Need a hand?

Having a baby is hard. You hear moms saying they haven't showered in a week and wonder "why not? It's just 10 minutes." You hear about all the lost sleep and wonder "well, how much time does a baby really take up?"

We feed our little girl 8 times a day: that's about every 3 hours. They involve breastfeeding, supplementing with formula, and pumping to help milk production. While she "only" eats for 25-45 minutes (usually, ... sometimes it's longer), we also need to clean her diaper before, sometimes after, then do the pumping, then clean all the accessories we've been using. We also need to make sure she's falling asleep and will let us sleep once we put her down. All these things take time and there's usually about an hour left of the 3 hour block for us. We manage by prepping food and eating while feeding her, handing her off back and forth in a choreographed sequence designed to maximize the use of our available hands, so that we can spend that hour sleeping. Sometimes we can't fall asleep despite being exhausted because it's 2pm and our bodies are just not used to that. New moms have a host of other things to deal with: massive hormone shifts, lochia flows, labor trauma or c-section recoveries. All these take from the available time and energy as well.

Sometimes she doesn't go down, and that spare hour becomes nothing. Even in the best case where we get almost 2 hours, our daily sleep is being segmented into these little naps - 2 hours at 9pm, an hour at 1am, nothing til 6am, another 45 minutes after that, and so on. A few failed blocks in a row starts to feel overwhelming. This little human is entirely dependent on you to survive and be happy, and they have very few ways to communicate: mostly they just scream. It's up to our parental intuition and learned trouble-shooting guides to figure out why. If you can't relate, imagine trying to set up a device and the only error information it can give you is "No!"

All that said, we have it pretty good:

1. Our baby is healthy and doesn't need any special care or assistance
2. Our baby sleeps relatively well, staying down between 6 of 8 and all 8 times in a day
3. We have family providing weeks of live-in support, which means we can hand baby off to loving grandparents we trust and know that our time will be ours until the next alarm
4. We have great insurance so all our needs are covered, and the total cost is capped and predictable
5. We have great medical support nearby. Our hospital and pediatrician are all within 15 minutes, and everyone we've interacted with has been really wonderful
6. We have deep financial reserves so we can throw money at many problems: we've placed about 2 dozen Amazon orders in the first week at home
7. We have a comfortable house with A/C
8. I get 12 weeks parental leave so I can stay home and help, learn, support, and grow as a dad

Now suppose these things we have going for us start to crumble away.
What if a baby is more fussy? The available time for the parents decreases, at the cost of their stress, sleep, and health.
What if a baby needs extra medical care? A parent has to be available to be there with them, or to seek out this care to begin with. They may not be able to afford special treatments either
What if there's no family to provide support? Every bit falls on the parents.
What if the partner doesn't get leave, or if they're not present? Every bit falls on the mom, stressing her further, and partner has to function at their day job while probably quite sleep-deprived.
What if the family doesn't have a lot of money? They now need to plan in more detail for the unknown, spend more time they don't have going stores in person when needed.
What if the doctors are far, or not paying close attention? A number of post-partum complications (even very common ones) could be harder to catch.
What if the house is too hot or too cold for baby? They'll either scream from discomfort (or not sleep) or parents may be tempted to engage in unsafe sleep practices like keeping the baby in bed with them.

Is it so crazy to think that any of these advantages could be not present for some? No. Is it so crazy to think parents are trying to make it work with none of these advantages? Not at all.

I not only don't understand how people make it work, but I don't understand how we think it's ok to ask people to make it work without providing some level of universal support. Federally supported paid time off and an advance on the child tax credit seem like a minimum bar, but new family counseling should probably be a part of the package as well.

Transparent nothingness

The Trump admin is pushing for regulations that would force hospitals and insurers to publish their negotiated rates for various procedures. Theoretically, this brings additional transparency to healthcare and allows customers to make better decisions about their costs and care. While this sounds good, I don't believe any aspect of this plays out in practice.

The negotiated rate depends at least on both parties: different insurers reimburse different amounts for care. It also depends on the details of the customer's plan. In other words, this negotiated amount might change on a very granular level, and it's not clear that such a value could be reasonably published. Furthermore, the negotiated numbers could change at any time: published rates would need to be kept up-to-date. This is certainly feasible, but it's an enormous list to manage. Consider the combination of the number of procedures, providers, insurers and plans. For a non-trivial procedure, it may not be clear to the customer what codes they will be charged for. In other words, the information is likely hard to parse, limiting its value.

