Because most philosophies that frown on reproduction don't survive.

Wednesday, October 10, 2007

The Numbers Game

Yesterday a friend emailed me a link to a post and its comments which strike me as somewhat endemic of a certain divide between "liberal" and "conservative" attitudes, and the moral difficulties that come with both. (Perhaps one of the few things that all of both persuasions agree on is that these terms are imprecise, yet they do evoke roughly what I'm looking for here, so I'll use them and consider all necessary provisos and qualifiers said.)

The topic is the S-CHIP legislation that made its way from congress to the president's desk, where it was vetoed. I'll admit, I haven't been following politics terribly closely the last month or two, but the basic purpose here is to federalize funding for a set of state programs to provide government paid healthcare to children in families up to twice the poverty line. You can read a pretty balanced (kudos to the NY Times) piece on the immediate debate that inspired this piece in this editorial. The thing that is causing so much controversy as of now is that the families the legislation is designed to help are decidedly middle class: Maryland has a household income cap of 55k/yr, and NY recently tried, but failed, to raise their cap to above 80k.

Now, it's true that there are certain circumstances in which even a middle or upper middle class family can have trouble getting affordable health insurance. Some friends of ours own their own fairly successful small business -- but their youngest daughter has Down Syndrome and even small business insurance refuses to cover her. They have to use a state program by which they can pay a flat amount per month (I believe around 500 dollars -- we had to look at the same possibility in our pre-corporate days because one of our daughters has a heart murmur) and get subsidized insurance for her separately.

However, given that independent estimates say that the proposed S-CHIP legislation would probably cover 6 million children, of which 30% would be children already covered by private insurance who would transfer out onto the public dole -- there are I think legitimate questions as to whether this is a good use of resources. While some underline the necessity of helping middle class families with undue burdens, others (and I would tend to fall in this camp) would tend to think that under certain circumstances it behooves you to seek out a job working for the state or federal government or for a large corporation in order to make sure that you can get the kind of insurance your family requires.

The actual question of the wisdom of the legislation, however, is not what I want to address. It seems clear to me that there are many different conclusions that reasonable people could come to in this situation.

Rather, what stikes me is a particular mode of moral thinking that seems deeply problematic. The interchange is taken from the discussion on this post. The two people talking are the author of the post (Katerina) and a commenter (Blackadder):
Katerina:
Democrats = kill the babies in the womb
Republicans = kill the children by not given them healthcare!

Blackadder:
There are approximately 1.3 million abortions in this country every year. How many children die in this country because they don’t have healthcare?

Katerina:
So you’re reducing the value of human lives to mere numbers?
Wow. What an ethic of life you have there.

Blackadder:
No, I’m not reducing the value of human lives to mere numbers. But you didn’t answer my question. How many children die in this country each year because they don’t have healthcare?

Katerina:
...I repeat it again: I don’t reduce human lives to numbers: if Democrats kill more than the Republicans and all that nonsense discussion. Even if there is only one child who has passed away because of the lack of healthcare insurance is enough for me....
Now, the blog author is very young, and so try to overlook some of the more college-activist phrasing here. That's an easy target, but that's not what I think is interesting about this exchange.

What is interesting is the modification of a very sound moral principle into an open mandate for unlimited government action. It is an oft observed principle that one may not perform a lesser evil (but still a clear evil) in order to avoid a greater one. The classic (though unlikely in any practical terms) example of this is the "If you kill this once innocent person, some great world improvement (end of hunger, peace between nations, etc.) will be achieved" illustration. Performing a "smaller" objectively evil act in order to achieve a good of a great magnitude is falling into the error of proportionalism. This is the issue we have when people argue: Sure, cloning human embyos and then killing them for their stem cells may be wrong -- but surely it's okay in the context of all the great cures we might achieve as a result.

What Katrina is doing, however, is not simply avoiding proportionalism. She's engaging in a very key shift in analysis. When she says "I don’t reduce human lives to numbers: ... Even if there is only one child who has passed away because of the lack of healthcare insurance is enough for me." she is arguing that a specific remedial action (funding $35 billion in additional government-paid healthcare) is morally necessary so long as it saves at least one human life.

In a sense, this is very similar to the argument for gun control which I was arguing against a while back, which went essentially: "So long as it is clear that some number of gun deaths, however small, will be averted by additional gun control measures -- the moral necessity of avoiding death trumps any desire some people may have to possess dangerous objects."

