# Fear not to “overreact”

Mar 29 JDN 2458938

It could be given as a story problem in an algebra class, if you didn’t mind terrifying your students:

A virus spreads exponentially, so that the population infected doubles every two days. Currently 10,000 people are infected. How long will it be until 300,000 are infected? Until 10,000,000 are infected? Until 600,000,000 are infected?

300,000/10,000 is about 32 = 2^5, so it will take 5 doublings, or 10 days.

10,000,000/10,000 is about 1024=2^10, so it will take 10 doublings, or 20 days.

600,000,000/10,000 is about 64*1024=2^6*2^10, so it will take 16 doublings, or 32 days.

This is the approximate rate at which COVID-19 spreads if uncontrolled.

Fortunately it is not completely uncontrolled; there were about 10,000 confirmed infections on January 30, and there are now about 300,000 as of March 22. This is about 50 days, so the daily growth rate has averaged about 7%. On the other hand, this is probably a substantial underestimate, because testing remains very poor, particularly here in the US.

Yet the truth is, we don’t know how bad COVID-19 is going to get. Some estimates suggest it may be nearly as bad as the 1918 flu pandemic; others say it may not be much worse than H1N1. Perhaps all this social distancing and quarantine is an overreaction? Perhaps the damage from closing all the schools and restaurants will actually be worse than the damage from the virus itself?

This is because the costs here are highly asymmetric. Overreaction has a moderate, fairly predictable cost. Underreaction could be utterly catastrophic. If we overreact, we waste a quarter or two of productivity, and then everything returns to normal. If we underreact, millions of people die.

This is what it means to err on the side of caution: If we are not 90% sure that we are overreacting, then we should be doing more. We should be fed up with the quarantine procedures and nearly certain that they are not all necessary. That means we are doing the right thing.

Indeed, the really terrifying thing is that we may already have underreacted. These graphs of what will happen under various scenarios really don’t look good:

But there may still be a chance to react adequately. The advice for most of us seems almost too simple: Stay home. Wash your hands.

# How beneficial is healthcare?

Mar 22 JDN 2458931

Healthcare has been a contentious issue in the US for generations, but became especially so during the Obama administration with the passage of the Affordable Care Act. To be honest, I never quite understood the opposition to transitioning to a single-payer healthcare system; we already spend as much public funds on healthcare as most other First World countries spend in their entire healthcare system (plus we spend even more than that on private spending!), so not only can we afford it—it would in fact save us trillions of dollars a year. We might not even have to raise taxes, but even if we did, we’d pay so much less out of pocket that most of us would end up with more money. I understand why the corporations that run HMOs don’t want single-payer; but why does anyone else oppose it?

It’s not as if there are no models to follow; we could literally just copy the Canadian system (or the British system, or the French system…). It’s always amusing to me when conservatives respond to the suggestion by: “But that’s socialism! Do you want to end up like Cuba?” First of all, I said copy Canada, not copy Cuba. But even if we did copy Cuba, healthcare is one of the few things that Cuba actually does extremely well. On a QALY-per-dollar basis, it’s probably the most cost-effective healthcare system in the world (and the US is probably the least). So yeah, you know what? I kinda do want to end up like Cuba.

And no, countries with single-payer healthcare systems do not have longer wait times. Even by standard measures, our wait types are in the middle of the pack. But in fact these standard measures are clearly biased in our favor. The main way that we reduce wait times is by excluding people from care entirely. That’s not a wait time of zero; it’s a wait time of the rest of your life. If we measured properly, we would clearly have the longest wait times in the First World, because of all those people who never get care at all.

But today I’m going to ask a different question:

How much harm is done by our awful healthcare system?

Or conversely:

How much benefit would we get from insuring everyone?

The largest randomized controlled experiment on health insurance in the United States was the RAND Health Insurance Experiment, and its results were quite surprising: The marginal benefit of better health insurance for most people was very small, in many cases statistically negligible. People who were very poor or very sick benefited from having health insurance, but everyone else used more medical care without getting much apparent benefit. Since this was a large randomized controlled experiment, it should probably be considered our most credible evidence.

On the other hand, the RAND study was done before I was born, so maybe it’s time for a new study?

More recent studies have used regression discontinuity analysis, looking to see if going on Medicare seems to change the trendline in your mortality rate. It doesn’t.Of course mortality rates go up as you get older, and people become eligible for Medicare by getting older… but still, if Medicare is helping, you’d think there would be some kind of kink in the trend, and as far as we can tell, there isn’t. Perhaps people are simply transitioning from one form of adequate health insurance (e.g. employer-provided insurance) to another.

