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.