Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Health Insurance
Clinton Health Plan and its replacements.

Legal Re-Definitions of Biological Facts (?)

Obstetrics. In this segment we examine the pros and cons of what we have already proposed, the donation of obstetrical costs, whether by the government or by compelling relatives to do it, and whether to every child or only in hardship cases. As a conservative, I sympathize with the conservative response of the "slippery slope" rejoinder, but even if the idea is rejected for such understandable concerns, I believe discussion of it is warranted. We seem to have forgotten what an important obstacle to healthcare financing is presented by this comparatively minor expense, coming at such a vulnerable moment. In one sense, there's no hope of waiting it out; obstetrical costs will be awkward, forever. The approach I favor is to donate the cost at birth to an HSA, wait ninety years, and see it reduced 500-fold. The main problem is keeping its custodians honest.

No matter how prosperous our country becomes, the birth of children always occurs at a time of marginal finances for the parents, zero finances for the baby, and considerable cost for the event. The cost impact will always present the alternatives to not having more children afterward. Thus the decision to have children is left in the hands of a couple whose goals may vary from those of Society. Furthermore, although the cost may appall the parents, it isn't great enough to justify alternative methods of obstetrical delivery. The amount of hospital internal cost-shifting -- and malpractice claims -- is so great that stripped away, the true cost no longer justifies a shift to less-trained providers or to home births. These are make-shifts, which ultimately prove not to save money. Do the procedure the best way you know, and find a different way to pay for it in the long run.

If economists are correct, our only choice is which parties must share the cost of "eating the loss". Economists also tell us adding new population is the main way to increase the growth of our economy. If both are the case, then the real dispute lies between immigration and increasing our birthrate. Arguments could be made in either direction, except our politics now place both contending groups in the same political party. Intervening in the argument often amounts to taking the choice away from the people directly at odds, thus decreasing the likelihood of a satisfying outcome.

In my mind, that last concern might justify procrastination in most major social distortions except this one. No more than a fifth or even a tenth of the rest of the world has reached our level of prosperity, but they are trying. China and India have applied drastic methods to reduce their overpopulation, and with luck will succeed. Therefore, while the supply of potential immigrants remains immense, it is foreseeably self-correcting. While the impoverished segment of the population shows scant sign of recognizing it, their economic future lies in continuing to outnumber them until the supply of immigrants has a chance to decline.

The Battlefield. It starts with birth, where a hospital can't refuse to deliver an uninsured baby when the mother goes into labor because the baby won't wait. When the bad debts from this source begin to be a problem, the distraught administrator has little option but to close the whole obstetrical unit. "We don't deliver babies" may be an effective way of stopping obstetrical bad debts, but it generates problems for even families who have insurance. Long before the hospital is driven to this resort, you can be sure the obstetricians have been delivering free care. Afterward, they can't do even that. A lot of people suffer indignities and worse from this situation, especially when the government offers scant reimbursement. And yet, within a few years, almost all of those children had some kind of job, making it possible for them to pay old debts. A few even became basketball stars or concert singers, but by that time the hospitals don't even keep records for debt collection. In retrospect, many of those debts were at least partially collectible, but in fact, hardly any were collected. Eventually, the Maternal Care Act was passed, eventually forming the basis for Medicaid. Surely, that was a far more expensive way to address the problem -- and an unsatisfactory one-- than to make a hundred-dollar donation, once, and wait for income to accumulate.

Social Change After Childhood. I caution we may not be ready for more, for some time. Without a firm commitment to stop at that point, attempting to equalize gender costs will be much slower if it works at all. There is a limit to what society is willing to change, especially if it takes decades to show results, and particularly after similar attempts have been unrewarded in the past. I recognize we have a recreational drug problem, an employment unfairness, and a host of marriage disturbances. But the volume of a complaint is insufficient reason to court failure by overreaching.

Originally published: Wednesday, July 06, 2016; most-recently modified: Thursday, May 23, 2019