Future of health care policy?

Excerpts from Interview with Atul Gawande

by WCE

A century ago, we really finally drove childbirth from being one of the biggest killers for women and newborns to becoming a rare cause of death for women and a much, much lower likelihood of death for children. It was a combination of the government and the private sector. The private sector innovated around how you save the mothers’ lives and babies’ lives. But public information—a century now of [recorded] death rates of every hospital, every death of the baby and the mom—total transparency about where things go wrong [also played a role].


The Department of Public Health would potentially shut down a hospital if it was having bad results. It would hold people’s feet to the fire to maintain a minimum standard of care. You could get real competition between places over everything from the experience of care and whether they have a Jacuzzi or whether they have great clinicians. But you weren’t competing over whether your baby would die or the mom would die in one place versus another. The lesson I’ve [learned] from working on the nonprofit side, working on the private sector side, and having worked on the government side is: Given how much the big have gotten bigger, there will need to be much more data transparency about the actual services that are provided and what the outcomes are—whether it’s childbirth, primary care, cancer care, or surgery.

There is going to need to be close involvement from people in the public health system around whether it’s serving its minimum quality and appropriate levels of care. And the pandemic has made that eminently clear. We don’t have the basic information on whether testing is being done and where, who has access, who doesn’t have access, how well it’s being done, where the holes are, how much mental health has been damaged, how much our specialty care has been affected.”

https://www.fastcompany.com/90590937/atul-gawande-interview-haven-healthcare

Mémé: I confess I don’t know what WCE intended by the excerpt she provided. I think it has something to with using good data to make policy. So I extracted some sections I thought interesting as well.

Primary care is a service where you should have ready contact for the majority of your medical needs at any time of day. It should be a team that you have contact with, who knows you well enough to know what your goals are and how you’re doing over time against those goals. And it then should be able to deploy the assets of the healthcare system, which are enormous, right? Whether it’s highly complex, specialty care, getting you a COVID test, or recognizing your goal is to get pregnant and getting you on the right path there. It should be a system that could enable all of the assets of the system to serve your needs and then follow along to make sure that when it doesn’t serve your needs, you’re in good hands.

That basic service is a fundamental building block of many systems around the world, but it is not of ours. We don’t have a system for the fact that half of your life or more is going to be spent with at least one or more chronic illnesses, whether it’s high blood pressure or a complex heart disease.

We have a fundamentally broken system by having a healthcare system built around where you work. It means when you stop working, you lose your healthcare, you lose your primary care. You don’t have the connections sustained for big parts of your life like it should be.

I think the way that Medicare Advantage is evolving, Medicare [Accountable Care Organizations], some of the capitated [fee per patient] Medicaid plans is the ideal way to go. And what is that? It means you have a primary care relationship. Dollars flow on a monthly basis to that team to meet a certain level of convenience and efficiency, to get the full range of your needs from medicines to preventive care, to be advocates for you. And if they don’t do a good job, then you take your payment from them and it goes to the next clinician and the insurers reward them for being able to deliver on a certain quality and manage the cost constraints. That has been immensely popular in Medicare with more and more people flowing into that part of the system. I think it would be of great interest if we were to expand in the under-65 population

152 thoughts on “Future of health care policy?

  1. Healthcare policy is one of those areas that is extremely complicated and not something easily discussed in a forum like this.

    I really do like Atul Gawande.

  2. WCE, I agree with you that health care should absolutely not be related to employment. But I disagree with you that the US can hold falling maternal and infant mortality rates up as an example. There was always a great disparity in them, and they have been increasing for Black people in our country over the past few years.

  3. I really do like Atul Gawande.

    So do I.

    I’ve said before, IMO the biggest problem with our healthcare system is the fee-for-service model.

  4. My observation is that most people I know *say*, but do not *behave* as though they value a relationship with their healthcare professionals. They go to the doctor when they or their kids are “sick enough” (not when symptoms first occur) to see the doctor or are required to (shots or physicals for school/sports) or incentivized to (my neighbors employer gives them 4 hours of leave if they get a physical each year and bring in proof they did so). For the system to work, you need the patients to be onboard as much as the healthcare providers are.

    I have only had one primary care doctor I felt comfortable with and felt that she was treating me as a whole person. She has left the practice and our area, I do not like her “replacement”. One of 2021’s To Dos is to find a new primary care doctor for me. Part of the issue, as noted by Meme, is that they must take my insurance and be taking new patients.

  5. They go to the doctor

    I bet that’s a lot of the problem. The insistence that you have to physically go to the doctor. With telehealth and patient portals it’s much easier to build a rapport with a physician.

    I recently had an issue and I e-mailed my doctor. He said, “I’ve ordered some labs.” So I walked over to Quest and got my blood drawn. The next day the results were back and he e-mailed me to say he sent my updated prescription to CVS. Why should that require me to physically go to the doctor, sit in the waiting room, wait for the nurse, wait for him to finish with his previous patient, etc? It’s all sooooo much easier.

  6. “One of 2021’s To Dos is to find a new primary care doctor for me. ”

    Same here!

    I hope telemedicine continues to be an option post-COVID. I also hope that we can increase medical school and internship spots to produce more GPs.

  7. “Dollars flow on a monthly basis to that team to meet a certain level of convenience and efficiency, to get the full range of your needs from medicines to preventive care, to be advocates for you”

    Sounds like the HMO I was in early in my career (or for those familiar, the Kaiser Health model that’s been around for a long time). It really was fine for that stage in my life.

    I agree completely re the disconnecting of health care coverage from employment.

  8. I’ll be interested to see what the health outcomes are for patients using Medicare Advantage versus other forms of more traditional fee for service models.

    Regardless of which model works best, I am very grateful that we have statistics available on death rates and other information that can pinpoint where public health efforts are needed, and that give us more of a point of comparison.

  9. Rhett – I didn’t necessarily mean physically go to the doctor, but many lower income clinics have not picked up on telemedicine as fast. Also, if you want prescription pain medication, it is likely you will have to go in.

    One thing the pandemic has shown us is the digital divide in my state and maybe nationwide. While my family has done some telemedicine (SO cannot because needs blood work at every oncology follow up), for older people, it often falls on the children to go to the telemedicine appointment and navigate the portals with them.

    In my city and surrounding areas, we have large numbers of people without any or fast enough internet to do that kind of thing. Less than an hour away from me, most people in the town have the equivalent of dial up internet. The school kids are driving to the school parking lots to get wifi and the school purchased buses and then tells families the location by telephone, then the families drive or kids walk to where the bus is to do school work.

  10. Grrr… When you add more process you slow things down. You can’t make the perfect the enemy of the good.

  11. I am really hating private insurers right now. Our main insurance, UHC, is severing its ties with one of the largest provider networks in NYC/Westchester. This means that two of the three major hospitals in the region are no longer covered in our plan which is a bit scary. Many people are losing all their providers. We are lucky that we are only losing one provider but it is a bad one – the developmental pediatrician that DD sees. The problem is, many of the providers in Westchester that are able to manage her issues do not take any insurance. She used to see providers in the one group we have left to us, but they were terrible. I would never go back to them. So now I am trying to figure out how expensive it will be to remain with the good provider out of network vs trying to find someone else, which may mean travelling into Manhattan (we travel to the Bronx now for this provider)

  12. My current PCP is okay but not great. I like the NPs that he works with better. The practice admin is not on the same page as the practitioners, either – when I saw the NP for telehealth last week it was because the admin people had called and wanted me to come in for a physical (lol, not likely during covid!), and the NP looked at my chart and said “you’re not due for a physical until next year”. In the meantime she refilled my synthroid rx for the year and sent an order so that I can go in for bloodwork anytime this year, “whenever you feel comfortable”. Much more efficient!

