Universal Basic Vaccines?

The following is a bloggier, graphier version of a long-form piece I wrote for Merion West last month on the case for free vaccines. If you’re so inclined, give it a read there so the editors think I’m cool!


In July, the Trump administration announced it had committed to buying 100 million doses of an unfinished Covid-19 vaccine being developed by Pfizer and BioNTech. The vaccine entered late-stage human trials on July 27, with the hope that it will be approved before the year’s end. If and when it obtains Food and Drug Administration approval, the vaccine will be delivered at no cost to the consumer, regardless of insurance status.

That could be characterized as an interesting play for an administration that made it one of its first orders of business to weaken the Affordable Care Act—not to mention a political party that spent the Obama years railing against “socialized medicine!” And indeed, many were quick to point out that in this instance, the United States is acting very much in the image of a country with a national healthcare system, the implicit critique being that the Coronavirus pandemic exposes weaknesses of “market-based healthcare” that are present under normal conditions.1

There’s some merit to this, of course. But more importantly, I think we’ve actually hit on a rare opportunity for compromise in the national healthcare debate: free vaccines. Whether or not this ends up being the first step in the path to single-payer healthcare, I think it would be a good idea. (Note: not all reform proposals are technically for a “single-payer” healthcare system. I’m using the term as a catch-all because it has a more neutral connotation than anything else I can think of.)

Why not just do it all?

To explain why, I need to take a detour. As you may know, I’m not a proponent of a government takeover of the healthcare industry (though my resolve against it has really subsided lately). My case against full-on single-payer is pretty much utilitarian—costs versus benefits.

The “costs” part of the equation isn’t super interesting. To summarize, they are enormous. The 2016 Sanders campaign offered by far the rosiest projection, putting the cost at $13.8 trillion over ten years. Most other projections are near $30 trillion over the same period—so about $3 trillion a year, or 85% of 2019 federal revenue.

Meanwhile, the benefits—in terms of objective measures of physical health—are really uncertain! I think people take it for granted that healthcare makes people healthier, but that’s actually not super clear. A high-powered experiment on this—often referred to as the “Oregon Medicaid Experiment“—was conducted in 2008. The state used a lottery system to enroll low-income, uninsured adults in Medicaid. It also selected a control group from the same population that was not enrolled so their outcomes could be compared.

The study found that Medicaid enrollment “had no statistically significant effects on blood pressure, cholesterol, or cardiovascular risk.” It did, however, produce a marked drop in depression, about 30% relative to the control group. This is why some have derided Medicaid as a “7-trillion-dollar anti-depression program.”

Medicaid enrollment did increase healthcare utilization substantially. But is this good if it’s not paired with better health outcomes? There is a widespread belief among doctors that Americans are already over-consuming healthcare. A recent survey of over 2,000 physicians found two-thirds believed at least 15 to 30 percent of medical care was unnecessary. Likewise, doctors have observed that most patients seem to be doing “just fine” despite abstaining from visiting the doctor during the current pandemic.

So to summarize my view, single-payer healthcare will cost a lot and might not do too much for us health-wise—it might even have negative effects on healthcare delivery. Its good effects can be replicated in more direct, cheaper ways. (E.g., if people are suffering from depression because they’re stressed due to finances, just give them money.) And while the healthcare system is in obvious need of reform, I’d like to see us at least try a market-oriented approach (such as forcing hospitals to be transparent about pricing) before we do something we definitely won’t be able to undo.

There are other justifications for single-payer healthcare that are harder to refute, moral arguments and the like. But this is the lens through which I personally think about it.

Why are vaccines different?

Vaccines, however, are—forgive me—immune to some of these problems. For starters, vaccines are wildly effective when compared to other types of medicine. Vaccination allowed for the global eradication of smallpox and may soon lead to the elimination of polio. In the case of other diseases like rubella, measles, and diphtheria, the United States has achieved a near 100% reduction in cases (and deaths) following the development of vaccines.

We have much less success with chronic diseases, which also happen to be responsible for the largest chunk of healthcare spending. There are probably lots of reasons for this. One is that patients simply aren’t great about adhering to long-term pharmacotherapy regiments. Approximately 50% of patients do not take their medications as prescribed, to which the Center for Disease Control and Prevention (CDC) attributes 125,000 annual deaths and 30 to 50 percent of chronic disease treatment failures. Additionally, risky behaviors—sedentarism, poor nutrition, and smoking, for example—contribute to the exacerbation of these illnesses, making treatment a more complicated process that can involve a big commitment on the part of the patient. Obviously, none of this is a problem with vaccines.

