Tag Archives: Obesity

CDC Makes a Bum Lead Steer: Alternate Reality vs. The Herd

16 Sunday May 2021

Posted by in Herd Immunity, Pandemic

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Jordan Schachtel enjoyed some schadenfreude last week when he tweeted:

“I am thoroughly enjoying the White House declaring COVID over and seeing the confused cultists having a nervous breakdown and demanding the continuation of COVID Mania.”

It’s quite an exaggeration to say the Biden Administration is “declaring COVID over”, however. They’re backpedaling, and while last week’s CDC announcement on masking is somewhat welcome, it reveals more idiotic thinking about almost everything COVID: the grotesquely excessive application of the precautionary principle (typical of the regulatory mindset) and the mentality of “zero COVID”. And just listen to Joe Biden’s tyrannical bluster following the CDC announcement:

“The rule is now simple: get vaccinated or wear a mask until you do.

The choice is yours.”

Is anyone really listening to this buffoon?Unfortunately, yes. But there’s no federal “rule”, unless your on federal property; it constitutes “guidance” everywhere else. I’m thankful our federalist system still receives a modicum of respect in the whole matter, and some states have chosen their own approaches (“Hooray for Florida”). Meanwhile, the state of the pandemic looks like this, courtesy of Andy Slavitt:

False Assertions

The CDC still operates under the misapprehension that kids need to wear masks, despite mountains of evidence showing children are at negligible risk and tend not to be spreaders. Here’s some evidence shared by Phil Kerpen on the risk to children:

The chart shows the fatality risk by age (deaths per 100,000), and then under the assumption of a 97% reduction in that risk due to vaccination, which is quite conservative. Given that kind of improvement, an unvaccinated 9 year-old child has about the same risk as a fully vaccinated 30 year-old!

The CDC still believes the unvaccinated must wear masks outdoors, but unless you’re packed in a tight crowd, catching the virus outdoors has about the same odds as a piano falling on your head. And the CDC insists that two shots of mRNA vaccine (Pfizer or Moderna) are necessary before going maskless, but only one shot of the Johnson and Johnson vaccine, even though J&J’s is less effective than a single mRNA jab!

Other details in the CDC announcement are worthy of ridicule, but for me the most aggravating are the agency’s implicit position that herd immunity can only be achieved through vaccination, and its “guidance” that the unvaccinated should be dealt with coercively, even if they have naturally-acquired immunity from an infection!

Tallying Immunity

Vaccination is only one of several routes to herd immunity, as I’ve noted in the past. For starters, consider that a significant share of the population has a degree of pre-existing immunity brought on by previous exposure to coronaviruses, including the common cold. That doesn’t mean they won’t catch the virus, but it does mean they’re unlikely to suffer severe symptoms or transmit a high viral load to anyone else. Others, while not strictly immune, are nevertheless unlikely to be sickened due to protections afforded by healthy vitamin D levels or because they are not obese. Children, of course, tend to be fairly impervious. Anyone who’s had a bout with the virus and survived is likely to have gained strong and long-lasting immunity, even if they were asymptomatic. And finally, there are those who’ve been vaccinated. All of these groups have little or no susceptibility to the virus for some time to come.

It’s not necessary to vaccinate everyone to achieve herd immunity, nor is it necessary to reach something like an 85% vax rate, as the fumbling Dr. Fauci has claimed. Today, almost 47% of the U.S. population has received at least one dose, or about 155 million adults. Here’s Kerpen’s vax update for May 14.

Another 33 million people have had positive diagnoses and survived, and estimates of seroprevalence would add perhaps another 30 million survivors. Some of those individuals have been vaccinated unnecessarily, however, and to avoid double counting, let’s say a total of 50 million people have survived the virus. Some 35 million children in the U.S. are under age 12. Therefore, even if we ignore pre-existing immunity, there are probably about 240 million effectively immune individuals without counting the remaining non-susceptibles. At the low end, based on a population of 330 million, U.S. immunity is now greater than 70%, and probably closer to 80%. That is more than sufficient for herd immunity, as traditionally understood.

The Herd Immunity Threshold

Here and in the following section I take a slightly deeper dive into herd immunity concepts.

Herd immunity was one of my favorite topics last year. I’m still drawn to it because it’s so misunderstood, even by public health officials with pretensions of expertise in the matter. My claim, about which I’m not alone, is that it’s unnecessary for a large majority of the population to be infected (or vaccinated) to limit the spread of a virus. That’s primarily because there is great variety in individuals’ degree of susceptibility, social connections, aerosol production, and viral load if exposed: call it heterogeneity or diversity if you like. Variation across individuals naturally limits a contagion relative to a homogeneous population.

Less than 1% of those who caught the virus died, while the others recovered and acquired immunity. The remaining subset of individuals most vulnerable to severe illness was thus reduced over time via acquired immunity or death. This is the natural dynamic that causes contagions to slow and ultimately peter out. In technical jargon, the virus reproduction rate “R” falls below a value of one. The point at which that happens is called the “herd immunity threshold” (HIT).