  13. (SO cannot because needs blood work at every oncology follow up)

    You can probably have his doctor send the labs to Quest or Labcorp. There are 11 and 12 locations just in Austin itself respectively. It might be more convenient and safer for him. I’m usually in and out in 5 min. YMMV

  14. Back when I was teaching our healthcare informatics course, we always did a unit on telemedicine. This is an area where technology moved ahead much faster than regulatory agencies or payers were ready for. Traditionally, one of the big obstacles to telemedicine was remibursement. Payers either did not reimburse at all, or reimbursed at significantly lower rates, so it wasn’t worth the doctors time. I think that did change with the pandemic.

  15. I agree with Reality that healthcare policy is a hard topic to discuss and am glad other people like Atul Gawande. Sorry to Meme that I didn’t have any clear idea for the discussion– I try to post a brief excerpt from articles that interest me so others can see if they might be interested without clicking a link.

    As an example of how access skews public health data, in my county, COVID testing requires a provider order (at least if you have insurance, but presumably you’d still have to pay for the appointments if you haven’t met your deductible) while in the next county over, a few hundred yards from us as the crow flies, they’re offering free testing twice/week at the fairgrounds without a provider order. Part of me understands the need to limit the tests offered due to limited testing capacity, but requiring people to pay for a physician appointment in order to get a COVID test skews the resulting statistics.

  16. MM,

    Is UHC through the hedge fund or the university? Is it possible to switch? I’m also surprised there aren’t tier options where if you pay more they cover 80% of our of network or whatever.

  17. but presumably you’d still have to pay for the appointments if you haven’t met your deductible

    I e-mail my PCP for lab orders all the time. You don’t need an office visit. Or to pay anything. But of course that requires an existing relationship with a PCP. Although now that I think about it, someone mentioned that their PCP will only see them for one complaint at a time to maximize revenue. So if your provider is a dick then that’s also an issue.

  18. Most likely we will do out of network, but that can get pricey so I am trying to figure out how much. I have one of those healthcare accounts through my employer, but I think every penny of the money in that will go to DS2’s teeth.

  19. “You can probably have his doctor send the labs to Quest or Labcorp.”

    Yes, that is what MSKCC is doing with most of its longterm followup kids. Only the ones who need scans or have complex medical issues are being seen in the actual clinic.

  20. Years ago, MSKCC needed a 24 hour urine collection done, and DS2 and the rest of us couldn’t go into the clinic because he had been exposed to chicken pox. So they told us to UPS the sample to them overnight. Seriously, we overnighted a large box o’ pee to MSKCC.

  21. Traditionally, one of the big obstacles to telemedicine was remibursement. Payers either did not reimburse at all, or reimbursed at significantly lower rates, so it wasn’t worth the doctors time. I think that did change with the pandemic.

    Yes it did. Providers can also bill for phone visit as well as text and email consultations.

    They go to the doctor when they or their kids are “sick enough” (not when symptoms first occur) to see the doctor or are required to (shots or physicals for school/sports) or incentivized to (my neighbors employer gives them 4 hours of leave if they get a physical each year and bring in proof they did so). For the system to work, you need the patients to be onboard as much as the healthcare providers are.

    The incentive for patients is to avoid doctor visits because they have to pay for them. If it didn’t cost anything, people would go much more frequently (in person or virtually).

    The problem with the Kaiser and Optum model is it incentivizes providers to withhold care. I know some NPs who used to work for Optum and they said their bonuses were based on how much money they saved. What Optum does is they buy patients’ medicare benefits, so they become the primary insurer. They have NPs who round on the patients in nursing homes and assisted livings, and those visits are all free to the patients. Any kind of tests – labs, imaging, etc, – or specialist visits are paid by Optum as the insurer. In theory, it’s a great idea to limit overall costs. In practice, it incentivizes them to try to avoid providing care to save money.

  22. Rhett – SO’s oncologist has the lab right there. His appointment time is 1 pm, he first gets the blood work done, then at 1:15 he is called back to weigh, check blood pressure, temp, etc., then about 1:30 pm he sees the doctor or PA, who can already see his lab results. He could not have them done elsewhere and the office have the results in 30 minutes. This is less of an issue now that he is not having chemo/radiation treatments.

    DD – I understand that health care visits cost money, but at one time when HMOs were the main part of our plan, people were encouraged to go when they were “a little” sick vs really needing the ER. It was all because they were touting that it is generally cheaper to treat a condition when it is mild or to get a condition like diabetes under control before you are “sick enough” that they need hospitalization.

  23. I had Kaiser for one year back in the 90’s. It was OK, but they had a really restrictive drug formulary. The BCP that I had been using was not on the formulary and the only alternative had caused minor but annoying side effects. At the end of the year my employer eliminated them as an option so I went back to traditional insurance and was happier.
    The other thing I remember about Kaiser was that there were a few kids with NB on our mailing list who had Kaiser. It was a real problem for them because Kaiser had no one with a ton of experience in treating NB, especially refractory NB, but they could not get coverage for anyone outside of Kaiser. It is not a plan I would want to be on if I got some rare and difficult disease.

  24. AustinMom, the thinking today seems to be to reduce utilization of healthcare as a way to drive down costs. So you DON’T want people going to their PCP frequently. That is the theory behind high copays – keep utilization down.

  25. He could not have them done elsewhere and the office have the results in 30 minutes.

    He could go to Quest two days before the telehealth visit. They’d just have to place the orders. Just something to keep in mind as we’re in the midst of what is hopefully the last surge before the vaccine.

  26. DH and I both have the same Medicare Advantage Insurer. He has a mid tier plan for which he pays extra to the insurer each month on top of his medicare part B and D premium. This is because he has a very expensive eye shot each quarter, which is zero cost at this tier. He also has dental through his former employer. I have the rock bottom basic plan, only what I pay Medicare each month. The basic plan which is assumed to be chosen for cost reasons, has add ons he doesn’t get . It gives me 2 free dental cleanings a year plus exam and xray, and 50 a quarter in free OTC goods from a mail order house. Fir Me, not for household members. The insurer sets up groups. He gets his care through a formal Kaiser style group. I am in a circle of care arrangement. Good local hospital. Works for now since I am an infrequent user.

  27. DD – I understand that health care visits cost money, but at one time when HMOs were the main part of our plan, people were encouraged to go when they were “a little” sick vs really needing the ER. It was all because they were touting that it is generally cheaper to treat a condition when it is mild or to get a condition like diabetes under control before you are “sick enough” that they need hospitalization.

    Totally, but as Rhett like to point out, lots of people don’t have the cognitive functioning to understand that. Or maybe they do, but they have bad or no insurance and can’t afford the $75 or don’t want to pay it.

  28. Nothing upsets me more than healthcare insurance. I just went to refill a prescription for concerta. I was old that my insurance no longer covers the generic (price $10). The name brand is $162 for a month’s prescription. This isn’t a drug that I can have the doctor switch out to one that has a covered generic. I had them run the price of the generic without insurance and it was $200. Whatever, I don’t have time to figure this one at the pharmacy, I need this pill today, and there is a snowstorm going on. So I paid $162 and now will spend my afternoon figuring out what to do for the next 11 months. I know there are options like GoodRX, but it will take time out of my day.

