[yourapostasy]

In the US, there are chicken-and-egg challenges all over the map that obstruct the adoption of such policies in small businesses. The big challenge is the out-of-control medical costs that pressure policy decisions elsewhere in the decision matrix.

A typical natural birth procedure alone in the US, with the distorting lens of the unfortunate US insurance landscape, costs (for whatever "costs" mean in this distorted context) around $10K. If you go to C-section due to typical child birth complications (can happen to even the most well-prepared and assiduous couples), it triples and can easily hit $40K. If there are additional complications, it can easily hit $100K and rapidly go up from there depending upon the specific set of complications.

If your startup has fewer than 50 participants in the company group health plan, even a completely normal natural child birth in one year will cause a rate rise the next year that is higher than it normally would be. On top of that, there are the costs of supporting parental leave: none of the expense is granted favorable tax treatment at the federal level (and not at the state level in my state).

For businesses with very high revenue per employee like in the tech industry, these intersecting facts don't sink the feasibility if the business leadership makes a commitment from the outset and plans their budgeting with the commitment in mind. I'm glad that AeroFS is publicizing this, adding to the trend of similar family friendly policy stories out of other tech companies in recent years.

But for small businesses in other sectors and even more marginal tech companies, these realities on the ground are just brutal on the odds of such policies making out of "gleam in the eye" stages. From a statecraft perspective, I'd be really interested in finding out if front-loading the expenses of encouraging family formation via tax breaks and incentives to mitigate the costs that employers currently bear, would compare favorably to the back-end costs (including externalities, where most of the back-end ramifications come from, starting with costs of monetary policy decisions partly made in reaction to a greying population) of dealing with an inverted population pyramid. That opens a whole other can of worms of whether or not an inverted population pyramid is desirable or not in the first place.

[Agustus]

The reason to hire someone from the company's perspective is to address work overload. If a start-up hires a tenth employee with amazing skills to address back-end server development, there was a need for back-end server development. When three months in the employee says their wife is having a baby in a month and wants to take the full allotment of FMLA, what is the company's role in this? The employee was the best and hired to address an issue, losing them for three months in a start-up environment would be a mission critical event. The company can A) hire a temp worker to fill in, who will either be let go when the employee comes back or hired on or B) go without a back-end developer, a position that is still mission critical.

The employee is doing best in their interest, but what about the company? A large profit margin company can go out and hire another employee, tech sector is great about this. Low profit margin companies will be unable to address this.

Here we have a situation where well-to-do companies are badgering middle to low profit margin companies into a government move. The European companies are hemorrhaging jobs because of the worker benefit packages (France, Greece, Spain) to China where the wages and benefits are lower. The middle to low companies leave and the barrier to re-entry is made worse by movements like this. Yourapostasy brings up a good point about front loading government tax breaks to encourage children.

[vonmoltke]

> the distorting lens of the unfortunate US insurance landscape, costs (for whatever "costs" mean in this distorted context)

On the topic of distorted costs, I nearly flipped out last night when I got the statement for my recent polysomnogram. The sticker price, if I walked in uninsured, would have been $8750. My insurance company is paying $616, and I am paying $15. I think it is abhorrent that the facility just ignores 93% of the sticker price just because I have insurance. I saw similar massive write-downs on my arm surgery. I imagine a C-section is the same.

[JeremyMorgan]

That "sticker price" isn't a real number. It's used so when uninsured people don't pay it, they can write it off.

[pc86]

Which becomes even more mind-boggling when, if your insurance declines it for whatever reason or there is a problem processing the insurance and it's not caught in time, you get a bill for $6,000 after a "discount." But typically by the time those letters arrive you've already got $1,500 in fees and charges.

[ashark]

The typical billing experience for anything non-trivial in US hospitals is batshit crazy.