And yet, if one thinks about it, almost any government funded service or increased level of regulation could be justified by the claim that it must save the life of at least one person. Can it be that we are morally required to turn over all money to government programs and institute all possible safety regulations (to the point of having every person wear a padded suit and banning all means of fast transportation other than emergency vehicles) simply because that would doubtless save some number of lives? Generally speaking, I am hesitant to claim that patently absurd precepts are necessitated by moral theology. That would be to assert either that theology itself is patently absurd, or that our faculties of reason are so terribly malformed that moral necessity looks like absurdity to us. A failure to "ring true" would seem to indicate a need to look deeper.

While I don't have a neat and clear solution to this problem, a couple of principles occur:

1) While at an individual level we have a duty to perform all reasonable acts to care for and protect those around us, trying to provide or regulate such things at the governmental level results in extreme inefficiency. So for instance, when it comes to gun safely, it is my clear duty to keep my guns in locked cases, keep ammunition out of reach and out of site, never shoot at an unknown target, and never use a weapon to threaten those around me. Following all of these rules carefully, and adapting them to the needs of changing situations, it is highly unlikely that my guns will ever be a threat to anyone. However, when the government tries to assure a similar level of safety across all gun owners and potential gun owners, we end up with a huge number of regulations, which still don't succeed in restricting people enough to avoid all crimes and accidents.

Similarly, if someone in your immediate circle desperately needs help paying for medical expenses, it's a clear and straightforward process for family and parish members to step forward and collect the needed money. However, when a government program attempts to insure that every such needy person is taken care of via government paid insurance, they end up paying all medical expenses (not only emergency, but routine and affordable) and also building a wasteful bureaucracy to do so.

2) While I don't for a moment think that fundamental moral principles change due to changes in technology, we currently have a lot to sort out in that medical care has moved, in the last 100 years or so, for a personal, corporate work of mercy, to a high technology and thus potentially high expense field. Once upon a time, the need to care for the sick was pretty much a need to devote as much time and patience as necessary to nursing. It's something that is often not fun, but is intensely doable. However, in this day and age, there are at times situations where the money required to perform some exotic operation (and honestly, that's what we need insurance for, not to pay for the $70 doctors visit and the $50 anti-biotic) can be tens of thousands, hundreds or thousands or even millions of dollars. What are we to make of the call to care for the sick, when providing the maximum of care for one person can, at times, take the financial resources that could feed thousands or tens of thousands of the world's poor?

3) Is there a fundamental difference between the level of charity which individuals may be morally required to provide to each others, and the level of government mandated "charity" which can or should be rightly exacted from society and given out to those determined to be "in need"? I suspect that, given government's lack of discernment and inefficiency, and the fact that such an act is not actually charity on anyone's part, the level of moral obligation government institutions have is different from that which individuals have -- but I'm not sure how to look deeper into the question.

16 comments:

Kate said...

A passing thought....I find that having to choose between catastrophic health care (betting against my families health, essentially) and having money on hand for routine wellness care (preserving our health and in some cases preventing far more expensive conditions) an entirely objectionable set of circumstances. 'Routine' health care is by no means as affordable and thus inconsequential as you've suggested. And where would you place maternity care on that spectrum of importance?

I'm as tired as anyone else of simplistic solutions to the health care crisis. It is even more painful to find discussion of these issues clouded by political 'dogmas' and alliances. Bush's stated reasons for this veto were, at best, disingenuous - he referred to the New York State 85, 000 income cap as though it were part of the SCHIP bill (though in fact the income cap in the bill would have refused federal funds for any state program exceeding 3x the federal poverty line, closing the door on NY's proposal), and spent most of his statement lamenting the imagined horrors of a government run health care system - even though SCHIP is actually mediated through private insurance companies and run by the states. Not that the other side is much better for rhetoric. As I have one, soon to be two children reliant on CHIP for basic health care, I'm sensitive to the way this has turned into a political football when there is so little time left before the original bill expires.