    As DD said above, lots of people don’t have the cognitive function to deal with stuff like this, nor do they have $162 to throw at it.

  29. Rhett – SO is not doing telehealth visits, they are in person, every 3 months. It is not an option to do telehealth with his oncologist. They want to look in his throat and touch his neck – treatment area and lymph nodes.

    They have very strict office, treatment room, and lab procedures due to most, if not all, their patients having some sort of compromised immune system. It is all in the same office with a one-way system. You go in one door, to the lab, then to the waiting area, then to the visit area an then out through another door. Unless you cannot manage yourself, you cannot have anyone come in the building with you. If you need actual treatment – chemo or radiation – your pathway is a little different, but still one way. Even if the doctor determines you need something, like more fluids, you go out and back in at the starting door.

  30. Or maybe they do, but they have bad or no insurance and can’t afford the $75 or don’t want to pay it.

    I also willing to bet that everyone involved with deciding that the co-pay should be $75 makes more than $100k a year. They really can’t grok the fact that many people consider a job that pays $20/hr with benefits to be a good job. For those people, tying to raise a family on $20/hr, $75 is a lot of money.

    It we convert it to totebag dollars that’s like the copay being $506.25*. And that’s not even a real conversion as the average totebagger has a fair bit of fat that could be cut to come up with that $506.25. Someone making $40k doesn’t really have a whole lot of room in the budget.

    *$270,000 / $40,000 = 6.75 6.75 x $75 = $506.25

  31. I also willing to bet that everyone involved with deciding that the co-pay should be $75 makes more than $100k a year.

    Less! I mean makes less than $100k a year.

  32. My PCP always sends in my lab order at my prior appointment so that I can get it done prior to my visit…thus, we have stuff to talk about. I don’t understand why a Dr would do anything different now. Her practice has other flaws…I can’t seem to get the portal to work. I’ve reset it a few times, which adds to the problem. She also is terrible at returning calls, but I have her cell and email, to which she responds quicker.

  33. Most insurance, but definitely health insurance, requires a good amount of executive function to work through to compare. Like most, my insurance was with my employer before I retired, but one of my retirement benefits is health insurance. It is the same plan as active employees until I turn 65 and then it becomes a medi-gap plan. However, we had significant changes in 2003-4 and since then our costs have gone up a lot with an associated decrease in what is covered.

    My DDs for a small premium are on my plan. They get a better deal because the “retiree” plan has an option for out-of-state participants. It turns their plan into more of a PPO, but still has lower costs for in-network providers. Both have used the plan for minor things and they are paying less than I do for the same care. I can’t change because your address must be out-of-state and the say they monitor your usage so that if you are using too much in-state they will assume you are cheating the system and switch you back. DD#1 sees her primary care doctor here every year and that hasn’t triggered any change.

  34. WCE,

    RMS already pointed out the flaw in your logic. By the logic of that podcast your religious tradition is preventing many thousands of births by discouraging teen and out of wedlock sexual activity.

  35. Rhett, not so much that preventing births is a problem but that car seats prevent 57 statistical deaths in crashes annually but contribute to the observed 52 annual deaths in hot cars.

  36. Rhett, not so much that preventing births is a problem but that car seats prevent 57 statistical deaths in crashes annually but contribute to the observed 52 annual deaths in hot cars.

    How would they know that? What’s the control group?

  37. And of course there are many many terrible outcomes of car crashes besides death. Traumatic brain injury, spinal cord injury, and on and on.

  38. Rhett, if people are interested, they can read the summary. The point is that seat belts would pass the car seat test for children two and up, child car seats are only slightly better at preventing only minor injuries than seat belts so why can’t we just let people use seat belts instead of car seats? The regulatory infrastructure to save less than net 50 lives/extreme disabilities is questionable.

    This podcast brought back an awful day for me when DD was two and the minivan went into Auxiliary mode in error while I was going around to buckle her so the fob wouldn’t unlock the minivan. I was able to get her to climb out of her carseat (only because she wasn’t yet buckled) and hit the red button to get the minivan out of Auxiliary mode (or whatever it’s called when the electrical systems work and the engine isn’t running, which is what it was stuck in) so that the fob would work to open the doors. If she’d been buckled, I don’t know what I would have done.

  39. The regulatory infrastructure to save less than net 50 lives/extreme disabilities is questionable.

    Again what’s the control? How would they know that?

  40. From that podcast transcript, I like that Levitt is clear that he has six distinct children.

    “Steve LEVITT: I have six different children, ages 20 down to 2.”

    Well good! No double-counting. Six different children.

  41. I think that ignores the fact that a lot of people really don’t like going to the doctor’s office for a whole host of reasons. It’s uncomfortable and inconvenient. And it’s hard to find a good doctor that meshes with your personality. I’ve certainly seen my fair share of jerks, and I’m healthy
    and pleasant enough without many complaints or maladies. I don’t particularly care for going to the doctor, and I’ve had to talk myself into going more regularly as I get older. And it is not at all about cost for me.

  42. WCE, I listened to that today and thought it would make a great topic for the totebag because it touched on so many things. Besides the carseat safety, there’s the issue of carseats reducing births, the pandemic reducing births, lower birth rates in general, and the idea that children get short shrift in current policy decisions.

    This podcast brought back an awful day for me when DD was two and the minivan went into Auxiliary mode in error while I was going around to buckle her so the fob wouldn’t unlock the minivan.

    Your fob doesn’t have an emergency key in it so you can manually unlock the doors if the fob isn’t working?

  43. I also willing to bet that everyone involved with deciding that the co-pay should be $75 makes more than $100k a year.

    They are the same people pushing high-deductible plans.

  44. Lemon Tree I just had the same experience with Concerta!!! I went to the pharmacy about an hour ago to fill DS1’s prescription, and discovered they were charging me $140 now!! What is with that?

  45. “I don’t particularly care for going to the doctor, and I’ve had to talk myself into going more regularly as I get older. And it is not at all about cost for me.”

    Yes, this. I have retiree health benefits and the copays for office visits and prescriptions are minimal. However, the nonmentary costs of accessing healthcare are nontrivial.

    Also, what DD said about HMOs having an incentive to minimize care is also relevant.

    When my daughter tore her ACL a few years ago, we went to the doctor. He wanted to wait a few weeks before starting the process of scheduling an MRI. She was on summer break from college and had a limited amount of time to get the MRI, get a diagnosis, have surgery and recover enough to go back to college. Initally, she went in to the doctor by herself, came out and said they wanted to wait before scheduling. I convinced the front staff that we needed to reconfer with the doc, Went back, explained the time schedule, explained that I knew how long it would take to schedule an MRI and that we needed the paperwork in today. He agreed, but it is irksome.

    My hand still isn’t right, but i can’t get an ortho consult for another two weeks.

  46. Rhett, not so much that preventing births is a problem but that car seats prevent 57 statistical deaths in crashes annually but contribute to the observed 52 annual deaths in hot cars.

    I didn’t see that fact quoted in the article. Where are you getting that from? The average number of hot cars deaths is 38….