There is some evidence that healthcare saves lives, if we restrict attention specifically to what is called mortality amenable to healthcare, deaths caused by diseases that we know can be effectively treated by medical intervention. (It’s really a continuum, with malaria at one end, and airstrikes at the other. Both kill thousands of people every year, but malaria can be treated with a few doses of quinine, while there’s nothing anyone can do for you if you were in the blast center of a Hellfire missile. In between we have diseases like cancer, which medicine can sometimes save you from but not always.) By this measure, the United States clearly lags behind other First World countries, and the reason is clearly that we deny a lot of people healthcare.

However, I think mortality is really the wrong measure to use, for the following reason: We already have a universal healthcare system when it’s literally a question of life or death, and that’s the ER system. The Emergency Medical Treatment and Labor Act, signed by Ronald Reagan (yes, Republicans also used to like saving poor people from diseases, not so long ago!), guarantees that anyone who needs emergency care can get it immediately, regardless of their ability to pay. They can still bill you later, which may be a big reason why medical costs are the leading cause of bankruptcy in the United States (and literally nowhere else in the world). But at least you won’t die.

A lot of it actually comes down to how we measure health. Self-reported measures are notoriously unreliable in various ways, yet ultimately I don’t see how we can tell whether someone is sleeping well, feeling energetic, or being in pain without asking them. Correlating self-reported measures with objective measures like records of doctor visits shows pretty good correspondence, albeit by no means perfect.

As healthcare spending has increased and medical technology has advanced, there has been a worldwide trend of reduced disability and mortality, and the US is no exception. Clearly healthcare is doing something.

Yet it remains a fair question whether most people need more healthcare—maybe we’re actually getting enough. Maybe most people’s health insurance is already adequate, and we don’t need to improve it in any substantial way.

On balance, I think the best evidence we have says that people who have no insurance at all, or really awful insurance, would strongly benefit from improved access to healthcare. There’s also evidence that people with severe chronic conditions benefit from having steady healthcare. But for most people most of the time, the benefits of more health insurance would be quite small.

Does this mean we should get rid of health insurance? Of course not. But it does mean that future reforms should be focused on getting it to people who have none, not improving it for people who already have it. We don’t need to lower co-pays or deductibles; we may not even need to raise or remove coverage caps. But we do need to get some kind of health insurance to people who don’t have any at all.
To this end, Obamacare has done fairly well: You can just look at a graph of the number of uninsured people in the US and see that not only did Obamacare reduce that number, the steady attempts to undermine Obamacare are starting to bring it back up.

Then again, a single-payer system would clearly do even better, maybe even get that number to zero… so explain to me again why we’re not doing this?

# Monopsony is all around us

Mar 15 JDN 2458924

Perhaps because of the board game (the popularity of which honestly baffles me; it’s really not a very good game!), the concept of monopoly is familiar to most people: A market with one seller and many buyers can command high prices and high profits for the seller.

But the opposite situation, a market with many sellers and one buyer, is equally problematic, yet far less well-known. This is called monopsony. Whereas in a monopoly prices are too high, in a monopsony prices are too low.

I have long suspected, but the data now confirms, that the most widespread form of monopsony occurs in labor markets. This is a particularly bad place for monopsony, because it means that instead of consumer prices being lower, wages will be lower. Monopsonistic labor markets are bad in two ways: They lower wages and they increase unemployment.

Monopsonistic labor markets are one of the reasons why raising minimum wage seems to have very little effect on employment.
In the presence of monopsony, forcing employers to increase wages won’t cause them to fire workers; it will just eat into their profits. In some cases it can actually cause them to hire more workers.

Take a look at this map, from the Roosevelt Institute:

This map is color-coded by commuting zone, based on whether the average labor market (different labor markets weighted by their number of employees) is monopsonistic. Commuting zones with only a few major employers are colored red, while those with many employers are colored green. In between are shaded orange and yellow. (Not a very colorblind-friendly coding scheme, I’m afraid.)

Basically you can see that the only places where labor markets are not monopsonistic are in major metro areas. Suburban areas are typically yellow, and rural areas are almost all orange or red.

It seems then that we have two choices for where we want to live: We can
live in rural areas and have monopsonistic labor markets with low wages and competitive real estate markets with low housing prices, or we can live in urban areas and have competitive labor markets with high wages and monopolistic real estate markets with high housing prices. There’s hardly anywhere we can live where both wages and housing prices are fair.

Actually the best seems to be Detroit! Median housing price in the Detroit area is an affordable \$179,000, while median household income is a low but not terrible \$31,000. This means you can pay off a house spending 30% of your income in about 10 years. That’s the American Dream, right there.

Compare this to the San Francisco area, where median housing price is \$1.1 million and median income is an impressive \$104,000. This means it would take over 35 years to pay off your house spending 30% of your income. (And that’s not accounting for interest!) You can make six figures in San Francisco and still be considered “low income”, because housing prices there are so absurd.