Of course, being Canadian, I am not so confident that involving the government in health care, as do the majority of western nations, is really such a disastrous idea. If Americans really have such a low idea of their own government's efficiency and honesty (as it seems they do) why not leave, or revamp the system, or run for office and provide a new crop of politicians? Heck, if the system is as broken as many US commentators make it sound, then why not work to overthrow it? As a newcomer here, this pessimism about one's own democratically elected government is pretty disheartening...but as I have already begun the time-consuming and expensive effort of becoming a legal resident here, I haven't been able to convince my husband that it wouldn't be a waste of time and money to go the other way and bring him home to Canada with me. ;-)

Darwin said...

Actually, the "routine healthcare" costs that I was quoting are (at least if memory serves) quite factual -- at least here. When we first got out to Texas we went a couple months without healthcare and during that period everyone in the family came down sick.

If memory serves it was indeed seventy dollars a visit at the local private chain of clinics (though perhaps I remember wrong and it was more -- certainly cycling everyone through a few times set us back quite a bit) and I definately remember fulfilling a rafter of $50 anti-biotic prescriptions.

As for maternity costs -- we actually did pay out of pocket for that last time around because MrsDarwin wanted to have a homebirth and our insurance wouldn't cover it: cost for monthly check-ups plus delivery is around $2400. Not fun, but doable if necessary.

On your wider question: If it's any consolation I think it's often rather mysterious to Americans why it is that citizens of so many other first world nations seem happy to be dependant on the government for nearly all major services -- and pay the taxes to support that. It's not that we consider our government particularly incompetant to do such things, but that we see everyone's as being so.

Patrick said...

This is a quandary for me, too. Both parties are using the issue to score points. Yet there is undeniably a problem. It is mainly the result of a vast web of perverse incentives created by government policy, both state and federal. Unravel all this and allow market forces to work, and much of the problem would be solved.

Unfortunately, we can't get from here to there overnight. Meanwhile, some people are suffering. Perhaps it is not as many as the alarmists would have us think, but the need exists now.

That being the case, I wonder if we should embrace things like SCHIP expansion as an intermediate step to provide immediate relief while working toward a more-perfect solution.

To make a comparison: if we could outlaw abortion except in cases of rape and incest, faithful Catholics would say such a law falls short of what is truly necessary. But I think most would support it because it would save some lives at least. We would then continue to work for a complete end to all abortion.

Kate said...

Darwin,

I'm sorry - I was unclear. It's not that the cost you name is necessarily inaccurate (depending on where you are and whether anti-biotics are an effective treatment), but whether it is indeed affordable - for people on the margins, the question of whether to sacrifice the grocery budget or leave a utility unpaid when someone gets sick can be a very real question.

We also paid out of pocket for the last birth, a homebirth. It was on a sliding scale and cost us $2000 for checkups and delivery. But the two doctor's appointments I went to before we decided on a homebirth cost $300 - almost a 6th of our midwives fees.

Hospital births are a heck of a lot more expensive (5000-6000 for the hospital stay and delivery, plus the office visits), and homebirth is illegal in some states (unless unattended) and difficult to come by in others. This birth will be in the hospital, because this time I do qualify for state aid, and we need to save money where we can (although I would love a homebirth again, and I wish I could convince the state of Louisiana that it would save them a chunk of money to agree to pay for one!)

My sisters in Canada have the option of a lay or nurse-midwife attended homebirth, lucky women. Saves the system money, and great outcomes for low-risk pregnancies.

Seriously, it does seem to me that a lot of US arguments against single-payer health care, when faced with evidence of working systems in other countries, come down to, "Well, it may work ok in those countries, but I wouldn't trust the Feds with health care!". Yet everyone admits that US health care needs to be improved and that too many people go uncovered. It's not really a great selling point for the US. I know americans hear all sorts of scary stuff about other countries systems, but, funny enough, no one in those countries seems to be lobbying for a switch to an American system (if you can call this patchwork a 'system'). When Canadians debate health care, it's to ask whether our system should look more like Germany's, or Englands (dear God, not more like England, please!)


I think that the number of people who give up enterpreneurial pursuits in order to work for a company large enough to offer comprehensive health care is likely to squelch the very spirit I find most appealing in Americans. I'm a small-community, act-local kind of girl: I like small, locally responsive businesses, and I know what a burden it can be for them to compete. (For many years my father in law paid for health insurance for his employees, even though he couldn't afford insurance for his family. What a choice to have to make!). Arguments saying that "well, I guess people are going to have to learn to work for the gov and the big companies" is a pretty sad and pessimistic solution to the health care crisis, if you ask me!

