post.  I thank Patrick Collison for some writing and editing assistance with this document, though of course he is not liable for its final contents or conclusions.

Mercatus call for short papers

Today, the Mercatus Center put out a call for policy briefs related to the COVID-19 pandemic. We hope to gather short, actionable analyses for decision makers in the public, civil society, and private sectors regarding both immediate response (what’s working or could be done immediately), as well as in the medium term (what do we need to be thinking about now so that we’re prepared in six to twelve months).

More information can be found here.

Papers will be published quickly (within 24 hours in most cases), and authors will receive a $1,000 honorarium.

The list of possible topics is advisory and by no means comprehensive; our goal is to assemble the smartest actionable analyses as quickly as possible.

Hedgehogs in particular: what do you know here that the foxes should hear?

Note that research need not directly relate to public policy, but also how the business sector and civil society can and should respond.

A report from the hospital front, from a reliable source

I visited *** Health Center in ***.  They are not a hospital, more like an urgent care clinic funded by the city and state. They act as triage for three area hospitals, take vital signs, can write prescriptions and send serious cases to Hospital ERs.  They have been overwhelmed with people worried about COVID-19…They had been testing people for the virus; they have run out of re-agent so they have stopped that….If they were provided with isolation beds and ventilators, could they take 20 patients?  No, it is not in their license and an application to change their license takes two years. When NYC reaches maximum hospital capacity, this clinic will not be part of the solution.

I visited [underfunded public health consortium] in ***, which was at the forefront of the response to H1N1 in 2009 and Sandy in 2012.  They typically see 150 ER patients a day; during H1N1 they averaged 350 at the peak; they think they will be over 1000 during COVID-19….There is no such thing as a “test kit” which tests for the virus; when people talk about those kits, such as those dropped onto that cruise ship, they are talking about a nasal swab packaged with some reagent, which is then mailed to a facility with a Polymerase Chain Reaction Machine that can look for the RNA from the virus.

You can find PCR machines on eBay for $25,000; such a machine is labor intensive and can do maybe 10 tests a day.  The hospital complex I visited, which has been designated a testing center, has been swabbing about 200 people a day and receiving multiples of that number from other hospitals. The vast majority they are sending off to a federal lab.  Two weeks ago the turnaround time was three days; now it is five to six.

There are much faster machines.  The Roche Cobas 6800 can do 3000 tests a day with very little human interaction; it costs $500k a year to rent, which is way outside a poor hospitals’s budget (while still not providing sufficient testing for the receiving area in the coming months.) Outside their budget until today, when we gave that money (I specified first year only, though they should be sure to ask in a year) as part of a larger check.  We also gave money for 10 transport ventilators with two ports, 20 isolation beds, the money to hire 14 nurses for round the clock coverage of those beds for 6 weeks, and other things that they need.  Overall it was a $1 million check, with a promise to talk to them in a week to cover anything we might have missed and to talk to them whenever they ask during the crisis.  Overall, I was pretty happy with the visit.  They were stunned, they work in a bureaucracy where everything takes 3 years.

One thing that they can’t get enough of is N-95s [face masks]. The first thing that almost every doctor I talked to mentioned was the frustration at having to re-use N-95’s, not for multiple patients, but for multiple days.

Again, here are the Emergent Ventures prizes to encourage work to support work to fight the coronavirus, and please support them if you can.

Robert Browning and Ingmar Bergman in a Bloomberg column

With all those fools going to bars and concerts, or running marathons, it is evident we still need to solve the problem of entertainment, as I argue in my new Bloomberg column.

It is instructive to look back to the days of World War II. The U.S. government played a critical role in encouraging Hollywood to make cheery movies, and it helped by not trying to force every actor into the armed services. Major league baseball, the national pastime of the era, continued to hold a regular season and a World Series, again to distract people from wartime worries. Many top players, such as Ted Williams, were away fighting, but there were adequate replacements. The government knew that wartime drama could not be the only drama on tap.

With Covid-19, the goal is to keep people at home, at least if they are not essential workers. But if staying at home is too boring, cabin fever will take over and people will run out to social gatherings when they ought to be staying put. So solving the entertainment problem is one very real piece of the puzzle for minimizing the effects of the coronavirus and keeping Americans not just in good spirits but healthy.