    On average, 38 children under the age of 15 die each year from heatstroke after being left in a vehicle.

    https://injuryfacts.nsc.org/motor-vehicle/motor-vehicle-safety-issues/hotcars/

  47. @WCE – I have also been skeptical about the cult of car seat perfection, and I remember reading about it in one of the Freakonomics books as well. Rhett is correct that they only talked about deaths vs other injuries. And kids would still need a booster seat as there are now shoulder belts in the backseat of any modern car. But the obsession with perfect car seats and 5-point harnesses into late elementary has always seemed more religious than data-based to me.

  48. “I’ve said before, IMO the biggest problem with our healthcare system is the fee-for-service model.”
    “The problem with the Kaiser and Optum model is it incentivizes providers to withhold care.”

    Is there a model that you like?

  49. One problem with the hotcar death stats is that they didn’t start keeping records until the 90’s. How many sleeping babies died in cars in the 60’s and 70’s? They used to use car beds for babies back then, and I imagine some people managed to forget their babies back then
    car beds

  50. “I was old that my insurance no longer covers the generic (price $10).”

    Why not just pay the $10 out of pocket?

  51. “I also willing to bet that everyone involved with deciding that the co-pay should be $75 makes more than $100k a year.
    “Less! I mean makes less than $100k a year.”

    Your point seemed to make more sense before your correction.

  52. My observation based on taking my dad to a slew of medical appointments is that a non trivial number of seniors actually *enjoy* going to see the doctor. Their spouses and children and friends may tire of listening to their litany of symptoms, but the nice ladies in the office listen and dutifully record them. They get a chance to talk about what ails them. They can banter with the receptionist when setting up the next appointment. For some, it seems to be the highlight of their day. Even with plexiglass and masks. And maybe they will go out to lunch afterward.

    I agree that busy and generally healthy professionals resent the time it requires to keep up medical appointments, but lots of older people with chronic health issues are essentially professional patients. This is their job now.

  53. Finn, her insurance had covered the $200 generic with a copay of $10, but the copay for the probably much more expensive Concerta is $160. If she paid out of pocket for the generic, it would be $200

  54. Finn, I was quoted $200+ for the generic w/out using insurance. The $10 was what Aetna previously charged me for generic. Now they completely dropped generic coverage. I’m sure when I shop around I’ll find a better deal, but needed that script filled today.

  55. Ivy – SAME. I basically followed the guidance from when #1 was born for the other 2, even though according to that guidance #2 would have still been in a booster seat at age 10 since he was under 80 pounds. I turned #1 around right at 12 months since she was barfing all over the car at that point when rear-facing. #2 and #3 were rear facing for longer since they didn’t get car sick as much.

  56. One of the issues with our current type of health insurance is its capriciousness, as illustrated by the sudden jump in Concerta price, and the fact that people in Westchester who are covered by UHC have suddenly lost a large percentage of local providers as of Jan 1. In European systems that use private health care, the insurers are much more tightly regulated and can’t make such sudden changes

  57. “I’m also surprised there aren’t tier options where if you pay more they cover 80% of our of network or whatever.”

    It’s the whatever part that can get you.

    I think a lot of those plans cover 80% of UCR for out of network, not 80% of what the provider charges you. UCR and what you are charged can be quite different, potentially leaving you on the hook for quite a bit more than 20% of the OON charge.

  58. In both 2018 and 2019, a record number of 53 hot car deaths were reported.
    Never thought about the car seat connection before.

  59. If there indeed has been a spike in hot car baby deaths, which we don’t even know because we don’t have records from the 60’s or 70’s, it is just as likely to have been caused by the fact that babies commute in cars a lot more now than they did back in those days, because of two career marriages. People back in the 60’s and 70’s were much less likely to be dropping off baby at the daycare or sitters on a daily basis. If babies went out in cars in those days, it was more likely to be shorter errands like grocery shopping/

  60. This made me think about when the DDs were toddlers. If a child was sick on Day 1, it was better to keep them home because if they were better you could send them back on Day 2. If you sent them to day care and the center sent them home, you were now out at least 2.5 – 3 days (Day 1 to go get them, Day 2 to let the issue run its course, and Day 3 for them to be fever free). Now, if you got a doctor’s note, you could come back “earlier” if it said so.

    Lower income parents were often looking at this as a math problem – 2+ days off work without pay, or 1.5+ days off without pay, plus the cost of a visit. Sadly, often the cost effective solution was 2+ days without pay.

  61. And the fact that I just shelled out $3000 for my deductible to cover 1 month of meds, it’s like the $162 just broke me. I don’t know how people without means handle it.

    MM – I hope that those NYC hospitals are still negotiating with UHC and it can be resolved soon. A few years ago BCBS dropped Children’s and a large hospital group and eventually they came to an agreement. It’s all about money, and not about humans, which is sickening.

  62. “Never thought about the car seat connection before.”

    Again, we don’t have records before 1998. By that time, everyone was using carseats. So we cannot compare against the pre-carseat era. We simply do not know.

  63. “her insurance had covered the $200 generic with a copay of $10”

    OK, I get it. The copay was $10, not the price.

    “I’m sure when I shop around I’ll find a better deal”

    What I’ve read, e.g., in CR, suggests you check the OOP price for the generic at places like Costco Walmart, and Sam’s.

    I had a somewhat similar experience a while back. The copay for the kids’ vitamins went up, so I checked at a few places and ended up paying less straight OOP than the new copay.

  64. In both 2018 and 2019, a record number of 53 hot car deaths were reported.

    Anyone using that number would be making a disingenuous argument, correct?

  65. I don’t know how people without means handle it.

    They don’t. As an example a guy is working the night shift at a casino and drinking Mountain Dew to stay awake. As time passes he gradually gets more thirsty and has to go the bathroom more often. But it happens so slowly he barely notices. It gradually gets worse and worse blurred vision, tingling, but he figures it’s just getting older, he needs new glasses. He’s reluctant to go the doctor as he has a $5k deducible and makes $45k a year. Then one night he gets up to pee for the 8th time and he’s peeing blood. He goes to the ED and his blood sugar is 880.

    And he had insurance.

  66. “not so much that preventing births is a problem but that car seats prevent 57 statistical deaths”

    Car seats are preventing births?

  67. Folks. The politics page serves several purposes. One is that it is “allowed” there to assume and accuse freely that other people are arguing in bad faith or that people employed in occupations represented among totebaggers and their families are selfish and not discharging their responsibilities. Just because some of the most argumentative posters have decided to avoid the politics page for various legitimate reasons doesnt mean that those comments can migrate to the main page . Kim is away and I am more of a hard nose

  68. Meme,

    I’m not saying WCE is making a bad faith argument. I’m saying her source is using statistical sleight of hand. In this case using an outlier rather than the average/median.

  69. “I bet that’s a lot of the problem. The insistence that you have to physically go to the doctor.”

    I had HMO coverage through my previous employer. They did not insist on physical doctor visits, and facilitated avoiding unnecessary visits.

    Every year, they’d send me a simple, plain English medical book that, among other things, provided guidance on how to treat various symptoms and when to seek medical attention. They also had a 24/7 phone line staffed by medical professionals, with no charge for calls, to provide similar guidance.

    Those measures probably resulted in many fewer doctor (or NP) visits, which not only reduced their costs directly, but reduced transmission of contagious diseases by minimizing the contact contagious people had with others.

  70. ” he figures it’s just getting older, he needs new glasses.”

    Shouldn’t his eye exams have picked up on his developing diabetes well before it got that bad?