Second, vaccines are pretty cheap, especially considering their efficacy. The 100 million doses of Coronavirus vaccine the federal government has ordered will cost $1.95 billion, an average of about $20 per dose.

As advocates for single-payer like to point out, governments are often able to secure more favorable prices for medications than private sector buyers. This is true with vaccines as well, and I assume it could be more so the case under a truly monopsonic regime. (A more rigorous consideration would have to weigh this benefit against the potential drag on innovation, which is worth thinking about. Perhaps the libertarian-socialist idea of issuing government prizes in lieu of patents could obviate this concern!)

Public versus private health consumption

Another good rationale for free-to-consumer vaccines concerns public health. There are efforts from single-payer advocates to construe all health as a public good. Sometimes this is quite a reach, but in the case of vaccines, it makes a lot of sense.

As more people are vaccinated against a disease, it reduces the disease’s ability to spread and reproduce itself. This has the second-order effect of providing some protection for people who can’t get vaccinated: very young infants, people with severe allergies, or those with compromised immune systems. To a much greater extent than other kinds of health care, then, vaccines have public health benefits in a way that doesn’t require contrivance by moral argument.


The United States already has a national vaccine program that’s been quite successful. In 1994, the CDC established the Vaccines For Children program (VFC), which pays to vaccinate children who meet certain criteria. Currently, the program provides vaccines for about half of all Americans under 18. We should just expand it to cover everyone.

For the cohort born between 1994 and 2013, the CDC has estimated routine childhood immunization will prevent 322 million illnesses and 21 million hospitalizations over the course of their lifetimes, and avert 732,000 premature deaths. In financial terms, the returns on the program have been equally impressive. Again, from the CDC: “Vaccination will potentially avert $402 billion in direct costs and $1.5 trillion in societal costs because of illnesses prevented in these birth cohorts. After accounting for $107 billion and $121 billion in direct and societal costs of routine childhood immunization, respectively, the net present values (net savings) of routine childhood immunization from the payers’ and societal perspectives were $295 billion and $1.38 trillion, respectively.”

With the Democrats officially leaving Medicare for All off their 2020 platform, the debate over systemic health care reform may rage on for some time. In the meantime, perhaps, given their impressive track record, free-to-consumer vaccines are something we can all get behind.

  1. Scare quotes because whatever you may call the current healthcare system, it’s hardly a project of market fundamentalism.

Smoking and the Hispanic Paradox

In the course of writing last month’s post about U-haul’s no-nicotine policy, I created the following graph:

This visualization didn’t make the final cut, but it’s nonetheless cool. It demonstrates that smoking rates among Hispanics are far less responsive to income than those of other ethnic groups (though even for Hispanics, the relationship between income and smoking rates is statistically significant). I was surprised to find this relationship, but apparently it’s a known factor of the phenomenon called “the Hispanic Paradox” (alternatively known as the “Latino Paradox”).

The paradox is that, on average, American Hispanics live longer than their non-Hispanic white counterparts, even though the former tend to have lower incomes and less education. The causes aren’t entirely understood, but Hispanics’ low smoking rates are thought to be a major contributor.

Source: Center for Disease Control, 2013

Some of the difference in smoking rates can be explained by immigration. Latin American countries tend to have lower smoking rates than the United States. Among those born in the United States, only Mexican-Ameicans seem to retain lower smoking rates and the attendant mortality advantage over non-Hispanic whites. It will be interesting to see if the Paradox ebbs as native-born Hispanics begin to account for more of the Hispanic population.

The Hispanic Paradox illustrates the capricious power of cultural influence on real-world outcomes — and conversely forces us to confront our limited ability to re-engineer the world.

We tend to think of (the physical, policy, social, or economic) environment and choice as the chief determinants of human behavior and outcomes. But we are just as much a product of the commingling of genetics and culture. The paths before us are well-worn by our predecessors, and we would be arrogant to think we can wholly resist their inclinations.

Cigarette Daydreams

Last week, U-Haul announced that beginning February 1 of this year it would no longer hire nicotine users in the 21 states that permit employers to take that information into account when hiring. To be clear, this covers use outside of the workplace, and it could affect former smokers who use nicotine patches or similar delivery systems.

If you didn’t hear about this, you have my envy and my respect, as it probably indicates that you’re employed and/or don’t spend hours on Twitter, where the topic was briefly trending.