The very worst scenario is that the coronavirus itself — how it is playing out, how officials and celebrities and neighbors are reacting — becomes our main entertainment. It could become an ongoing horror show that drives us crazy and makes people even more cynical about politics.

To avoid such a mix of frustration and terror, I have a modest proposal: We should restructure a few of our traditional entertainments to be safe from the coronavirus.

As suggested on Twitter, how about inducing a few of the cable providers to offer free streaming for a few months?  The Met has announced a big increase in opera streaming.  And:

Or how about proceeding with some version of the NBA Finals? Take a subset of the best qualifying teams, test every player for coronavirus, isolate them in a remote area with a college gymnasium, and have them proceed with a shortened version of the real thing in front of only a TV crew. With so many other public events closed down, television viewership would probably reach an all-time high, and the sense of drama would be incredible. It would be one NBA Finals we would never forget, and the quality of play would respond to the very high psychological stakes.

Ben Golliver serves up a concrete NBA proposal.  You’ll have to click through to get to the Browning and Bergman parts, the latter being Easter egg.  At least the Candidate’s Tournament still seems to be on in chess, you can all watch that for the next few weeks, starts Tuesday I believe, try www.chessbomb.com.

Lecturing alone won’t work: we really do need to make it more fun for people to stay at home!

Pay people to quarantine

Once a pool of money has been allocated to a city or region, the people who are paid to quarantine would be determined by auction. There are many options around how to design pricing mechanisms to incentivize consecutive days of quarantine and other types of health improving behaviors. Based on the committed payments for a city, the price of remaining quarantined would be set on a daily basis.

Consider what the cost might be to pay to place 10% of a city’s population into quarantine. I believe that it costs significantly less than minimum wage for those people. The population that would be quarantining would be the young, elderly, the sick, and those for whom working at home is possible. Quarantining a sizable portion of a population dramatically slows the progression of a virus. Even at 30% of the population, I expect the price would remain well below minimum wage. This would have a dramatic impact on the pace of spreading.

That is from Nate Baker, enforcement would be by cyber-surveillance.

How can you best volunteer?

David Brooks writes:

If you know someone who lives alone ask them to join NextDoor, which is Facebook for neighborhoods. It helps them stay in touch with those right around them. Vital in a crisis.

I am not familiar with that project, but I would trust David’s judgment in such matters.  How else can people volunteer usefully, especially if they do not wish to leave their homes?  Keep in mind that useful volunteering is also a good way to keep people occupied and at home!

Please do leave your suggestions in the comments.  if nothing else, even “placebo volunteering” could be highly worthwhile.  I will put up some of the best ideas in a later post.

What US Government should do regarding Covid-19

This is (by far) the best document I have seen on what to do on the medical side.  It is about 3 pp. long and I believe it will be updated periodically.  Excerpt:

  • Consider guaranteeing top tier treatment and ICU beds for people directly working on treatments or vaccines. We need to keep relevant science labs open. (They’re likely to be closed as things stand.)
    • No doubt logistically challenging but may be necessary. Can you get scientists to keep going without this?
  • Announce $10B prizes for first vaccine and for first cure.
    • Think about mechanics. Should there be awards for second place, too? How should collaboration be factored in?
  • Issue $1B of research grants to all competent labs and organizations that could plausibly use them. They just have to report on progress every 30 days and require that they actively share all progress with other labs.
    • Proposed structure: $100M to each of 5 companies.
    • $10M to each of 40 labs.
      • Remainder based on discretion.
    • Take what’s required for treatment cases and make an “open source” version whose bill of materials costs less than $1,000. Commit to purchasing at least 100k. Even if US turns out not to need them, donate to other countries.

The author is anonymous, but I know that he/she has followed the issue very closely from the beginning, and his/her predictions have been largely on the mark.  If you are in USG I am happy to put you in touch, just write me.

Again, here is the document, highly recommended.

*The Seventh Seal*, directed by Ingmar Bergman

We watched this movie the night before, and it struck me as very different this time around, perhaps because it is set during the time of the Crusades with the plague as a major theme. I no longer think the death character is real, and I now view the film as about how much we flirt with the idea of death, and apparitions of death, in order to make life tolerable and to feel in control. Don’t take the opening scene “as is,” but rather contrast it with all the other ways humans use the death theme for their own theatrical purposes (theatrical, both literally and figuratively) over the next 30-40 minutes of the movie, and then later throughout. Perhaps the key line is “All the damn ranting about death. Is that sustenance for modern people?”

