Do you need a fourth Covid booster shot? Probably not. Pfizer and Moderna have asked the FDA for authorization of a second booster, or fourth shot, for patients over 65 and all adults, respectively. The FDA reportedly will authorize, but not recommend, the fourth shot for patients over age 50.

Philip Krause and Luciana Borio, writing in The Wall Street Journal, say if your immune system is healthy, three or even two doses of these mRNA vaccines should be sufficient. Dr. Krause is a consultant to the World Health Organization and was deputy director of FDA’s Office of Vaccines Research and Review. Dr. Borio is a senior fellow for global health at the Council on Foreign Relations and was director for medical and biodefense preparedness policy at the National Security Council.

It is important to understand that vaccine-induced protection against infection is short-lived and doesn’t get much of a boost from extra shots. Yet the initial two-dose regimen is enough to provide most patients excellent protection against severe disease – mediated by durable cellular responses (B and T cells), not the neutralizing antibodies that rise and wane quickly after vaccination.

What have we learned from studies of those vaccinated?

The New York State Health Department’s large database shows the effectiveness of full vaccination (at least two mRNA doses) remained above 90% against hospitalization, including during the recent Omicron surge. Similar studies done in Sweden had the same results. Studies done in Qatar and California showed no decline in protection against severe disease with Omicron.

Those who favor more boosters point to other studies that show declining vaccine effectiveness over time, especially against Omicron. But these appear unreliable, reporting a range of results for vaccine efficacy against symptomatic disease from as high as 40% to 50% to as low as negative 40%.

To understand these numbers, it is important to know when assessing vaccine efficacy how scientists compare the rate of disease between vaccinated and unvaccinated groups. A larger difference indicates higher vaccine efficacy. But as more unvaccinated people become immune through infection (natural immunity) – especially with a highly transmissible variant such as Omicron – the gap between the groups narrows even if the vaccines are still effective.

What about studies reporting reduced rates of Omicron hospitalization in the boosted v. unboosted?

The variant’s reduced virulence means that a much smaller percentage of vaccinated people end up in the hospital – whether vaccinated or not. Those who do are likelier to have serious underlying health conditions – which may be the real reason for their hospitalization. Boosters for this population are helpful. But for immunocompetent people with one or no risk factors, two doses remain 95% effective in preventing severe Covid.

The evidence for a fourth dose booster is even less compelling. In a large Israeli study, fewer than 1 in 200 people over 60 who got Omicron ended up with severe disease after just three doses. A fourth dose reduced that likelihood even more, but the effect was driven by those with major risk factors. There’s no evidence that introducing boosters last fall had a significant impact on the course of the Omicron surge in the U.S.

In summary, if you’ve had two doses, you have a lot of protection against severe Covid disease. The same is true if you’ve been infected with the virus. If you’re over 65 or otherwise at high risk, it was reasonable to get the third shot. A fourth shot is already authorized for the severely immunocompromised, but for everyone else, the data haven’t shown meaningful benefits for the third dose, let alone a fourth.

Everyone knows Medicare is a healthcare system for seniors. Since 1965, Medicare has been providing healthcare for Americans age 65 or older. But Medicare Advantage is a newer plan, first begun in 1985 as a limited option available only in select markets, known as “HMO risk contracting.” It evolved to a new program established in 1997 as Medicare+Choice. The name changed later to Medicare Advantage in 2003.

Healthcare economist James C. Capretta, writing for the American Enterprise Institute, says Medicare Advantage (MA) has come a long way since those early days. He gives us a review of the present state of MA using three recent reports along with data supplied by the Medicare trustees.

Medicare Advantage is Medicare managed care. Managed care enrollment in Medicare has increased at a steady pace since the option’s first introduction in the 1980’s, with particularly high growth rates over the last decade. MA plans accounted for 40.1 percent of program enrollment in 2020, up from 25.3 percent in 2011.

This trend continues, according to an analysis from The Chartis Group. MA enrollment grew from 37 percent in 2019 to 45 percent in 2022. Much of the growth in MA has been fueled by a drop in enrollment in traditional fee-for-service (FFS) Medicare with many new program enrollees choosing MA. FFS Medicare enrollees have declined by 2.6 million since 2019.

The reasons for this trend are clear. Researchers at the Kaiser Family Foundation have found 39 different MA plans, up from 19 in 2011. Nationwide, insurers are offering a total of 3,834 different MA options! The market is dominated by HMOs and PPOs, which together account for 96 percent of all the plans offered in 2022.