More importantly, the negotiated rate is not what the customer pays. Look at any EOB form, there are 4 line items:

1. Total billed by the provider
2. Negotiated amount paid to the provider
3. Amount covered by insurance
4. Patient's out-of-pocket obligation

The policy proposes to reveal item 2, but customers should care about item 4. Complicating the relationship is that a patient can have conditions on item 4. For example, most HSA plans have a deductible and out-of-pocket maximum. For example, suppose the following scenario for a knee MRI (taken from personal experience):

1. Total billed = $1239
2. Negotiated amount = $802
3. Amount covered = $410
4. Patient obligation = $392

Ordinarily, I'd owe $392. However, once I've hit my deductible limit (spent enough out of pocket for the year), I only owe 10% of the negotiated amount: $80.20. And, once I've hit my out-of-pocket maximum (a cap for the year), I owe nothing. All of this resets on January 1st. A published table would not capture any of these dynamics. I'd be on the hook to understand the details of my plan. I fully advocate people understanding such things, but it does make the calculation that much trickier.
So, isn't this better than nothing at all? Maybe. I'm deeply skeptical of anything this administration does, and I think there's a potential nefarious motive. It'd be great if all consumers were well-informed, but this is, has been, and always will be a fantasy (especially with a subject as complex as medicine). Our President knows this as well as anyone; he has made a living scamming anyone he could, and surrounded himself with others who do the same. Suppose I am one of those uninformed people and need a knee MRI. I look up some published costs and find that some other lab is willing to do it for $700, or maybe the lab I that performed mine is willing to give me a 50% discount if I pay cash on the same day. That would bring the cost down to $619.50. What a savings! I choose that option. I ended up coming out worse than if I'd run it through insurance ($0-392, depending on my other details). Not only did I come out worse, my insurance came out better! They got to save $410 while still charging me the same amount for my plan. The provider is the loser in this scenario ... maybe the insurers are better connected with the GOP or Trump.

Even if I navigate a potential procedure correctly and pick the cheapest one, how do I know I'm getting a similar quality of service? The tables would just be for a billed code. Maybe some other lab's MRI is older and yields a worse picture. Maybe a procedure is done by a worse doctor who misses something. There's virtually no way to evaluate these things without being an expert - and almost none of us are experts. Picking providers piecemeal also fragments medical records, preventing the next provider from having a full picture of our medical history, likely resulting in worse overall care. There's even a problem on the purely fiscal front. Choosing an out-of-pocket alternative provider runs the risk of not contributing towards my deductible or cap. I might have saved money on this procedure, but don't get a benefit on the next. Since my next procedure after the MRI was a surgery, I would have just paid that much more of my out-of-pocket there. I would actually come out worse by saving money in the short term! To predict this, I'd have to have enough medical knowledge to predict what procedures might be following.

My inclination is that getting people to focus on the dollar amounts of their care will lead to a lot more Dr. Googling and broadly worse overall care outcomes. As people rely more on skipping insurers, those insurers can better justify offering junk plans that give them profits with less and less risk. The GOP has been misdirecting the public for decades, I think this is another example. Why would Trump suddenly care about people?

A house with no walls

The right has been quick to trot out the analogy that you would never leave your doors unlocked, or have a house with no walls or a fence … so why don't you want the same for your country? This analogy is somewhat intuitive to half the country, and seems completely ridiculous to the other half, but why? What is really so wrong with it? Let me count the ways!

On a most basic level, very few people have fences for strong security. As even wall proponents will point out, the most a fence does against a motivated intruder is slow them down. Most people create a fence as part of a visual aesthetic, a privacy barrier, or a way to keep their pets and children on their property. "You built a fence, therefore you should build a wall" doesn't hold water - they address different problems. Furthermore, if my fence doesn't wrap around my entire property, the intruder will just walk to the part where there is no fence and come in there. A partial fence is useless as a barrier.

Well, but you wouldn't build a house without walls, would you? Of course not, that'd be antithetical to the point of a house: to keep the weather out. Houses are, first and foremost, a form of shelter: a defense from the elements. We put valuable things into the same houses as well and also want to protect them from the rain and freeze and scorching sun. We place windows into those walls so we can get natural sunlight and bask in our surroundings. These windows present a super weak barrier against intruders: a simple crowbar or rock will defeat the window in seconds. Motivated invaders are definitely not deterred.