One visit can generate three or four bills from different people and institutions. Some of these bills they'll tell you to ignore if you call about them because insurance is covering all or part of it, but they sent the bill before that was sorted out, for god knows what reason. Don't worry, you'll get more, corrected (hopefully? maybe?) bills later. Then explanation of benefits letters arrive, which look sort of like bills but aren't. Almost certainly, at least one of the billing people and/or the insurance folks screwed something up and you'll get to spend most of a day on hold with insurance and a hospital or test processing company or whatever sorting it out. If you miss anything in this mountain of mostly-useless paperwork you may find late notices in your mailbox a month or two later.

Now you get to try to figure out whether the charges on those late notices were legit, or whether they're the result of some seemingly-alway-incompetent hospital billing department's error. While racing against the date on which it goes to collections, and while fees and such accrue.

By four months out you finally, maybe, know what your total costs were/are, after hours of dealing with it and filling half a filing cabinet drawer with documents.

Now, consider that most procedures will include several visits generating a similar number of bills in the months leading up to it. You'll being bombarded with this garbage non-stop for months on either side of the Main Event. You'll also have some follow up appointments and/or tests. Fun!

Basically everyone involved either doesn't care about doing their job correctly or is actively trying to steal your money. Half the time they don't know WTF is going on. You or your loved ones get to deal with that while you're sick or recovering. We call this health care. Some people prefer to pay a premium for this "service" instead of having single-payer or a national healthcare service because... that would make us less free?

That's how bad it is with insurance. Without is, I'm sure, much worse, though probably less complicated.

[pc86]

I had my gallbladder removed in 2009, and was lucky in that at the time I had what is still the best insurance I've ever had. The sticker price of the procedure was approximately $50k (ER visit + admission + emergency surgery the following morning), of which I paid less than 1%. But the amount I did pay was split between the hospital (at least two separate bills), the surgeon (who was a contractor for the hospital and billed separately), and my insurance (who paid something in full but two months later decided I actually owed them $20 for it). This is not counting the $100 ER copay which was refunded to me 90 days after I was admitted (ER copays are typically waived if you're actually admitted to the hospital for non-US folks).

I was barely out of college at the time so had my parents look over everything and it was as far as we could tell correct. But still a mountain of paperwork, and I did miss a legitimate bill and end up paying a $30 late fee on a < $100 bill, which was frustrating.

So yeah. A mess, basically :)

[DanBC]

In England we're currently having a crisis in A&E units with unprecedented volumes of patient ("winter crush"[1]) and a shortage of nurses. Targets are being missed. 95% of people who turn up at A&E must be seen and treated, or admitted into a ward, within 4 hours. At present only about 92% of patients meet that target. At its worst only about 89% of patients met the target.

The trip to A&E would cost you your petrol money or cab fair. The treatment in A&E, and the hospital is free at the point of delivery[2]. The hospital might send you home with a month of medication which would again be free atpod. A regular prescription would cost £8.05 per item per month although there are many exemptions and many people don't have to pay for meds.

If you wanted to pay for your hospital visit you can. You get your own room and a free telly, maybe a bit more nursing and a few more HCAs. (In the NHS beds you possibly have a telly that you pay to use.)

The weird thing is that we get all this while we spend less per capita on healthcare than the US government. Free healthcare is cheaper than the US system. And you don't need to get rid of private provision either - so anyone who wants to pay at the point of delivery can.

[1] more people attend A&E in summer. But the people who attend in winter tend to be iller and to need a hospital admission.

[2] see how I nearly avoided "it's not free you pay for it in tax" comments

[vidarh]

Yikes. I'm in the UK, and while we had everything covered on the NHS in the end, we inquired about the costs of an elective/scheduled C-section (which the NHS does not offer - you do get a C-section if it is medically recommended, but not if you want it just for the "convenience"), and a C-section carried out privately by one of the top surgeons in the country at one of the top hospitals would have come out well under half the number your quoted for the US.

[dtparr]

For reference, my first-born was a non-elective C-section in the US and my total cost for the stay, including the OB performing the procedure and 2 nights in the maternity ward was also under half the number quoted. Admittedly, I can't recall if that was the negotiated rate from the insurer, or the amount actually billed, but I don't remember them being wildly different.

[Chinjut]

Sounds like an argument for detangling healthcare from the employer-employee relationship, possibly through a single-payer system...