Tuesday, April 6, 2021

U.S. COVID-19 Restrictions Cost-Benefit Analysis

Using an unlikely assumption that COVID-19 restrictions cut the U.S. death and hospitalization count in half from what they would have been without restrictions, the U.S. spent 5 trillion dollars to lose 86 million QALY. The problem is doing population-wide public health measures on an illness that is disproportionally fatal for the frail aged.

Public health cost-benefit analyses are usually done using Quality Adjusted Life Years (QALY). QALY ranges from 0 to 1, with 0 being death, and 1 being a fantastic year. When COVID-19 lockdowns began in the U.S. in March 2020, leaders rushed to implement unprecedented totalitarian public health measures that were first used in China. They ignored a viewpoint (later known as the Great Barrington Declaration) that, based on the 1000-fold difference in mortality risk between young and old, called for a focused protection approach for the vulnerable old, while letting non-vulnerable young people live normal lives. What is the cost-benefit analysis for these policies based on a year of experience?

The U.S. states had differing approaches that varied over time, from severe lockdowns to milder measures. Typically, Republican governors chose less restrictive measures than Democratic governors. No state (or Western country) did a full Great Barrington-type policy, which involved no general testing/contact tracing/quarantining, letting non-vulnerable younger people live near-normal lives, while protecting the vulnerable essential workers by giving them disability pay to stay home, protecting vulnerable people in multigenerational homes by giving them the option to live elsewhere at government expense, protecting vulnerable people living alone by delivering all food and supplies, and doing a better job protecting nursing home residents.

Regression analysis indicates that there is little correlation between level of restrictiveness of public health measures and COVID death rates, indicating that it’s unlikely that a less restrictive approach would have made much of a difference in death rates. It’s possible that a Great Barrington focused protection approach would have resulted in fewer deaths. It’s certain that a focused protection approach would have been much less expensive, and avoided the collateral damage of lockdowns and other restrictions.

I will do a cost-benefit analysis for the U.S. being especially generous to lockdown proponents, using CDC data for March 19, 2021. Let’s assume that the U.S. COVID death count of 535k is an accurate number of people who died of COVID (it actually includes many frail elderly with comorbidities who died with COVID). Let’s assume that without lockdowns and other restrictions that the U.S. death count would have doubled, from 535k to 1.07M. Considering the high percentage of elderly people in this death count, including 81% above 65 years old, and 59% above 75 years old, and about 1/3 nursing home residents, QALY lost will be much less than for younger people. Older people have fewer years remaining, and these years are far less than 1 QALY each due to health conditions, restricted mobility, etc. To be generous, let’s assume an average of 5 QALY lost per COVID death. That implies that lockdowns/restrictions saved 535k * 5 = 2.7M QALY.

Immediate family and close friends of the COVID deceased would have lost QALY. Let's assume 0.5 QALY lost for immediate family member, with an average of 3 immediate family members for every deceased. Let's also assume 0.25 QALY lost per close friend, with an average of 2 close friends per deceased. Then lockdowns/restrictions saved 1.6M immediate family members from losing 803k QALY, and 1.07M close friends from losing 268k QALY.

There have been 1.88M U.S. COVID hospitalizations. Let’s assume that these would have doubled without lockdowns/restrictions to 3.76M. Let’s assume 0.5 QALY lost per hospitalization. That implies that lockdowns/restrictions saved 1.88M * 0.5 = 0.94M QALY.

Let’s also assume that all of these extra hospitalizations would have taken hospital beds away from other people who needed them. There is a finite hospital capacity that cannot be changed even in a crisis. That assumes no temporary field hospitals, no cross training medical professionals to work with COVID patients, no bringing medical professionals out of retirement, no transporting medical professionals from other regions to help out during a surge, and no way to treat COVID patients at home by delivering oxygen tanks and medications. Then there will be 1.88M non-COVID patients who are denied hospitalization. Some will immediately die, others will die sooner than they otherwise would have, and others will have lower quality of life due to lack of care. Many of these people would have been elderly, as they are more likely than younger people to have conditions that require hospitalization. Let’s assume 3 QALY lost per missed hospitalization. That implies that lockdowns/restrictions saved 1.88M * 3 = 5.64M QALY.

Hospital staff were stressed out during COVID surges this past year. Doubling the number of COVID hospitalizations, and requiring them to triage, would have added to this stress. There are about 6.6M hospital employees in the U.S. Let's assume that hospital employees would have lost an average of 0.25 QALY each due to the doubling of COVID hospitalizations. Then this implies that lockdowns/restrictions saved 6.6M * 0.25 = 1.65M QALY. 

The impact of COVID on other health problems is controversial. During the pandemic, people have died from heart attacks, strokes, suicide, drug overdoses, dementia, etc. Did some of these people who wouldn’t have died if there were no pandemic die because of COVID, or because of restrictions? COVID made a lot of people afraid to get care, or find it hard to get care. The lockdowns and restrictions almost certainly increased this fear. Lockdowns and restrictions didn’t cancel emergency care, but did cancel some elective surgeries and other non-critical care. Social isolation is a risk factor for many medical problems, especially mental health and cardiovascular issues. Enforced social isolation due to COVID social distancing restrictions likely contributed to additional excess deaths, along with increased morbidity from many non-COVID health problems. Missed cancer screenings will contribute to excess deaths in the coming years. For the sake of simplicity, and to be generous to lockdown proponents, I will ignore this impact on other health problems in the QALY calculation.   