Of course, student loans are denominated in nominal terms, so you might actually be able to pay off your student loans faster living in San Francisco than you could in Detroit. Say taxes are 20%, so these become after-tax incomes of \$25,000 and \$83,000. Even if you spend only a third of your income on housing in Detroit and spend two-thirds in San Francisco, that leaves you with \$16,600 in Detroit but \$27,600 in San Francisco. Of course other prices are different too, but it seems quite likely that being able to pay \$5,000 per year on your student loans is easier living in San Francisco than it is in Detroit.

What can be done about monopsony in labor markets? First, we could try to split up employers—the FTC already doesn’t do enough to break up monopolies, but it basically does nothing to break up monopsonies. But that may not always be feasible, particularly in rural areas. And there are genuine economies of scale that can make larger firms more efficient in certain ways; we don’t want to lose those.

Perhaps the best solution is the one we used to use, and most of the First World continues to use: Labor unions. Union membership in the US declined by half in the last 30 years. Europe is heavily unionized, and the most unionized of all are Scandinavian countries—probably not a coincidence that these are the most prosperous places in the world.

At first glance, labor unions seem anti-competitive: They act like a monopoly. But when you currently have a
monopsony, adding a monopoly can actually be a good thing. Instead of one seller and many buyers, resulting in prices that are too low, you can have one seller and one buyer, resulting in prices that are negotiated and can, at least potentially, be much fairer. This market structure is called a bilateral monopoly, and while it’s not as good as perfect competition, it’s considerably more efficient than either monopsony or monopoly alone.

# Ancient plagues, modern pandemics

Mar 1 JDN 2458917

The coronavirus epidemic continues; though it originated in Wuhan province, the virus has now been confirmed in places as far-flung as Italy, Brazil, and Mexico. So far, about 90,000 people have caught it, and about 3,000 have died, mostly in China.

There are legitimate reasons to be concerned about this epidemic: Like influenza, coronavirus spreads quickly, and can be carried without symptoms, yet unlike influenza, it has a very high rate of complications, causing hospitalization as often as 10% of the time and death as often as 2%. There’s a lot of uncertainty about these numbers, because it’s difficult to know exactly how many people are infected but either have no symptoms or have symptoms that can be confused with other diseases. But we do have reason to believe that coronavirus is much deadlier for those infected than influenza: Influenza spreads so widely that it kills about 300,000 people every year, but this is only 0.1% of the people infected.

And yet, despite our complex interwoven network of international trade that sends people and goods all around the world, our era is probably the safest in history in terms of the risk of infectious disease.

Partly this is technology: Especially for bacterial infections, we have highly effective treatments that our forebears lacked. But for most viral infections we actually don’t have very effective treatments—which means that technology per se is not the real hero here.

Vaccination is a major part of the answer: Vaccines have effectively eradicated polio and smallpox, and would probably be on track to eliminate measles and rubella if not for dangerous anti-vaccination ideology. But even with no vaccine against coronavirus (yet) and not very effective vaccines against influenza, still the death rates from these viruses are nowhere near those of ancient plagues.

The Black Death killed something like 40% of Europe’s entire population. The Plague of Justinian killed as many as 20% of the entire world’s population. This is a staggeringly large death rate compared to a modern pandemic, in which even a 2% death rate would be considered a total catastrophe.

Even the 1918 influenza pandemic, which killed more than all the battle deaths in World War I combined, wasn’t as terrible as an ancient plague; it killed about 2% of the infected population. And when a very similar influenza virus appeared in 2009, how many people did it kill? About 400,000 people, roughly 0.1% of those infectedslightly worse than the average flu season. That’s how much better our public health has gotten in the last century alone.

Remember SARS, a previous viral pandemic that also emerged in China? It only killed 774 people, in a year in which over 300,000 died of influenza.

Sanitation is probably the most important factor: Certainly sanitation was far worse in ancient times. Today almost everyone routinely showers and washes their hands, which makes a big difference—but it’s notable that widespread bathing didn’t save the Romans from the Plague of Justinian.

I think it’s underappreciated just how much better our communication and quarantine procedures are today than they once were. In ancient times, the only way you heard about a plague was a live messenger carrying the news—and that messenger might well be already carrying the virus. Today, an epidemic in China becomes immediate news around the world. This means that people prepare—they avoid travel, they stock up on food, they become more diligent about keeping clean. And perhaps even more important than the preparation by individual people is the preparation by institutions: Governments, hospitals, research labs. We can see the pandemic coming and be ready to respond weeks or even months before it hits us.