Fine then, your house is basically worthless for defense. So why do you lock your doors then? I suspect this is largely for the same reason that people want a wall on the southern border: it will make them feel safer. Most doors are pretty easy to kick in, and if not, there are those windows again. Certainly depending on the neighborhood, people may walk by and try to open random doors. Locking them will deter some less-motivated intruders: the opportunists. Those who think there is something of value within, and think they can quickly come in, and get out with it, with a reduced chance of being noticed.

So, how motivated are people who are coming over the border? And what are they coming for? I hear they are incredibly motivated and are coming for our jobs. In the above analogy, the highly motivated intruder will not be kept out by the defenses presented by most homes. But, the thing they want is to intrude and then stay... which is exactly not what the home intruder is trying to do. And we know they are staying, because we're so full of illegal aliens, right?

We're talking about erecting the equivalent of proposing a nuisance fence as a serious part of a solution to the problem of motivated people wanting to come into our house and then wash our dishes and laundry and all the other things we really don't like to do. If you don't want someone else handling your undies, that's fine, but don't pretend that a single silly barrier will make the difference between them trying to come here and not. 

Immigration chain addendum

Our chief idiot is floating that he will strike down birthright citizenship with an executive order. It's probably all hot air, and would be struck down in the courts, but it definitely stokes fears of immigrants. One of those fears is that parents will come to the USA just to have their kids and make their own path to citizenship easier.

While this is sort of maybe technically true, let's look at the details. As I've outlined in the past, the "links" in "chain immigrations" are prohibitively long. To recap, a US Citizen of age 21 or higher can petition for their parent to be given a green card. Using the anchor baby as the basis, this baby will need to live for 21 years, then petition, then wait at least 7 years, but usually 20+ (especially for those from countries that certain people tend to worry about). 40-45 years after giving birth, a mother can be reunited with their child in the USA. This is an exceedingly long play: the mom has a decent chance of not living that long, and the people worried about this abuse are even less likely to be alive by the time it happens.

Another concern is they are going to leach off American benefits. If the kid stays in the country, then yes, I suppose they will … but they will grow up in America like any other kid, will probably get a job like any other kid, etc. In other words, they'll be like any other kid and should get the same exact support. It's economically sound, and morally right. If they don't stay in the country as a minor, then they won't get any of the benefits and problem solved. 

Working on the immigration chain

"Chain immigration" is now a common topic of discussion. How does it work?

Claim: Well, anyone in America can just bring their random relative over.
Fact: The family-based visa program is limited to nuclear family: parents, children, sibling, spouse.
Fact: The family-based visa program is limited to sponsors who are already US Citizens.
Fact: The family-based visa program allows a US Citizen to _petition_ for a visa for a close family member. The applicant must be background checked, interviewed, etc. There is no guarantee they will be granted a visa.
Fact: Once approved, the family member receives a green card and can stay permanently in the USA.
https://travel.state.gov/…/family-based-immigrant-visas.htm…

Claim: Ok fine, it's limited, but then people arrive and just repeat the process.
Fact: Remember, sponsors must be US Citizens. It takes a minimum of 3 years to receive citizenship after arriving and getting a green card.
Fact: Family-based visas are limited in number (currently about 200k are given out in a year). This means there are backed up waiting lines, often in the 5-10 year range (and more for some countries). Your married child or sibling from Mexico or the Philippines would have been waiting for 20+ years to be approved today.
Fact: The only group that is approved faster (about 2 years) are unmarried minor children.
https://immigrationroad.com/vis…/visa-bulletin-by-month.php…

Claim: But the chain! They will just work around the law by getting their parent, who will get their parent, who will get their other child, who will get their child, and now the cousin is here. Also I can't do math.
Fact: I will do the math for you. It will take a US Citizen, who is at least 21, at least 7 years to get their parent in the country. That parent will then require another 3-5 years to get a citizenship. So, in 10-12 years, they can sponsor their parent and there's no guarantee it will be approved. By the time it might be approved and your grandparent immigrates and becomes a citizen, you are at least 41 and your grandparent probably isn't alive anymore. But if they are, they can try to repeat the process twice more, and 20-25 years later your cousin is here. You are at least 61 by this time. Also, these are the absolute best-case times.

