The time tax

This article from Annie Lowrey on how our bureaucratic failures tax us through our time is terrific. I meant to post on it a couple months ago, but since it is assigned reading for my Public Policy class today, today gets the post:

The issue is not that modern life comes with paperwork hassles. The issue is that American benefit programs are, as a whole, difficult and sometimes impossible for everyday citizens to use. Our public policy is crafted from red tape, entangling millions of people who are struggling to find a job, failing to feed their kids, sliding into poverty, or managing a disabling health condition.

The United States government—whether controlled by Democrats, with their love of too-complicated-by-half, means-tested policy solutions; or Republicans, with their love of paperwork-as-punishment; or both, with their collective neglect of the implementation and maintenance of government programs—has not just given up on making benefits easy to understand and easy to receive. It has in many cases purposefully made the system difficult, shifting the burden of public administration onto individuals and discouraging millions of Americans from seeking aid. The government rations public services through perplexing, unfair bureaucratic friction. And when people do not get help designed for them, well, that is their own fault.

The time tax is worse for individuals who are struggling than for the rich; larger for Black families than for white families; harder on the sick than on the healthy. It is a regressive filter undercutting every progressive policy we have. In America, losing a job means making a hundred phone calls to a state unemployment-insurance system. Getting hit by a car means becoming your own hospital-billing expert. Having a disability means launching into a Jarndyce v. Jarndyce–type legal battle. Needing help to feed a toddler means filling out a novel-length application for aid…

Or consider the tentpoles of American assistance for working families: the Supplemental Nutrition Assistance Program, or food stamps; the earned-income tax credit; and the child tax credit. Food stamps reach some 40 million Americans in 21 million households. In many states, applying for them involves a quick online request, a quick approval, and a quick turnaround to start getting benefits. But not always. SNAP is workfare, meaning that adult participants judged to be “able-bodied” need to log their work hours or demonstrate that they are looking for a job. Folks get thrown off the rolls constantly for, say, not having a functioning computer. (These work requirements do not boost employment, by the way.)

As for the earned-income tax credit, 22 percent of eligible recipients miss out on the generous benefit because they do not file or misfile their taxes. “Credit eligibility depends on marital status at the end of the year, earnings, income, and citizenship status,” the Tax Policy Center notes. “There are additional tests of relationship and residency for people with children. Eligibility can vary from year to year.”

Experts worry that millions of children—mostly ones growing up in unstable, extremely poor households—will miss out on the new child allowance because their parents do not know that the policy exists and will not sign up for it. The online portal for households that do not regularly file taxes is only in English, written in difficult-to-parse language, and not mobile-friendly. No paper or telephone sign-up option exists. The government has thus far developed no plan to reach the poorest kids.

The time tax is also imposed through smaller, clunkier programs. Getting housing aid is excruciating. Consider the process in Butte County, California. An applicant first needs to get on a waitlist for rental assistance. The waitlist opens only periodically, sometimes for just a few days at a time, when a “public announcement is placed in area newspapers” and information is posted on a website. A person needs to win a lottery to get on it, and then needs to wait—generally for half a decade. When finally selected, hopefuls are contacted by mail. Next comes an eligibility appointment, an application, and finally verification, which might or might not be successful, a process that “could take several weeks or months.”

Many programs meant to aid the poorest of the poor have demeaning, invasive, and time-consuming screening requirements. More than a dozen states require welfare applicants to submit to a drug test. State Women, Infants, and Children programs generally require in-person interviews and numerous in-clinic appointments, meaning applicants need to take time off work and find transportation to a WIC office just to get help buying formula and diapers.

Lots more in there and well worth reading the whole thing.  And my family has very much seen this first-hand.  With my son Alex requiring a legal guarding and being declared officially permanently disabled, there’s a lot of bureaucracy involved.  Fortunately for us, my wife actually has the time to do it, but if we were both working full-time-plus just to make ends meet, it would be nearly impossible.  Not to mention, my wife literally has a PhD and has found a fair amount of the bureaucracy to be confusing and hard to figure out.  So, imagine an overworked parent of limited education– yikes! 

Boost me.

First, an NYT Op-Ed arguing that I (as a recipient of a single J&J) need to get a booster:

However, given the spread of Delta, there are concerns over how well the Johnson & Johnson vaccine holds up. While there is no systematic data collection on vaccine breakthrough cases nationally, reports from multiple locations suggest a higher breakthrough rate for Johnson & Johnson versus the other vaccines. In the Provincetown outbreak, a higher proportion of cases occurred from Johnson & Johnson recipients than from Pfizer or Moderna recipients, when adjusting for the number of vaccines given. Among people who are immune compromised, early studies suggest that there may be notable differences between the vaccines. One recent study, which has not been peer-reviewed, found that 33 percent of Johnson & Johnson-vaccinated dialysis patients did not develop antibodies, compared with 4 percent for Pfizer and 2 percent for Moderna.

The Johnson & Johnson vaccine is certainly better than no vaccine, regardless of the variant. A recent study from South Africa found it reduced the risk of hospitalization from the Delta variant in health care workers by 71 percent relative to the unvaccinated general population. While this finding is encouraging, it does not address whether a subsequent dose of Johnson & Johnson or another vaccine might be even better.