From what I can tell, the reaction has mostly been cynicism about U-Haul wanting to cut healthcare expenses. I think that’s probably true; smokers can indeed be charged higher premiums than non-smokers under the Affordable Care Act, and presumably U-Haul will cover at least some of this.

But since I spent a small chunk of last year’s blog posts talking about selection effects and signalling (most notably here, here, and here), I feel obliged to point out that selecting against smokers is also an effective way to screen for other undesirable qualities in employees. As smoking rates have plunged, smoking has become an increasingly good proxy for a bunch of socioeconomic factors.

(Pardon the use of 2013 data in the following charts; I happened to have this version of the BRFSS on my laptop, and went with it for convenience. I don’t think there’s a good reason the general idea should have changed much in the interceding years.)

For example, smokers, and to a lesser extent, former smokers, miss more days due to their physical or mental health than non-smokers:

Smokers miss more days
The examples given in the BRFSS codebook of “usual activities” are work, self-care, or recreation.

They’re also more likely to have less education and to have lower incomes:

Educational attainment by smoking status

Income bracket by smoking status

Notably, U-Haul is pitching this as a step in “fostering a culture of wellness”:

“We are deeply invested in the well-being of our Team Members,” said U-Haul Chief of Staff Jessica Lopez in a press release. “Nicotine products are addictive and pose a variety of serious health risks. This policy is a responsible step in fostering a culture of wellness at U-Haul, with the goal of helping our Team Members on their health journey.”

So here we have a company policy that is ostensibly for the benefit of employees’ health, but the actual consequences of which will be to save money for the employer and disproportionately preclude the candidacies of many low-SES applicants. Mind you, this is for a job at U-Haul during a period of supposedly record-low unemployment.

I think what bugs me most about this is a feeling (which could be wrong but is at least widespread) that there are diminishing opportunities—especially for low-SES Americans—to participate in the productive side of the economy, which by all indication is something that gives people a sense of meaning and self-respect.

I also can’t shake the feeling that a more powerful or organized constituency would be able to generate some public sympathy in a similar situation. If U-Haul made it policy to deny employment to obese people, presumably to similar effect, there would have been a cascade of outraged NYT opinion pieces and an ACLU lawsuit.

Still more hilarious is the contrast with growing corporate, public, and governmental acceptance (or even endorsement) of marijuana use. A new, publicly announced prohibition on employee use of marijuana would come across as horribly retrograde and likely receive more negative attention.

Smokers, alas, are nearly universally reviled, out of the graces of the upper classes and on the wrong side of demographics.

Sex!

Now that I have your attention

A week or two ago, the Atlantic published a great article by Kate Julian about the declining rates of sexual activity in young Americans. This was a bit of serendipity, as I’d recently been digging through the General Social Survey (GSS) searching for evidence of the same trend.

Looking at 18- to 35-year-old respondents—segmented by race and sex and without adjusting for other factors—I found that, loosely speaking, almost all demographic groups seemed to be experiencing a slight increase in celibacy.

No Sex
Note: In 2012, respondents from almost all groups reported nearly zero instances of sexlessness in the last year. I chalked it up to an outlier year and left it off to (hopefully) lend more accuracy to the trend lines.

This is rather surprising, given societal and technological developments over the last 30 years. To paraphrase Ms Julian’s opener: Sexual mores have greatly relaxed. Birth control and other forms of contraception are ubiquitous and affordable. Dating apps make it easier than ever to link supply and demand.

The stage seems set for a hedonistic revolution, but that’s not what we’re seeing.

Some factors implicated by her reporting include the over-scheduling of young adults, helicopter parenting, bad sex that leaves them (particularly young women) hesitant to come back for more, and increased inhibition among Millennials of both sexes.

But what interests me most is how the decline in sexual activity is partly due to a rise in anti-social behavior brought on by technology—a retreat from the interpersonal “meatworld” to bespoke pornography, sexting, and often fruitless screen-swiping. A feedback loop forms: The rarefication of in-person courtship has rendered it overly forward, which leaves less opportunity for young people to develop the social skills necessary to meet partners without the aid of an app.

I’ve never considered myself a Luddite; as recently as a few months ago, I was praising the internet for making “it easier than ever for people to exchange ideas.” But I have to admit I’m finding myself increasingly disillusioned by technology of the social media variety. Insofar as its mission is to bring people together, it seems to be failing.

Perhaps I’m growing cynical and dismal in my old age. Or—more likely “and”—perhaps there’s no suitable substitute for IRL socialization, and our quest for online community-building is inherently quixotic.