Claim: Oh, I got it, instead of parent to parent to child to child, we can do parent to sibling to child. That eliminates one step.
Fact: Yay, a critical think! Now the best case is your cousin can be here in 30-35 years.

Claim: Actually it's 25 cuz the cousin will be here after 5 years, you counted 5 more years for them to get a citizenship but they're already here and have done all the crimes so nana nana nana.
Fact: You got me there. Everything I've said must be invalidated then. Unless I remind you that 7 years for the wait is the best-case, and good luck with that. For Mexico, each step will take 25 years, so by the time your cousin gets here, you'll be 100 years old and you won't even remember them.

So how does it work? It doesn't. Not in any real practical terms.

How does society advance

We were once cavemen. We would spend our days hunting mammoth and gathering berries or whatever, and that was that. We banded together with others we could trust so that mammoth hunts would succeed, but our daily life was still this loop: find it, get it, eat it. Repeat. Occasionally fight off an intruding sabre-tooth tiger or bear or giant beaver. There was little time for anything else.

Eventually civilizations rose. Their hallmarks were governing bodies and the ability to grow and store food. Without having to worry about where calories would come from each day, people could spend their time doing other things: organizing group efforts to build structures, developing science to help with that, learning how to build tools and ride camels, etc. Society became more functional because people had more time for activities beyond basic subsistence.

Even today, the next great invention or startup or idea will materialize because someone has the time and freedom for it. We can best elevate society by removing or lowering subsistence barriers as much as possible.

Rampant deregulation flies in the face of this. It allows some who are innately aware of certain things to thrive. Suppose we don't have a guarantee of clean water. Those of us who know how to test it will take some time to do that and then go about our lives, and the rest of us will have lots of gastrointestinal or death issues. All of us will waste a tremendous amount of time either testing the water or suffering from its effects and be unable to do actually productive things.

A significant measure of society is its cumulative productivity. Productivity requires food, health, education, and a low enough baseline stress level to function. Said stress level is often related to the availability of food, health, and education.

Maybe we need to create a food voucher program for everyone, not just the needy. Remove the conditional administration overhead and just give everyone a FedFood card that reloads every month, no questions asked. If you want to buy something fancy and have the money for it? Cool, do that. Isn't that some crazy huge tax though? Math time:

1. The USDA estimates the basic cost to feed an adult is about $50-60 per week.
2. Approximately 12-14% of USA households are food insecure

The shortage in dollars is, therefore, at most $50-60 per week * 12-14% = $6-8 per week, or $300-400 per person. Most food insecure households have some money for food, so the actual number is significantly lower. This is how much tax redistribution, per person, it would take to make sure everyone has enough money to eat. The average tax per person should be about the $50-60 per week. For those of us who already can afford all our food, a portion of our expenses just makes a trip to FedFood via these taxes. That money is even tax-advantaged (in my hypothetical system), meaning many of us would come out net better - I get $3000 a year less in net pay, but don't pay taxes on it either. If I get it back as a tax-free spendable credit, I've come out ahead even when adding the several hundred dollars overhead to cover those in need.

We can make a similar argument for healthcare; this is a well-discussed area.

Betsy DeVos is currently trying to go the opposite route in education to make people like her richer. Instead of undermining one of our basic societal needs, she should just go stick her $1B net worth in stock market and buy a new yacht every year. We can instead spend a fraction of the $600B annual defense budget on federal teacher resource supplements: no more buying crayons for their classrooms out of their own paychecks. Or just give them bigger paychecks.

Clearly these are not carefully thought through end-to-end, but maybe there's something there. As a society, we should find the issues that negatively affect most of our members' ability to lead productive lives, and address them. Repeat.

Parallel Universes

This is not about physics. Or time. It's about lies.

When a person lies, they create a parallel universe. In this universe, some fact is different.
The person now has to take care to live in both universes: the real one with the people they haven't lied to, and the alternate one with the rest.

But don't alternate realities collapse when the main character meets themselves? In the same way Marty McFly can't let other Marty McFly see him, interactions between those in the real and alternate universes are fraught with peril. If they talk to each other and discuss their versions of the same fact, the universes become incompatible.

Every time the person lies, they create more and more parallel universes and have to maintain each one. Juggling them is hard work, eventually some will drop. The only universe that stays stable is the one with all truth. In the long run, reality wins out. Lies requires additional energy and become unsustainable.

Unfortunately "the long run" can be quite long on a human lifespan scale.