Most vaccines used today — whether for a childhood disease like measles or an adult one like shingles — use multiple shots to strengthen the immune response. Johnson & Johnson reported on Wednesday that a second dose of its vaccine increased levels of antibodies against the coronavirus. Other data strongly suggests that an additional dose of an mRNA vaccine could improve a Johnson & Johnson recipient’s protection from disease. Multiple studies have found that an additional dose of an mRNA booster following a single dose of the AstraZeneca vaccine (a vaccine similar to Johnson & Johnson’s) produced stronger immunity compared with getting a second dose of AstraZeneca.

Experience also suggests that getting an mRNA dose after the Johnson & Johnson or AstraZeneca vaccine is safe. According to C.D.C. data, more than 90,000 Johnson & Johnson recipients have already received an additional Covid-19 vaccine dose, even though this is not yet recommended. The mixing and matching of vaccines has already been endorsed in multiple European countries. Several prominent people have shared that they have gotten an mRNA dose after their Johnson & Johnson or AstraZeneca vaccine, including Chancellor Angela Merkel of Germany, multiple infectious disease experts and various pharmaceutical company executives. So far, none of them have reported serious adverse events, nor have there been unanticipated side effects in countries using the strategy.

Meanwhile, one of my many pandemic gratitudes is that I’ve made friends with NC State’s resident virologist, Matt Koci.  I really liked his explanation on boosters here (via a Q&A with my long-time friend, Matt Shipman):

The Abstract: What is a booster?

Matt Koci: Great question. In the past I’ve described vaccines as vocational training for your immune system, as compared to on-the-job training from getting an infection. To extend that analogy a bit further, booster shots are like refresher courses. You took the class and passed, but you haven’t had to use that skill on the job yet. Now that it’s been some time since you graduated, you haven’t forgotten the material completely, but you know if you were to retake the exam you wouldn’t do as well as you did before. Then your boss tells you, “I know we hired you because you took those courses and we haven’t given you the chance to show what you can do. Don’t worry, in the next few weeks I’m sure you’ll get the chance to shine.” You’d likely go home and start reviewing your old notes.

That’s the job of a booster shot. You got the vaccine. It taught your immune system how to respond to the disease so it would be ready to handle it as soon as it showed up. However, with masks and social distancing, your immune system hasn’t needed to flex those new skills. Now that cases are as high as they’ve been at any point during the pandemic, and people aren’t hunkered down in their homes like they were, the chances that you need your immune system to be at the top of its game are as high as ever. So, booster shots help make sure you’re ready.

One thing to point out: the booster shots the CDC has recommended people start getting is just another dose of the vaccine, against the same version of COVID. It is not specific to the delta variant. Delta is different enough from the original virus that the vaccine doesn’t work as well as it did against the original COVID virus. However, the vaccines still work well enough that there isn’t a need for a new, variant-specific vaccine – at least not yet. I wanted to mention that, because I know some people, and some physicians, have been confused when trying to find a place to get their booster, thinking it was a different vaccine or was being given at different locations. Any place giving out vaccine will do.

TA: Why are boosters being recommended for people who received the Moderna and Pfizer vaccines?

Koci: The short answer is, around the world we’ve seen the levels of antibodies start to drop after about six months after your second shot. This decrease in antibodies isn’t a lot. Antibody levels are actually high enough to fully protect you from the original version of COVID. It’s not that the vaccine isn’t as good as you were told, it’s that we’re fighting a different variant of the virus now.

The delta variant is just different enough from the original COVID virus that the drop off in antibody level after six months seems to make a difference in how many people are getting mild-to-moderate infections with the delta variant. The idea behind getting the booster now is that it will help get the immune system back up to its peak performance, which will hopefully help reduce the number of breakthrough infections, and/or ensure those infections are as mild as possible.

I really like that last point (thus both bold and italics by me).  I see far too much analysis that is either strictly waning immunity focused or Delta focused, but it really makes sense that it is the interaction of the two.  If we were still on Alpha, I think we’d be seeing way fewer breakthrough cases.  We knew all along that antibodies would go down, and if not for damn Delta, there’d still be plenty to prevent most all infections.  But Delta is just different enough where that decline in antibodies seems to make a real difference.

Now, it never hurts to emphasize the vaccines are still wonderfully effective at preventing serious disease.  But, against Alpha we were preventing almost any disease with the vaccines and that was truly awesome.  It’s only natural that we’d be frustrated and want to return to something closer to that, and I’ve seen multiple credible places making the case that a third dose–even though not Delta-specific– pretty much does that.

And, finally I appreciate that Peter Hotez makes the clear case that US boosters are simply not going to have a very significant impact on what happens in the rest of the world.  We need to manufacture and distribute way more vaccines, boosters or not:

One of the major concerns about boosters is that of vaccine equity. The US, Europe, and Israel are busily giving (or preparing to give) boosters to their population when <2% of the people in low-income countries have received any vaccination.

The wealthy countries have been hoarding vaccines and now have an excess. In several US states, vaccine doses are being wasted and destroyed because of abysmal vaccine uptake. Adalja notes that one of the major problems is that of “government export restrictions.” Hotez shared a thought-provoking perspective with me: “Even if the US donated its entire stockpile of vaccines tomorrow, it would make very little impact. The focus around sharing existing doses will solve about 10% of the problem [and is not the solution]. We can and must produce 6 billion doses for the world now, while delta is circulating in Africa. Biden has already said what it’s committed to send out globally (is) 200 million Pfizer this year, 300 million next year. That number won’t change regardless of whether we boost or not.”

 

 

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