*

P.S. I looked into sexual activity frequencies for respondents ages 18 through 22 since the GSS started including the question in 1989, looking for changes in the college-age population. It’s not much, but it’s a bit interesting, so I’m including it here.

18-22 sex

Insurance Coverage Numbers Are Important, But Not All-Important

Whether you’re into this sort of thing or not, you’ve probably been hearing a lot about healthcare policy these days. Public debate has roiled as Republican lawmakers attempt to make good on their seven-year promise to repeal and replace the Affordable Care Act (ACA). As the debate rages on, one metric in particular appears to hold outsize importance for the American people: the number of Americans covered by health insurance.

Analysis by the Congressional Budget Office, which showed that 14 million more Americans could lose coverage by 2018 under the Republican replacement, caused intense public outcry and was frequently cited as a rationale for not abandoning the ACA. There is immense political pressure not to take actions that will lead to a large loss of coverage.

But here’s the thing: the relevant metric by which to judge Obamacare isn’t insurance coverage numbers. To do so is to move the goal posts and place undue importance on a number that might not be as significant as we imagine.

The ultimate point of health insurance, and the implied rationale for manipulating insurance markets to cover sicker people, is that people will use insurance as a means by which to improve their health, not just carry a plastic card in their wallets.

Health Insurance ≠ Health

The impulse to use insurance coverage as a proxy for health is misguided but understandable. For one thing, it’s a simple, single number that has dropped precipitously since the implementation of the ACA; that makes it a great marketing piece for supporters. For another, health insurance is the mechanism by which most of us pay for most of our healthcare.

And yet in 2015 the uninsured rate fell to 10.5% (down from 16.4% in 2005) while age-adjusted mortality increased for the first time in a decade.

It turns out a nominal increase in the amount of insured Americans doesn’t necessarily translate into improved health outcomes for those individuals. A newly released paper from the National Bureau of Economic Research (NBER) finds that while the ACA has improved access to healthcare, “no statistically significant effects on risky behaviors or self-assessed health” can be detected among the population (beyond a slight uptick in self-reported health in patients over 65).

These results are consistent with other studies, like the Oregon Medicaid Experiment, which found no improvement in patients’ blood pressure, cholesterol, or cardiovascular risk after enrolling them in medicaid, even though they were far more likely to see a doctor. There were, however, some notable-but-mild psychic benefits, such as a reduction in depression and stress in enrollees.

In short, despite gains in coverage, we haven’t much improved the physical health of the average American, which is ostensibly the objective of the ACA.

Why Not?

To be fair, the ACA is relatively young; most of its provisions didn’t go into effect until 2014. It may well be that more time needs to pass before we start to see a positive effect on people’s health. But there are a few reasons to think those health benefits may never materialize–at least, not to a great extent.

A lot of what plagues modern Americans (especially the poorest Americans) has more to do with behavior and environment than access to a doctor. Health insurance can be a lifesaver if you need help paying for antiretroviral medication, but it won’t stop you from living in a neighborhood with a high rate of violent crime. It won’t make you exercise, or change your diet, or stop you from smoking. It won’t force you to take your medicine or stop you from abusing opioids, and it certainly won’t change how you commute to work (that’s a reference to the rapid increase in traffic deaths in 2015).

Here’s something to consider: A lot of the variables that correlate to health–like income and education–also correlate to the likelihood of having health insurance. If we want healthier Americans, there may be more efficient ways to achieve that than expanding insurance coverage, like improving employment and educational opportunities. Maybe something creative, like Oklahoma City’s quest to become more walker-friendly, could yield better results?

Of course, all things being equal, more insurance coverage is better. But nothing comes without cost, and as a society we want to be sure that benefits justify costs. So far, that’s not clear. This poses an existential question about our current pursuit of universal coverage, and, by extension, the relevance of coverage as a metric for the success of healthcare policy: If insurance isn’t the cure, why are we prescribing it with such zeal?

The Hidden Cost of Public Health

Starting on January first of next year, the City of Philadelphia plans to impose a “soda tax” of 1.5 cents per ounce. The new law—already set to be challenged in court—has proved highly controversial, even within the political left where its revenue-raising potential is pitted against concerns over its regressive nature. The political right seems fairly uniformly unenthused.

But that’s boring. What’s really interesting is that Philadelphia’s government is avoiding calling the tax a public health measure, instead choosing to focus on the additional revenue it might generate, despite soda taxes’ endemic appeal to the public health profession.