  71. Is there a model that you like?

    I think something along the Kaiser/Optum model is the right idea, but rather than be a for-profit entity it should be a cooperative. That save a big chunk of expenses on the billing department and removes the incentive to limit care in the name of profits.

  72. “I also hope that we can increase medical school and internship spots to produce more GPs.”

    DS thinks the MD shortage is overstated, and our medical systems are not efficiently using MD resources. More use should be made of computer systems and AI.

    E.g., our test results, x-rays, symptoms, etc., should all be entered into a program that analyzes them and spits out possible diagnoses and/or suggestions of which additional tests should be done or symptoms to check. More radiology should be done by computer vs MD.

  73. Shouldn’t his eye exams have picked up on his developing diabetes well before it got that bad?

    Think about it for a second.

  74. “I think something along the Kaiser/Optum model is the right idea, but rather than be a for-profit entity it should be a cooperative.”

    Kaiser is a non-profit.

    “That save a big chunk of expenses on the billing department and removes the incentive to limit care in the name of profits.”

    My experience with Kaiser was that the billing part of it was really easy on my end. Pay copayment on day of treatment/exam, and that’s it.

  75. Rhett, you mean he ignores his deteriorating eyesight?

    That would argue against driver’s license renewal by mail of other not in person means.

  76. Car seats are preventing births?

    Yes. Long story short, births have decreased among parents who already had two children at car seat ages because people don’t want to have to buy a minivan or other large vehicle so they can fit three car seats. Read the transcript of the podcast WCE linked to (or listen to it) for the full explanation.

  77. Rhett, you mean he ignores his deteriorating eyesight?

    I mean he thought he needed new glasses but didn’t think it was bad enough to warrant spending the money to get a new prescription and new glasses.

  78. “That would argue against driver’s license renewal by mail of other not in person means.”

    Hey now! That’s my petty complaint from yesterday you are messing with! :)

  79. I think I’d rather have to go in person every 4 or 6 years to renew my DL than have Mountain Dew guy driving around with impaired vision.

    And that doesn’t even consider how much less of a burden MD guy would be on our healthcare systems if his diabetes were caught early and he switched to black coffee.

  80. ” people don’t want to have to buy a minivan or other large vehicle so they can fit three car seats.”

    I.e., interference with backseat procreation was not considered as a factor?

  81. “It’s all about money, and not about humans, which which is sickening.”

    “The patient has nothing to do with it!”
    — Dr. Anspaugh, Chief Of Staff, Chicago General Hospital, (ER, Season 3 (1998), which I’m streaming)

    It’s amazing, even though Michael Crichton is a doctor, how real that show is.

  82. Kaiser is a non-profit.

    And non-profits still hire executives who like to make a lot of money. In a coop, any and all profits go back to the members/customers.

  83. ““I also hope that we can increase medical school and internship spots to produce more GPs.””

    PCPs are increasingly NPs and PAs.

    After DS picked his school, I looked at nearby medical practices that participated in our PPO, Nearly all the available PCPs were PAs or NPs.

    One thing I really liked at Kaiser was that I had a PCP team, an MD and a PA. During my time with them, I had 3 different MDs, but one PA. I appreciated the continuity the team approach provided.

    I found out after I lost my 2nd, and favorite, MD that he’s the BIL of a good friend from college. He left his PCP position to start a geriatric care group within that Kaiser clinic.

  84. No matter the model, there’s always someone in the equation who is trying to keep costs as low as possible. Even if that doesn’t drive the CEO’s bonus.

    In the Kaiser/Optum/HMO model if payouts are under premiums collected, that delivers a surplus which can be plowed into more facilities to expand market share, do more preventive care/outreach which can further reduce outlays. I guess in the ideal world even limit premium % increases each year.

    In the high-deductible, HSA world (my world) those who do not fund their HSA enough each pay period are always facing the OOP cost for the office visit / RX (until they’ve met the deductible), so they try to wait stuff out, see if it clears up on its own, avoid paying the negotiated price of $125 to see a doc (even telemed). Because Totebaggers fund their HSA they either pay for services directly thru the HSA (clunky) bill pay or debit card or, maximizing return, use their points/cash back CC and then pay the statement when it shows up.

    LT – I looked. That med was $300 on GoodRx, so probably not your solution. Is the $162 taking into account you’ve already met your deductible?

  85. Fred, I’ll end up paying $162 until I meet my $6000 out of pocket max…I’m halfway there. Typically, I’ll meet the $6k max by June (and everything is “free” after that), but this year most of DD’s high expense screenings (such as echo) won’t occur, as she has been moved to every other year. But, if I sit down and look at all expected medical expenses. We may still end up meeting the $6k max later in the year, so either I get to the out of pocket max by paying these prescription copays, or I get there paying $3000 in lab draws and specialist visits, it doesn’t matter in the long run.

  86. Mountain Dew guy seems like the classic case for the HMO. Very low cost visits (my copays were $5) and free phone consultations encourage patients to not ignore symptoms (IIRC, eye exams were also covered with the $5 copay).

    In his case, an MD or NP might’ve had him switch from MD to black coffee as a simple way to stop the progression to diabetes.

  87. BITD, we received a fair amount of medical care in school I remember getting regular vision and hearing screenings (which made sense, since that affected the effectiveness of delivery), dental hygienist visits (including lessons on dental self-care), vaccinations, scoliosis screenings, and probably other things I don’t remember or didn’t understand.

    That seems to be a pretty efficient model for delivering some care, and catching some issues early, when treatment is often much more effective and less expensive.

    More generally, it seems free/very low cost screening and self-care education should be a part of any model.

  88. A couple of things to consider regarding car deaths from an earlier time, IME only:
    1. Many more things were manual, which meant if you were making sure doors were locked, windows were up, etc., you had to physically look at each one.
    2. AC in cars even in my state was not all that common in the late 60s/early 70s, heck for used cars even in the late 70s for mine. This meant, in general, if you put a child in the back seat, you tended to roll down the window. When you got out, you didn’t forget the child because you had to open the door to roll the window back up.
    3. Not very many people used car seats, which meant toddlers were often standing up holding on the drivers head rest. Again, harder to miss this child.
    4. People tended to put small children, even those infant beds in the front seat – harder to forget them.
    5. People often left the windows down in the car if they were running into the store or even in their driveway. I don’t recall tinted windows either. Cars also weren’t as sound proof, so a crying child was more likely to be heard/seen.

    A friend of mine’s parents were taking one of her siblings to the doctor – late 60s – and the other kids were at home with the oldest. The dad was driving, the mom was holding the child on her lap in the front seat. Another driver ran a red light, hit them causing the mother and child to be thrown forward with child’s head to hit the unpadded dashboard. The child had permanent brain damage and lost her ability to walk, speak well enough to be understood or toilet herself and had one arm that was completely paralyzed. If the parent had been belted, if the child had been in the back seat, if, if, if, this might not have been the outcome. No one intentionally does things to harm their children.

    There are many things that I have done that I look back and think how grateful I am that something turned out OK, but it could have resulted in death or significant injury to me or someone I love.

  89. Austin, good points. BITD, it was much more common for people to leave their windows open to some when parked extent to keep the cars from getting so hot inside.

    IME, which may differ from others here, when I was a kid it wasn’t so universal to lock cars either, which meant a lot more people also left their windows down quite a bit..