So yes, do wash your hands regularly. Wash for at least 20 seconds, which will definitely feel like a long time if you haven’t made it a habit—but it does make a difference. Try to avoid travel for awhile. Stock up on food and water in case you need to be quarantined. Follow whatever instructions public health officials give as the pandemic progresses. But you don’t need to panic: We’ve got this under control. That Horseman of the Apocalypse is dead; and fear not, Famine and War are next. I’m afraid Death himself will probably be awhile, though.

# How I’d run an airline

Mar 1 JDN 2458910

I’m traveling this week, so I have less time for blogging than usual and airlines are very much on my mind. So I thought I’d write a short post about things I would change if I were to run my own airline.

1. Instead of overpriced first-class seats, offer the option of seats with more space for a proportional amount. First class prices are almost never worth it, and people seem to be figuring that out: Use of first class is in decline. But sitting in that middle seat is so miserable, why not simply eliminate it? I think a lot of people would be willing to pay 50% more for 50% more space.

2. Offer every passenger two free checked bags, but charge for the carry-on. Carry-on bags are far more awkward and disruptive, and slow down boarding and deboarding much more, than checked bags. The airline should be trying to incentivize passengers to use checked baggage as much as possible. I’d still give each passenger a free personal item (like a purse, backpack or laptop bag), and some people would still want a carry-on bag (e.g. for cameras that can be damaged by radiation); but most people really don’t need to have a roller bag as a carry-on.

3. Power outlets in every seat. This is a trivial amount of cost in terms of manufacturing and electricity, compared to what an airplane already requires; but it makes flying much more convenient for your passengers, and thereby allows you to demand higher prices. This is a no-brainer. (Some airlines, like Delta, already do this.)

4. Assign seats and load the plane based on the seating positions. The first boarding group should be the people who sit furthest in the back, so that no one needs to pass seated passengers in order to find their own seat. Ideally window seats would be filled before aisle seats, but since people like to board and sit together, that might not be feasible. But at the very least we can make boarding faster by seating the back rows first.

5. Give pilots and flight attendants reasonable hours and plenty of vacation time. Airline pilots around the world are dangerously overworked and sleep-deprived. This is dangerous for customers, and if it leads to crashes or lawsuits it can be very expensive for the airlines too. Having an aircraft idle overnight really isn’t that great a cost, especially since red-eye flights command lower prices and are thus less profitable for the airline. Working fewer hours makes people more productive per hour—often to the point of making them more productive overall.

7. Include carbon offsets in the ticket price, and advertise this aggressively. Despite the fact that airplanes are a major source of carbon emissions, carbon offsets are actually remarkably cheap compared to the cost of airline tickets. Adding offsets would typically raise the price of a ticket by about \$30, which on a \$300 ticket is unlikely to shock people. And by advertising the carbon-neutrality of your airline, you can probably get a lot of customers who are willing to pay more, potentially even more than the additional cost of the carbon offsets themselves. This could be a win-win for the airline and the environment.

8. Invest heavily in research on more efficient jet engines. The second-biggest cost for an airline is fuel expenditure. (First is the wages of the crew.) If you can install more efficient engines on your aircraft, you can both reduce your environmental impact and dramatically lower your cost. Current state-of-the-art engines can reduce fuel consumption by as much as 20%; future research could improve this even further.

9. Include snacks at every seat before passengers even board. Putting a bag of pretzels and a water bottle at every seat would be trivially easy, and would allow passengers the opportunity to be eating while the plane takes off—and chewing reduces the discomfort of changing air pressure. If the worry is that people will try to put their tray tables down (which is genuinely unsafe during takeoff), install electronic locks that prevent tray tables from being lowered except when authorized.

10. Install seats that don’t recline. The additional comfort for the passenger reclining is far smaller than the reduced comfort for the passenger behind them. Combine that with the additional cost of maintaining the seats and the additional risk of injury during rough landings, and the answer is obvious: Seats shouldn’t recline.

11. Offer better food. Charging less for airplane food honestly isn’t feasible: Because space and weight are at such a premium, it really is that expensive to store and transport food on an aircraft. But the cost comes mostly from the bulk and weight of the food; it really doesn’t much matter what kind of food it is. To that end, airlines should offer high-quality food that people feel more comfortable paying such high prices for. A steak weighs about the same as a hamburger, and champagne has about the same density as Sprite.

12. Reduce, or even eliminate, fees to change flights. Yes, it’s expensive to have empty seats on a moving airplane. But most flights can be filled by standby passengers, and those that can’t often weren’t full anyway. It’s actually fairly rare for a cancellation to result in an empty seat that would otherwise have been full. And the additional goodwill you get from making life easier for your passengers will make up the difference. (Southwest figured this out; other airlines don’t yet seem to have caught on.)

Would these changes revolutionize air travel? No. But I do think they’d make it a bit more pleasant, without greatly reducing the profits of the airline.