Public health officials often laud soda taxes as a means of reducing demand for sugary drinks that are linked to obesity, diabetes, tooth decay and other maladies. The underlying economics are relatively straightforward—raise the price of soda and people will consume less of it. The hope is that doing so will reduce the incidence of the aforementioned conditions and curb associated healthcare spending.

But despite the wide approval of public health professionals, it’s far from clear that a soda tax is an appropriate solution in this scenario. Not only is there reason to doubt it’s efficacy, but in a sense, such a policy blurs the line between public and what we might call ‘private’ health in a way that marks a pernicious slide away from self-determination and seems to me unethical.

Using a tax to “correct” demand is one of the classic methods of solving collective action problems, which tend to involve public goods or open-access resources and often require regulatory oversight. President Bush’s cap and trade initiative in the 1980s, meant to reduce emissions of sulfur dioxide, is a successful example of such an endeavor.

The idea is that if a resource is shared (in this scenario, air quality), then it makes sense to have a centralized agency impose regulations to account for the “social cost” associated with its degradation. If something can be proven to affect others (without requiring an onerous amount of nuance), there’s a compelling case for using coercive public policy to address it.

That’s certainly the case when air quality is concerned. But there are key differences between air pollution and obesity; even though they both affect people’s health, one is far more likely to be incurred privately. We all breathe the same air; but your neighbor drinking a Double Gulp everyday doesn’t affect your waistline. Someone else being fat doesn’t harm you. Right?

Actually, depending on how an individual’s healthcare is paid for, that last part is up for debate.

Soda drinkers tend to be poorer, (the same is true for users of tobacco, which is subject to similar tax-based deterrence) and therefore more likely to have their healthcare publically subsidized. In a not-so-tangential sense, that means it’s very much in the interest of the taxpayer that those people be deterred from such actions. After all, any tax dollars not spent on healthcare can be spent on something else or not collected.

In my view this poses an ethical challenge—does public financing of healthcare erode beneficiaries’ sovereignty over their health-related decisions? And, if it does, what sort of precedents are we setting should America switch to a universal healthcare system, which would effectively render all health public?

It does seem to be the case that as more resources are poured into social safety nets, there is increased incentive for societies to attempt to engineer the results they want through coercive means. The resulting policies range from ethically dubious taxation to outright illiberalism.

Take, for example, the rather harsh methods by which the Danish government discourages immigration and asylum seekers: seizing assets worth more than $1,450; using policy to force assimilation (in one city mandating that pork be included on municipal menus); cutting benefits to refugees by up to 45%.

A similar situation is unfolding in Sweden, where the extensive social safety net has turned immigration into a tug-of-war between classical and contemporary liberal sentiments. The Economist writes:

The biggest battle is within the Nordic mind. Is it more progressive to open the door to refugees and risk overextending the welfare state, or to close the door and leave them to languish in danger zones?

Closer to home, Canada has recently received some scrutiny for its habit of turning away immigrants with sick children so as to not overburden its single-payer healthcare system.

Some of this might sound cruel or discriminatory. Some of it is. But these are rational responses from systems forced to ration scarce resources. In a sense, it’s the ethical response, given that governments are beholden to their taxpayers.

It’s a natural goal for public health experts, economists, and others whose jobs are to optimize society to try to promote a healthier nation. Our national health and wealth would clearly be improved if obesity, diabetes, etc. were eradicated. And yes, that could conceivably be achieved by any number of forceful policies—what about a Trump-style deportation of the obese?!

But we must consider the costs as well as the benefits of such policies. Are the potential gains worth ceding dominion of our personal decisions to rooms of “experts?” Is it possible for the conversion of health from a private to public good to coincide with our liberal values?

I don’t think so, at least not in the extreme. If health becoming a public resource means that the government must take an increasingly paternalistic and protectionist role in our society, it’s not worth whatever we might gain—or lose around the midsection. After all, if people can’t be trusted to decide what food to eat, what can we be trusted with? If a soda tax is okay, what about a tax on red meat, sedentarism, or motorcycles? Surely we’d be healthier if we did less of each.

I do believe there is an appropriate role for government to play in promoting the private health of the masses, but it’s significantly more parochial than the sort of collective action scheme fetishized by academics. To loosely paraphrase the Great Ron Swanson: people deserve the right to make their own peaceful choices, even if those choices aren’t optimal.

Side note: I would also argue that there’s some pretty heavy cognitive dissonance at play here as far as soda taxes go. The federal government hands out generous subsidies—collected from taxpayers—to corn producers that make junk food and soda cheaper to consumers. If more expensive soda is the remedy, why not remove those subsidies rather than tax consumers twice?