A population with lots of variation in susceptibility will have a lower HIT. Some have estimated a HIT in the U.S. as low as 15% -25%. Ultimately, total exposure will go much higher than the HIT, perhaps well more than doubling exposure, but the contagion recedes once the HIT is reached. So again, it’s unnecessary for anywhere near the full population to be immune to achieve herd immunity.

One wrinkle is that CIVID is now likely to have become endemic. Increased numbers of cases will re-emerge seasonally in still-susceptible individuals. That doesn’t contradict the discussion above regarding the HIT rate: subsequent waves will be quite mild by comparison with the past 14 months. But if the effectiveness of vaccines or acquired immunity wanes over time, or as healthy people age and become unhealthy, re-emergence becomes a greater risk.

Sub-Herd Immunity

A further qualification relates to so-called sub-herds. People are clustered by geographical, social, and cultural circles, so we should think of society not as a singular “herd”, but as a collection of sub-herds having limited cross-connectivity. The following charts are representations of different kinds of human networks, from Nathan D. Grawe’s review of “The Rules of Contagion, by Adam Kucharski:

Sub-herd members tend to have more degrees of separation from individuals in other sub-herds than within their own sub-herd. The most extreme example is the “broken network” (where contagions could not spread across sub-herds), but there are identifiable sub-herds in all of the examples shown above. Less average connectedness across sub-herds implies barriers to transmission and more isolated sub-herd contagions.

We’ve seen isolated spikes in cases in different geographies, and there have been spikes within geographies among sub-herds of individuals sharing commonalities such as race, religious affiliation, industry affiliation, school, or other cultural affiliation. Furthermore, transmission of COVID has been dominated by “super-spreader” events, which tend to occur within sub-herds. In fact, sub-herds are likely to be more homogeneous than the whole of society, and that means their HIT will be higher than we might naively calculate based on higher levels of aggregation.

We have seen local, state, or regional contagions peak and turn down when estimates of total incidence of infections reach the range of 15 – 25%. That appears to have been enough to reach the HIT in those geographically isolated cases. However, if those geographical contagions were also concentrated within social sub-herds, those sub-herds might have experienced much higher than 25% incidence by the time new infections peaked. Again, the HIT for sub-herds is likely to be greater than the aggregate population estimates implied, The upshot is that some sub-herds might have achieved herd immunity last year but others did not, which explains the spikes in new geographic areas and even the recurrence of spikes within geographic areas.

Conclusion

It’s unnecessary for 100% of the population to be vaccinated or to have pre-existing immunity. Likewise, herd immunity does not imply that no one catches the virus or that no one dies from the virus. There will be seasonal waves, though muted by the large immune share of the population. This is not something that government should try to stanch, as that would require the kind of coercion and scare tactics we’ve already seen overplayed during the pandemic. People face risks in almost everything they do, and they usually feel competent to evaluate those risks themselves. That is, until a large segment of the population allows themselves to be infantalized by public health authorities.

Perspective on U.S. Health Care Spending & Outcomes

05 Sunday Aug 2018

Posted by in Health Care, Health Insurance

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The U.S. spends a lot on health care, and our health care system is frequently criticized for poor health outcomes. The chart below is an example of evidence used to buttress this argument. It shows combinations of health care spending and life expectancy over time for the OECD countries. The U.S. appears to be a severe outlier and inferior to the other countries. A variation on this chart appeared on the home page of The Wall Street Journal this week. It accompanied (but was not part of) a good article by Joseph Walker in which he used 12 other charts in an effort to explain why the U.S. spends so much on health care. (Sorry, this link is probably gated.) Walker discusses several important cost factors, including third-party payments, tax treatment, and the deployment of expensive technology in the U.S. However, the claim that the U.S. is really an outlier is worth examining on other grounds.

The chart’s construction suggests that a reliable link should exist between health care spending and life expectancy, but there are several reasons to question whether that is the case. U.S. life expectancy has been held down historically by high rates of smoking, but reduced smoking rates should help moderate the U.S. life expectancy gap in coming years. Obesity in the U.S. is a more persistent problem, especially for the poor, and an even bigger contributor to low U.S. life expectancy than smoking at present. (See this report for evidence on the contributions of smoking and obesity to shorter life expectancy for older adults.) Other contributors to low life expectancy in the U.S. include high motor-vehicle deaths and homicides, the latter attributable in large part to the war on drugs. All of these factors contribute to higher health care spending and directly reduce life expectancy.

The status of the U.S. as an outlier in terms of health care spending is questioned on the Random Critical Analysis blog (RCA). The author’s detailed analysis includes the following points among many others of interest:

  • Health care is a superior good: as income rises, spending on health care rises faster;
  • The U.S. has a much higher standard of living than any of its peer nations;
  • U.S. consumption spending relative to GDP is an “outlier”, like health care spending relative to GDP;
  • Consumption is a stronger predictor of health care spending than income;
  • Relative to consumption, health care spending in the U.S. is not an outlier, nor is spending on pharmaceuticals, physician/nursing compensation, and the levels of health price indices.