  90. Finn, of course I have HSA. Doing some quick math, my total medical expenditures a year (premiums and HSA contributions) is ~$15,000. Can you imagine a family of four making $45,000 a year getting by after spending that much on medical? Anyway, based on current Contribution Limits, the HSA is not a savings model for me (dental eats up the rest of my account).

    Thinking about why people don’t go to the doctor…Yesterday I went to get my ski boots looked at. My feet have been uncomfortably cold this winter. Part of the reason is that my feet have expanded/flattened a bit due to not wearing shoes…but part of the problem is that the liner of my boot was all scrunched up in the toe, making the toe box smaller, and that I’m apparently wearing too thick of ski socks. The boot fitter (this is his profession) was nice about it, but made me feel like an idiot for the bunched liner, and not knowing I should have a thinner sock. End result, new socks and customized foot bed. Now, take that feeling at the doctor….most people are going to be told they need to lose 50 pounds, drop the body fat around their waist, and take their heart medication, all after paying a copay (maybe?). It’s not a good feeling, and I can see why so many people just ignore it.

  91. Another possible factor in hot car deaths is that windows in older cars could be opened whether or not the key (no fobs back then) was present. So, e.g., a 3yo kid in the car very likely could’ve rolled down a window himself/herself.

  92. “Anyway, based on current Contribution Limits, the HSA is not a savings model for me (dental eats up the rest of my account).”

    I’m curious as to why not.

    It sounds like a common model for totebaggy HSA holders is to pay their deductibles and copays OOP and let the HSA balances build tax-free.

    Of course, this model does depend on having enough cash available to cover deductibles and copays, but that’s typically not a problem for totebaggers.

  93. LT, where do you go for boot fitting?

    Not having boots that fit well has taken away from my enjoyment of skiing. I miss my Lange Thermofits.

  94. “people don’t want to have to buy a minivan or other large vehicle so they can fit three car seats.”

    We could fit three car seats in the back seat of our old Camry.

    FTM, we used to regularly fit me and the two kids, in their car seats, in the back seat of DW’s Accord when we’d take her Dad with us.

  95. There is a local place here that only does ski retail. They live and breathe skiing. During the boot fitting they were all talking about various High School racers and how they did at the last race, then talking about some up and coming local pros, and general discussion of ski resorts. They aren’t looking to oversell you. Another customer came in and they were asking him what he skis, what type of runs he does, and they were like, wow, the last place you went to put you in an advance skier boot and a size too big. He ended up leaving with a lower price boot that is meant for a dad skiing the local blues with his kids.

    Next time you are out west, I’d investigate the local ski shops for a boot fitter. A good one will try to keep you in your boot, and if not, find something that works. I went out last night (granted it was warm), but my feet were more comfortable. This weekend I’ll test it out some more. If I still have problems, I’ll go back and look at new boots. It had gotten to the point where after 2 hours I couldn’t ski anymore. That is definitely a problem when the chalets are closed and I can’t go warm up.

  96. BTW, I know families that stopped at 5 kids because more than that would mean the entire family would exceed the number of seatbelts in a minivan.

    Or at least that’s what they cited as why they had exactly 5 kids.

  97. LT, yeah, I got my old Lange Thermofits from a ski shop that had a boot fitter (maybe more than one?) on staff. He had me do the exercise where I kept trying the boot one size smaller until I found the size that was too small.

    In late Feb/early March I was planning a bunch of travel for work, and was trying to see if I could work in a visit to a ski shop during that travel to get fitted for a pair of boots. Part of the problem is finding a store with a good boot fitter; not all ski shops have them, and some are better than others.

    One travel destination I was planning was Austin, and that’s still on the list of destinations if/when I get vaccinated and it’s deemed safe again. I was considering routing my flight through Denver if I could identify a shop with a good boot fitter, and make an appointment (DD, RMS, any recommendations?).

    Perhaps when I can travel again I’ll consider routing through your city so I can visit your boot fitter.

  98. LT and Fred,

    I’ve never worked at a place that offered an HSA compatible plan. Are you doing it as it’s tax and/or another wise cost effective? Or is this all they offer?

  99. “Now, take that feeling at the doctor….most people are going to be told they need to lose 50 pounds, drop the body fat around their waist, and take their heart medication, all after paying a copay (maybe?). It’s not a good feeling, and I can see why so many people just ignore it.”

    +1. I still resent having my thyroid issues missed for 10+ years, because the doc just assumed my constant fatigue and weight gain was because I needed to sleep more and eat more vegetables. At some point you just stop asking.

  100. And every time we have this conversation, I realize that I can never retire, because I have fully-paid healthcare with a $30 copay, a formulary that covers all my meds, and something like a $2K OOP max.

  101. +1. I still resent having my thyroid issues missed for 10+ years, because the doc just assumed my constant fatigue and weight gain was because I needed to sleep more and eat more vegetables. At some point you just stop asking.

    +2. But did any of the thyroid stuff show up in the routine annual blood panel?

  102. +1. I still resent having my thyroid issues missed for 10+ years, because the doc just assumed my constant fatigue and weight gain was because I needed to sleep more and eat more vegetables. At some point you just stop asking.

    Seriously? The first thing you do when a female patient complains of fatigue is check her TSH.

  103. @Finn – The highest-rated car seats of the last 10 years that fit the strictest recommendations are bigger and do not fit 3-across in most cars – certainly not Accord or Camry. It is a topic of endless conversation on parenting blogs/message boards, trust me on this. Lots of tears of guilt over the thought of putting a 6-year old in a booster seat and putting them “at risk” to make room for new baby’s seat (new of course because the 6-year old’s baby seat is “expired”), etc.

  104. One of the things I noted when I listened to that podcast over lunch was the reference to 2-6yo kids in car seats.

    For most of that age range, my kids were in booster seats.

    Another detail that bugged me was the discussion of people who could afford to have a third kid, but didn’t because that meant buying a minivan, and the uncoolness of a minivan prevented some of them from having a third kid. Have they not heard of 3 row SUVs?

    They also referenced the lack of testing, but I thought CR does testing of car seats, or looks at test results, when they rate them.

    It’s an interesting and provocative podcast, but I were ~20 years younger and already researching this stuff I don’t know that it would’ve changed my mind about anything.

    Ivy, I’m wondering if car seats are bigger than ~20 years ago.

  105. Rhett, my only health insurance option is a high deductible with option to have an HSA. I use it for the pretax discount. Sure I could pay $6k out of pocket and build the HSA to a respectable amount, and use it as a retirement vehicle. But right now we still have child care expenses, among other things, so I’d prefer to pay medical out of the HSA and keep cash flow available.

    For years DH had his own HSA, and no medical expenses, so he has built that up and it sits as a small investment. The HSA was definitely created by rich people looking to create more advantages for them. Someone making $45,000 a year is barely funding one.

  106. If we postulate that car seats have gotten bigger over the last 20 years or so, going from where 3 could fit in the backseat of a midsize car to where only 2 can now, that would suggest that the researchers interviewed in the podcast would need to account for that in their analysis.

    Not accounting for it would seem to put their findings into question.

  107. Man, around here, people get the SUV as soon as the first kid shows up, unless they already had an SUV.
    I think the much bigger constraint on having more kids is the expense of childcare. That costs way more than the upgrade to a minivan, which are not wildly expensive.

  108. I had to do quite a bit of research and order cheap car seats from Kmart in ~2009 in order to get 3 that would fit 3 across in a Buick Century, which has a relatively large back seat.