Long COVID is another problem that costs QALY. It’s unclear how many people have long COVID, but one suggestion is 10% of COVID infections. There have been 29.4M U.S. COVID cases. A CDC estimate of total infections is 4.6 * cases, or 4.6 * 29.4 = 135.2M. 10% of this number of 13.5M. Let’s assume that these long COVID cases would have doubled without restrictions to 27M. Long COVID is more common among younger and healthier people than being hospitalized for or dying of COVID, so QALY lost should reflect that. Let’s assume that QALY lost for long COVID is the same as that lost for hospitalizations, or 0.5. That implies that lockdowns/restrictions saved 13.5M * 0.5 = 6.75M QALY.

Total QALY saved from lockdowns/restrictions is 2.7M + 0.80M + 0.27M  + 0.94M + 5.64M + 1.65M + 6.75M = 18.75M. Deaths, impact on family, impact on friends, hospitalizations, missed hospitalizations, impact on hospital workers, and long COVID would have affected a total of 1.07M + 3.21M + 2.14M + 3.76M + 1.88M + 6.6M + 27M = 45.66M people without lockdowns/restrictions.

Now we need to find the QALY lost from lockdowns/restrictions. Everyone who didn’t die, wasn't family/friend of deceased, be hospitalized, miss out on hospitalization, was a hospital worker, or develop long COVID lost QALY due to the lockdowns/restrictions. To simplify the analysis, I will assume a uniform level of moderate restrictiveness in the U.S. (in reality, there was a lot of variation across states). Healthy young people, who had the least to fear from COVID, lost the most. A normal year for them is about 1 QALY. Being denied the ability to socialize, travel, go to school in person, participate in group sports, go to concerts, shows, sporting events, etc. for a year deprived them of much of this 1 QALY. Being subjected to testing/contract tracing/quarantining/masking for a virus that posed little risk of death or serious illness also deprived them of QALY. Being subjected to stay-at-home orders (essentially house arrest) for periods of time deprived them of QALY. Some young people did better than others. Considering that restrictions limited most social activity outside of the home, married people and people in relationships did better than single people, and single people living alone did the worst. Social distancing and masking made it difficult for single people to meet other single people in the few public places that were open. Children who attended in-person school did better than children who attended remote school. The parents of children who attended in-person school did better than the parents of children who attended remote school. Introverted/socially anxious people did better than extraverted people. Professionals who were able to work remotely did better than essential workers who were forced to show up for work and risk exposure to the virus. Let’s assume that young people lost an average of 0.5 QALY each. Older people have less QALY to lose, and would have isolated even without lockdowns/restrictions. But some older people would have wanted to travel, see family, go to concerts, etc. Let’s assume that QALY lost for older people was 0.1 QALY each. Middle-aged people would be somewhere in between older and younger people, say 0.3 QALY each. There are 171.2M younger Americans (under 40), 103.3M middle aged (40 – 65), and 54M over 65. Weighted mean of QALY lost is (171.2 * 0.5 + 103.3 * 0.3 + 54 * 0.1)/328.5 = (85.6 + 31.0 + 5.4)/328.5 = 0.37. Subtract the 45.7M who died, were family/friends of deceased, were hospitalized, denied hospitalization, were hospital workers, or developed long COVID from 328.5M to come up with 282.8M. 282.8M * 0.37 QALY = 104.6M QALY lost.
Net QALY lost is 104.6M – 18.8M = 85.8M. The U.S. federal government spent $5 trillion to lose 86 million QALY.

While all of the numbers used as input to this calculation are open to reasonable criticism, it’s unlikely that any change will affect the outcome that net QALY will be negative. I show QALY lost being over 5 times QALY gained from the restrictions. The reason for this is that even for an aging society like the U.S., people over 65 who are most vulnerable to COVID only make up about 16% of the population. Due to their age and comorbidities, dying from COVID results in a relatively low number of QALY lost. Taking away a fraction of a QALY from the much larger healthy younger and middle-aged population to save some elderly people from dying has more cost than benefit.

Assuming that COVID lockdowns and restrictions cut the death and hospitalization rates in half is almost certainly an overestimate, even if nothing at all was done. “Letting it rip” would have resulted in front loading deaths and hospitalizations to the first (spring) and second (summer) waves, but would have had a much milder impact for the fall/winter wave. It would have allowed for the buildup of herd immunity with the less contagious earlier variants of COVID-19, which would have protected a majority of the population from the more contagious later variants. Most remote working, unemployed or retired vulnerable people living in the community would have self-isolated regardless of government restrictions. Nursing homes and assisted living facilities would have been pressured to restrict visitors and socially distance residents regardless of government regulations. Letting it rip would have avoided the collateral damage that the lockdowns/restrictions occurred.

Following the Great Barrington focused protection approach would have also avoided the collateral damage, but would have better protected the vulnerable. It’s possible that the Great Barrington approach would have ended in the same or lower death/hospitalization count than what actually occurred, while allowing the non-vulnerable to live near-normal lives. The government would have spent a fraction of the $5 trillion, and avoided the QALY lost from locking down the non-vulnerable.