These multiple options offer less expensive supplemental and drug coverage than the alternative options. In 2022, 89 percent of MA plan offerings include part D prescription drug coverage (called MA-PD), and 98 percent of all Medicare beneficiaries have the option to enroll in MA-PD plans that charge no premium beyond what is required for Medicare Part B. A study by Mark Farrah Associates reports that 82 percent of all MA offerings have premiums below $50 per month.

Furthermore, all MA plans are required by regulation to include an out-of-pocket limit on annual costs for services covered by parts A and B. This limit is a major advantage of MA over FFS plans that have no catastrophic protection. To compensate, most FFS enrollees purchase Medigap policies. Most MA plans offer other coverage options, too. Kaiser reports 98 percent include eye exams and eyeglasses, 95 percent cover fitness services, and 94 percent provide dental care at some level.

What’s not to like?

Not every doctor accepting Medicare will also be available on every MA plan. Personally, I participate in some plans, but not others. Many doctors are excluded from certain plans that promise high patient volumes to those who accept lower reimbursements. Recently, a long-time patient of mine switched to an MA plan only to find out later I was not a provider on her new MA plan. Be sure your doctors are providers on a MA panel before you switch.

Mr. Capretta says there is no turning back the clock. MA plans will likely continue to grow in popularity since they have significant potential to bring innovation and efficiency to the provision of medical services to the nation’s elderly. He says the next step should be to improve the payment system so that the competition among MA plans, and between MA and FFs, is fair and delivers savings to taxpayers as well as the program’s beneficiaries.

Fifty-three years ago, I went off to college with a plan to be a doctor. I had no idea how much it would cost nor how much debt I would have when I finished school. I had no idea how much money I would make, but I knew doctors made better than average income. I wasn’t worried about any of those issues; I just knew I was excited about learning how to take care of people.

Today, it’s much more complicated. Young people are worried about the amount of debt they will have when they finish college. They’re worried about the income they’ll make to pay off that debt. They’re worried about finding a job in their chosen profession. I don’t envy their situation; but at least they have better tools to make their decisions than I had.

Florida is one of several states that have passed “right-to-know” laws that provide young people information that assists them in choosing a career and a college to prepare for that career; or maybe instead of college a trade school. Last year Gov. Ron DeSantis signed the bill to make it easier for high-school students and parents to find more-affordable college paths and financially rewarding degrees.

Tarren Bragdon, writing in The Wall Street Journal, says his eldest son, a 10^th-grader, is already considering whether college will help him become an entrepreneur. His daughter, a ninth-grader, has already told him she wants a “return on investment” for whatever path she picks post-graduation. He and his wife also have twin boys in seventh grade. They’re still five years away from finishing high school, but he’s already worried about the cost of possibly having four children in college at the same time!

To assist them in their planning, the State of Florida now has a web site called My Florida Future, that lets students and parents see average actual earnings for degree programs one, five, and ten years after graduation; average student loan burdens; comparisons of earnings across all 12 state universities; and other helpful information. Using this information, their son has already learned that a degree in business administration at Florida Gulf Coast University near them will pay 10% less than the same degree at Florida State University. After five years, the gap will be $7,900. But he can also see that 42% of business and marketing majors graduate with loans, and more than 20% walk away with more than $20,000 in debt. As a result of this information, he’s already considering other options, like marketing, that could help him learn sales and succeed more quickly as an entrepreneur.

For their daughter, they’ve learned that a career in fashion, which means a degree in fine arts, (who knew?) pays less than a degree in food science. In the latter program, she could be making $100,000 a year a decade after graduation, nearly twice as much as the fashion career likely will pay.

Florida is not alone in providing this information. In the past two years, 10 states have enacted such measures, and some have gone further. West Virginia, Kentucky, Arkansas and Missouri take an even broader approach than Florida to providing families with useful information about college expectations. Most will list their states’ most in-demand jobs and required education levels, the average cost of every college and vocational school, and the average monthly student loan payments and default rates for each school. Additionally, some states will extend the transparency to both public and private schools. Many databases will also give students the typical starting salaries for graduates of trade schools, as well as a breakdown of the benefits of apprenticeships and technical education programs.

It’s a different world from when I went off to college. I’m glad students have much more information available as they consider their futures. But, the most important thing they have to decide is what career they are passionate about. When you know that, the rest is really unimportant.