  109. Here, I had my kids out of booster seats by the time they were six or so and could sit in the minivan back seats and be comfortably belted in. I did follow the no kids in the front passenger seat till twelve pretty closely. I’ll admit that moving from rear facing to front facing and then booster was based more on when I thought the kids were ready to move vs. going strictly by the recommendation.

  110. “I did follow the no kids in the front passenger seat till twelve pretty closely.”

    I’ve read that for newer cars, adults are better protected from crashes in the front passenger seat than in the back seat.

    It’s not clear whether that’s true for kids.

  111. “ One of the things I noted when I listened to that podcast over lunch was the reference to 2-6yo kids in car seats.

    For most of that age range, my kids were in booster seats.”

    @Finn – Yeah. That’s exactly what I mean. The trend is toward bigger seats and keeping kids in true car seats well into elementary school vs booster seats. That is a real influence. Does it really mean people didn’t have a 3rd kid that otherwise would have? I don’t know if I’d go that far, but it is a serious consideration.

    As for SUV’s. To get a functional 3rd row means a much larger model. I remember a friend going crazy trying to find 3 seats that would fit in a Pilot, for example. (As WCE said)

  112. FWIW, I followed the law. I did not follow the strictest of “good UMC mommy” recommendations. And I never bought the “best” car seat. I bought mid level ones. He also has never travelled all that much by car, really.

  113. “To get a functional 3rd row means a much larger model.”

    Right, but the podcast specifically mentioned families that could afford third kids and the associated expenses, but chose not to have third kids specifically because that would’ve necessitated minivans.

    I called BS on that based on the existence of 3 row SUVs.

  114. To get to the 3rd row – which is tiny and takes up the cargo space – you have to be able to fold up a seat in the 2nd row which could mean taking a car seat out to get to it each time. It is also awkward to buckle a young child into a tiny 3rd row on a daily basis. Obviously, this is not an issue for me personally as a sedan owner with one older child. But it is a real problem that people worry about. This is the only reason I even know it is an issue – it is a widespread worry!

  115. Dang, I’ve heard that women aren’t heard, that we’re told our problems are our own fault, etc, at doctors’ offices as well as elsewhere, but if Laura and Rocky are (were) getting pushed around and ignored, I’m shook!

  116. I’ve read that for newer cars, adults are better protected from crashes in the front passenger seat than in the back seat.

    It’s not clear whether that’s true for kids.

    It definitely true for over 8 years old and probably true for 5+. I’m pretty blase about letting my kids sit in front. Recommendations won’t change this decade because no one is comfortable with doing less. The science is solid that front of cars post 2000 is the safer place.

  117. Here, those who wanted to and could afford a third child had one. Many did go to minivans, some bought SUVs that worked for them. Most families in my neighborhood are single income families with one partner earning a relatively high income. Most have three kids. Fitting three kids, in car seats in a vehicle wasn’t a consideration, I’ll wager. Most people make car changes as they move through life.

  118. I thought the issue with kids in the front seat had to do with the air bags, not the construction of the front seat area. Air bags are designed for adults and I had always read that they are more dangerous for kids who are smaller.

  119. Whether or not to use a booster seat has to do with height, not age. Unfortunately, two of my kids were very tiny, so they stayed in booster seats throughout elementary school. They preferred it because they couldn’t see out of the window otherwise.
    DS2 and DD refuse to ride in the front passenger seat. They say it makes them carsick

  120. I thought the issue with kids in the front seat had to do with the air bags, not the construction of the front seat area.

    Yes, that’s the issue.

    Whether or not to use a booster seat has to do with height, not age.

    Yes, but using age rather than height is easier for people to understand and follow.

  121. I just took a look at car seat rules….the convertible seat (which is huge w/5 point harness) is recommended until age 4 and 40 pounds. Then they move to a booster with a back, and then once they are tall enough, just a booster. People with small kids (raises hand) have to use convertible and boosters for much longer. My kids were in convertibles in Kindergarten (I refused to drive through the drop off/pick up lane because they couldn’t independently get out quickly). My oldest still doesn’t reach the 4’8″ requirement to get rid of a booster (although she is 12, so we did promote her).

    There is a lot of parent guilt out there about child restraints. I know several families that ordered convertible and booster seats from Europe so they could fit three across. I also know several that moved to the bigger SUV with the a child in the third row and the mom still has to climb into the back to latch that child in. I have sat in back row of an suv in between two booster seats….it was extremely tight (and I’m small). I don’t think car choices solely impact a families decision to have a third child, but it is part of the equation.

    If it’s been a while since you’ve had small children, consider a walk down the car seat aisle at Target. You’d be shocked at how big they there. The marketing is bigger is better.

  122. “DS2 and DD refuse to ride in the front passenger seat. They say it makes them carsick”

    Now that DS can drive, oftentimes when the four of us go somewhere, DS drives, DH is in the front passenger seat with him, and I sit in the back with DD. I’m finding that sitting in the back makes me queasy. This was never an issue when I was a kid and sat in the back seat all the time.

  123. Ada, do you have references? I did a quick search on PubMed, and found some studies that show a lower mortality for front seat passengers, but they were mostly based on adults, and seemed to indicate that it is because seat belts in the rear are not as good as seat belts in the front, as well as airbags in the front.
    This one did include children 9 to 15 and found the rear seat was still associated with lower mortality
    https://pubmed.ncbi.nlm.nih.gov/20728650/

    There are also papers that suggest that the increased number of deaths for rear seat occupants is explained by lower seat belt usage.

    I also am finding a lot of studies that still find the rear seat is safer’
    https://pubmed.ncbi.nlm.nih.gov/16595421/

  124. “Yes, but using age rather than height is easier for people to understand and follow.”
    You go to the well child visit, get your kids height, and one year you say “Hey kid, we can ditch your booster seat now”
    It isn’t hard. It is just that the mom advice articles don’t explain that it has to do with height.

  125. I don’t think car choices solely impact a families decision to have a third child, but it is part of the equation.

    Right, it’s one factor in the overall cost of having a third child. The study showed it is enough of a factor to have a statistically visible impact.

  126. You go to the well child visit, get your kids height, and one year you say “Hey kid, we can ditch your booster seat now”
    It isn’t hard. It is just that the mom advice articles don’t explain that it has to do with height.

    You’re assuming that everyone takes their children for their annual exams.

  127. Rhett – (HSA)

    Back when my employer first started offering the high-deductible + HSA plan ~10yrs ago they also offered the “co-pay” plan with high- or low- deductibles and the traditional indemnity plan.

    For the 3 my premium share was, say $3000-$4000/yr (family plan). For the HDHP, $250/yr. Seriously. And the deductible was ~$2500.

    Finance guy here. I did a nicely color coded breakeven analysis looking at “if I consumed $x of medical/pharmacy/labs which plan would be the lowest out of pocket”. Well, the HDHP won, hands down. Mostly because the ante was only $250, so unless/until I spent way over my deductible (and very hard to to because >$2500, I only paid, and still pay, 10% in network) I was money ahead. For the first year I funded my HSA with the premium difference between the plan I would have chosen sans HDHP and the high-deductible plan, so maybe $2750. And my employer kicked in $400 on my behalf (the incentive). Since then my annual has increased to the max.