Take a look at the following sequence from the RCA blog linked above (the animation might not be visible on a phone):

So the argument that the U.S. health care system is inferior to peer countries based on cross-county spending comparisons and life expectancy, to the extent that it holds up at all, is subject to strong qualifications. Inferior lifestyle choices, diets, and lack of exercise might be problematic in the U.S., but the healthcare system cannot be faulted based on spending levels relative to other OECD countries.

In fact, the superiority of the U.S. health care system in many areas is not even in dispute. As Mahdi Barakat points out, wait times for care, cancer survival rates, and stroke mortality are all clearly better in the U.S. than in many peer countries:

“Lives are indeed saved by the many types of superior medical outcomes that are often unique to the US. This is not to mention the innumerable lives saved each year around the world due to medical innovations that are made possible through vibrant US markets.”

Barakat compares dubious progressive claims that up to 45,000 American lives are lost each year due to a lack of insurance with the likely incremental lives lost if various performance measures in the U.S. were equivalent to those in other countries:

  • 25,000 additional female deaths per year with Canada’a wait times for care (no estimate for additional male deaths is given by Mahdi’s source);
  • 64,000 additional stroke deaths each year with the UK’s overall stroke mortality;
  • 72,000 additional cancer deaths each year with the UKs survival rates.

Theoretically, the national spending figures could be adjusted for the cost of queuing, i.e. wait times. While Obamacare certainly increased wait times in the U.S., the adjustment would likely reduce or eliminate the spending advantages that several OECD countries appear to have over the U.S.

The performance of health care systems in many countries with single-payer systems or universal care is subject to challenge, as some of the statistics offered by Barakat demonstrate. In “The Truth About SwedenCare“, Klaus Bernpaintner expresses his dismay at the romanticized view of health care in Sweden among so many Americans. His effort to convey the truth about Sweden’s stultifying health care bureaucracy is illuminating. There are few private physician practices in Sweden. Care is generally rationed and waits are lengthy, and it is delivered by disinterested, centrally-assigned providers.

“For non-emergency cases in Sweden, you must go to the public ‘Healthcare Central.’ This is always the starting point for anything from the common flu to brain tumors. You must go to your assigned Central, according to your healthcare district. Admission is by appointment only. Usually they have a 30-minute window every morning, when you call to claim one of the budgeted slots. Make sure to call early or they run out. Rarely will you get an appointment for the same day. You will be assigned a general practitioner, probably one you have never met before; likely one who does not speak fluent Swedish; and very likely one who hates his job. If you have a serious condition, you will be started on a path of referrals to experts. This process can take months.”

Bernpaintner calls this Sweden’s health care “bread line”, where people go to die. He mentions several other nightmarish features of health care in Sweden that Americans should hope to avoid. In particular, we should resist calls for a single-payer system, like Bernie Sanders’ Medicare-For-All proposal. An analysis by Charles Blahous of the Mercatus Center at George Mason University has shown that it would increase federal spending by $32.6 trillion over ten years. This estimate is basically in-line with others mentioned by Blahous. Much of the additional federal spending would represent a transition away from private spending, a process that would be massively disruptive. However, the study gives the plan the benefit of several doubts by accepting the assumptions made by Sanders: 1) a huge saving in prescription drug costs; 2) a huge saving in administrative costs; 3) providers will happily accept Medicare reimbursement levels; and 4) new immigrants will not be attracted by an essentially free health care program. Fat chance. But given all of these questionable assumptions, total health care spending would fall even as the government takes on the massive new outlays. Take away just fantasy #3 and total national health care spending would rise, a swing of $700 billion by 2031.

John Cochrane makes a useful distinction between two conceptions of universally-accessible coverage: one that all must use vs. one that all can use. (He calls them both forms of single-payer systems, though that usage sounds a bit awkward to me.) The voluntary form is preferable for several reasons: it can preserve choice in terms of coverage and providers; while the public-payer’s share must be funded, it demands little or nothing in the way of cross-subsidized pricing; and it does not imply that government must act as a single “price setter”. Cochrane warns of the possible consequences of a universally-mandated single payer:

“Not only is there some sort of single easy to access health care and insurance scheme for poor or unfortunate people, but you and I are forbidden to escape it, to have private doctors, private hospitals, or private insurance outside the scheme. Doctors are forbidden to have private cash paying customers. That truly is a nightmare, and it will mean the allocation of good medical care by connections and bribes.”

The presumption that universal health care will improve quality and save lives is unsupported by any real evidence. Its proponents incorrectly assume that the uninsured do not get care at all. Providers might go uncompensated, but the uninsured can often get needed care with more immediacy than they could with the lengthy wait times typical of many single-payer systems. The quality of care is likely to deteriorate under a single-payer system given the stresses placed on providers, the highly regulated conditions under which they would be forced to operate, and restricted treatment options. And of course a single-payer system would suspend the price mechanism and any semblance of competition in the health care marketplace.

The health care system in the U.S. has massive problems, but they were created and exacerbated by a series of governmental intrusions on the marketplace over many years. A flourishing market requires choice for consumers and competition between providers—in both health care delivery and insurance coverage. It also requires a roll-back of regulation on providers and insurers. But as Cochrane emphasizes, such a marketplace can exist apart from a voluntary, tax-funded payer-of-last-resort.