Recommended, especially the new Blu-Ray edition of Bergman’s complete works.

Should we ration coronavirus testing by price?

This is making the rounds on Twitter:

Just went to Seattle’s UW Medical Center to ask how much patients are being charged for a coronavirus test. $100-$500 if they have insurance. $1,600 if they don’t.

Put your emotions aside and ask the logical question: since the number of tests falls short of current demand, how should we ration those tests?  I would think we most wish to test potential super-spreaders, so they can self-quarantine or otherwise be isolated or avoided.  A priori, I would expect potential super-spreaders to be those who work in service jobs connected to many other people.  Individuals who suspect they already have the disease are also more likely to be super-spreaders, if only because there is a decent chance they actually do carry the disease.

Now at a price say of $500, you will rule out some of the poor, some of the “frivolous testers” (there are people who will try anything that is new), but you don’t rule out many of the middle class people — or wealthier people — who think they might have the coronavirus.

You end up targeting potential superspreaders by “those who think they have it,” but not by “those who work in service jobs where they come in contact with a lot of people.”

An imperfect solution, but not an entirely bad one either.  It is probably better than random allocation.  And still all of the available tests get used.

How about a government price of zero, combined with rationing?  Of course it depends what the principle of rationing would be.  From other countries, “I came into contact with a traced person” seems to be one standard, noting that the United States has nothing close to Singapore’s surveillance mechanism in this regard.  So you would get a very loose version of that standard, with many flu-laden nervous nellies taking the test, claiming they came in contact with a sick person.

That could perform either better or worse than the market solution.  In Singapore it is probably better than the market solution, but I am not sure for the United States.  My intuition would opt for the market prices, but I admit that is not verified by either model or data.

A separate issue, hard to judge from current information, is whether there is any positive supply elasticity at the higher price.  Of course if there is, that will make the higher price look better, but perhaps other regulatory and pipeline restrictions on testing will mean the higher price won’t matter.

And note that as the supply of tests becomes much greater, as is happening right now, the case for those high market prices becomes much, much weaker.  Zero price and no rationing is where we would like to end up, and I think we will.

I find that this problem, and how you tackle it, is a good test for whether or not you think like an economist consistently.

The Danes wish to know more about the coronavirus

From Martin Permin, for formatting reasons I have imposed no further indentation:

“Thanks for the excellent coverage on MR.

I lead a small team of tech workers in Copenhagen, who are donating our time and money towards building a covid-19 self-reporting tool for those citizens not (yet) in contact with health care services.

As countries shift from containment to “flatten the curve” strategies, authorities lose track of the number of non-critical cases, and to which degree people adhere to social distancing dictums. This makes it hard to predict the number if ICU beds needed a few days into the future. We’re aiming to solve this by asking all Danes for daily status updates.

Denmark is a good testing ground, but we’ll open source everything, and are building with developing countries in mind. We’re aiming to launch Monday — currently working on a green light from local health authorities.

We’re determining which data to collect. We’d love it if you’d help by asking your audience: “What daily self reported measures would you most like to see from the complete population Denmark?” (or some variation thereof).

There is of course a tradeoff between data fidelity and engagement.

What we’re considering:

  • Symptoms
    • Binary
    • Type
    • Severity
  • Whereabouts
    • Degree of social distancing
    • Hygienic measures
  • Moral
    • How concerned are you
    • Do you know anyone who’s been sick”

Are there comparable efforts to do this elsewhere?

Which are the safest restaurants to eat in?

This is my subjective impression, not based on scientific sampling.  Nonetheless, I think you should prefer cooked, hot food from a cuisine whose associated country already has had a traumatic experience with coronavirus.  They will take the risk more seriously.  You should avoid uncooked salads from lackadaisical countries that have been slow to respond.

In other words, I believe Chinese food is safest.  Furthermore, entry restrictions have been on Chinese people for some time, so the chance that your cook or waiter picked up the coronavirus from China and is still carrying it is very small, whereas Italians have been free to come and go with no real questioning at the airport.

Chinese restaurants also tend to be in the suburbs, and they pack in the tables less closely.