    I usually spend the HSA funds (3 boys + me, remember) what with broken leg, appendectomy, 3x wisdom tooth extractions, both DW and me getting new hips, and now as we age some more costly Rx. We do pay small, <$50, things out of cash flow vs HSA.

    For 2021 my annual premium for the HSA is ~$500, the family deductible is $3000, and I'm maxing out the contributions. No employer funding incentive.

  128. RCM – Yes. I know several women who are shorter than 4’8″. They drive on a pillow booster (and have pedal expanders). As a passenger they typically don’t sit on a pillow/booster, but some will on longer road trips. Otherwise the belt cuts into their neck.

  129. Thanks, LT. I understand using a booster for comfort and usability; I just wonder if the cops pull you over and write the driver a ticket for not using a booster seat for an adult passenger.

  130. I don’t believe so. Looking it up just now only references “child” in the language. I think the idea is that an adult has stronger bones and muscle to withstand impact (frail 95 year old aside).

  131. Of course not, but how many people are going to measure their kid’s height to see if they are tall enough to not need a booster seat? You are assuming that most people have the desire and awareness to do that. Most people are much more likely to follow a rule of “booster seat until age 10” than “booster seat until 4-foot-8.”

  132. “Whether or not to use a booster seat has to do with height, not age.”

    When to ditch the booster seat isn’t the issue at hand here. It’s keeping kids in the giant seats with a 5-point harness as long as humanly possible that is pushed among the “good mommy” set. Shaming parents for not having their 7 and 8 year olds in boosters rather than 5-point harness seats. Those seats are HUGE to accommodate older kids, and there is a cohort of parents that literally cry with guilt over putting their kids in a booster until absolutely necessary. THAT is what I am talking about. Like LT said – if you have older kids, take a walk down the aisle in Target. The seats are gigantic.

    Again – I don’t know that this is actually keeping people form having a third child, but there is MUCH energy put into finding the right car that will fit 3 of the “best” car seats. And no – people don’t want minivans.

  133. And BTW – the car seat mafia have many, many diagrams for exactly how your child is supposed to fit in the car before you can ditch the booster seat. We just went with “when the seat belt was hitting him across the shoulder instead of the face”.

  134. I am short, as is DD. So she is (and will be) in the 5 point harness seat for awhile. Pick up is a huge PITA, because I can’t just reach back and buckle her in quickly. I got dirty looks the one time I got out of the car, even though it’s faster than me unbuckling myself, contorting, buckling her, buckling me, and then waiting for the driver’s seat to slowly move back into position so that my leg can reach the pedals and I can drive. DH mainly does pick up now. :-)

  135. If people are making their procreation choices based on their distaste for minivans, well, I dunno.

    Personally, I think the cost of childcare is a far bigger impact. People literally cannot afford that many years of childcare.

  136. Thinking about all the stages of mom mafias – breast feeding, staying in the workforce, mommy and me enrichment classes, car seats, kindergarten placement, foreign language immersion (specific to my area), honors track in elementary, when is it safe to let kids roam around the neighborhood, when is it safe to let them stay home alone.

    That is just through the elementary ages. So much energy spent on parenting and what the mom mafias spew repeatedly.

  137. The study referenced in the NYTimes seems to blame the seat belts in the back seats, which haven’t been upgraded to front seat standards. That is something that is pretty fixable. I can’t get to the full article that is referenced so it is hard to know what it really says.

    I was able to find the full text for the first article through good ol’ Google Scholar (my university does not subscribe to that journal). It is an interesting article because it looks at newer cars, focuses on occupants wearing seatbelts or other restraints, and includes children. But its findings for children are pretty mixed. The big increase in fatalities for rear seat occupants is in the over-55 group.
    “The estimate of risk of
    fatal injury among restrained rear row occupants age 55 and older
    (1.2%) was notably higher than the estimated risk for the age
    groups younger than 55 (0.3%). There was a clear fatality risk
    reduction for restrained children ages 0–8 years in the rear as
    compared with the front. Of note, the relative risk of death for
    restrained 9–12 year-old children was higher in the rear vs. front
    row (RR 1.83, 95% CI 1.18–2.84). This was due primarily to an
    unusually small fatality risk in the front row for restrained
    9–12 year-olds (<0.1%), rather than an elevated risk in the rear.
    There was no clear evidence for a difference in risk of death in the
    rear vs. front row for restrained older adolescents and adults ages
    20–54. "

    and in the discussion
    "A variety of legislative and education efforts have largely
    succeeded in getting children younger than age 13 in the rear seat;
    in the current study, adults accounted for the vast majority of right
    front seat passengers, while 86% of children younger than age
    13 were in the rear. More than half of all rear row occupants were
    younger than age 13, and 3 out of 4 were younger than age 20.
    While children younger than age 9 were clearly better protected in
    the rear vs. front seat, older adults (age 55+ years) do not appear to
    be as well protected in the rear. They had the highest risk for any
    age group of both serious and fatal injuries. We also noted a higher
    relative risk of death to 9–12 year-olds restrained in the rear as
    compared with the front seat as well, though this resulted from an
    unusually low risk of death to restrained 9–12 year-olds in the front
    passenger seat, which may represent a statistical aberration for the
    time period of study, due to relatively sparse data. Additional
    research is needed to clarify whether this unexpected finding is
    maintained with larger samples of crashes."

    and the full conclusion
    "Results of this study extend prior research on the relative safety
    of the rear row as compared with the front by examining restraint
    system performance in a more contemporary fleet of vehicles. The
    rear row is primarily occupied by children and adolescents and
    clearly remains a relatively safe seating position for children
    younger than age 9. However, the increased risk of serious and fatal
    injuries for occupants 55 and older highlights the challenges for
    vehicle and restraint system manufacturers in providing optimal
    protection to a wide range of rear row occupants. Findings of an
    elevated risk of death for rear row occupants, as compared with
    front row passengers, in the newest model year vehicles provides
    further evidence that rear seat safety is not keeping pace with
    advances in the front seat, and highlights the need to continuously
    re-examine findings such as those presented here with more
    recent data. Continued research is needed to identify the best
    means by which to preserve the safety of the rear row for the
    youngest occupants, while improving the performance of restraint
    systems for the oldest occupants."

    In other words, rear seat restraints haven't kept pace with front seat restraints (similar to the study cited by the NYTimes) but this mainly seems to impact the safety of the over-55 set.

    I just don't think it is settled yet as to whether children are safer in the rear or the front, and probably never will be since car and seatbelt designs change all the time

  138. Also, it seems that the tests involve collisions from the front, not being T-boned or rear-ended, which would change the relative back and front risks.

    I remember less than an inch between the carseat and the passenger door in the Buick Century and thinking about being T-boned, which is not uncommon on 2 lane highways with driveways and side roads.

  139. If people are making their procreation choices based on their distaste for minivans, well, I dunno.

    No, it’s the cost of having to buy a new vehicle because your current vehicle doesn’t fit a third carseat.

  140. “it’s the cost of having to buy a new vehicle because your current vehicle doesn’t fit a third carseat.”

    If money is so tight that an appropriate vehicle is a budget buster, then perhaps not having that third kid is a wise choice.

  141. I will say this. People make decisions based on stupid reasons, rash reasons, no reasons all the time. Do I think that there are enough people who don’t have a 3rd specifically because they don’t want a mini van to make a statistically measurable “trend”? Probably not. But that doesn’t mean it’s not a thing people think about.

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