I agree with Patrick that until we have real alternate solutions, we need to take care of the actual people in front of us, by whatever means are readily available. I disagree inasmuch as he places the blame for the current crisis solely on government incentives, where I would argue that the profit-seeking motive in the insurance industry is in itself a barrier to making health care more widely available. (Think of people who are refused coverage because of pre-existing conditions. Now consider the advent of genetic testing and what insurance companies would love to do with that kind of information). There needs to be tort reform as well to protect drs. from outrageous malpractice suits and the resultingly high malpractice insurance rates.

Ahhhh....it would be nice to encounter a think tank devoted to this topic that was truly open minded, rather than formed in response to a number of politically motivated presumptions.

Anonymous said...

Seriously, it does seem to me that a lot of US arguments against single-payer health care, when faced with evidence of working systems in other countries, come down to, "Well, it may work ok in those countries, but I wouldn't trust the Feds with health care!".

That's not the argument against a single-payer system at all. It's not about the particulars of the U.S. government, but the incetives of any government monopoly on health care delivery. Monopolies generally have pretty poor incentives for innovation and socially-optimal output, and therefore have to be regulated into doing these things.

Besides, we can't afford to pay for Social Security and Medicare as it is... And you're saying we should take on health care for everyone? There's the budget deficit to consider... So no, it's not about distrusting our government per se, but about the technical aspects of making such a system work.

Donald R. McClarey said...

Those enamored of government medicine in the Great North might want to read this article.

http://www.city-journal.org/html/17_3_canadian_healthcare.html



Then perhaps they might want to keep in mind the 325 mile trip a Canadian couple, the Jepps, had to make to Great Falls Montana in August to have their Quads delivered.

http://www.google.com/search?hl=en&q=great+falls&btnG=Google+Search

Lotar said...

It is just plain innefficient to include wellness care under insurance.

In the case of private insurance, it is built into the cost of the premium. So, for example,instead of paying the $75 to see your doctor, you pay a copay (if that is your type of plan) and the insurance pays the rest. The problem is that your visit is anticipated in the cost of insurance, so in reality you pay the difference plus the handling costs, whether you actually make the appointment or not. In total you are probably paying at least $85 for a $75 check up.

With the government it can be even worse, since about 70% of each dollar is wasted in.

All the other Western countries can have socialized healthcare because we subsidize them. Because of the USA other countries can afford to have basically no armed forces, and since they set low prices on drugs, we pay for all of the R&D.

Darwin said...

Kate,

While I think many people would agree that the current system has problems (litigation and bureaucracy being two major ones) there really are reasons for not liking the government run idea. (As for why Canadians never think of switching back -- privatizing a socialized system is usually very chaotic, look at Eastern Europe. This is one of the reasons we want to be cautious, because socialization is often a one way street short of total, catastrophic breakdown.)

I'll admit, I'm not quite sure I can make out the tension between not liking the idea of some people needing to work for the government or for a large corporation in order to get coverage for the kind of issues they have (we do after all need police and soldiers and public school teachers -- and I can attest that some large companies are actually much more entrepreneurial places to work than some family owned businesses) and yet being comfortable with centralizing the entire healthcare industry: a major portion of the economy. Under a centralized system, the local chain of clinics where we've been able to get care (still under insurance now as we did back when we were low income and uninsured) would be eaten up by the national health service. That would mean turning the local institution we deal with into a tiny part of a giant one. And it's not really an idea I like.

Lotar,

I think you make a very solid point about the issues with covering routine care/wellness care. I can imagine how much more people would trot in for oil changes and tire rotations if that was covered by their auto insurance.

Heck, it annoys me to hear people around the office talking about various elective treatments (Lasik is a major offender) which "I thought as might as well get since it's covered." Free pretty much guarantees waste.

Donald R. McClarey said...

More on government medicine in our neighbor to the north.



"Canada's Expectant Moms Heading to U.S. to Deliver
Wednesday, October 10, 2007

By Sara Bonisteel


Mothers in British Columbia are having a baby boom, but it's the United States that has to deliver, and that has some proud Canadians blasting their highly touted government healthcare system.

"I'm a born-bred Canadian, as well as my daughter and son, and I'm ashamed," Jill Irvine told FOX News. Irvine's daughter, Carri Ash, is one of at least 40 mothers or their babies who've been airlifted from British Columbia to the U.S. this year because Canadian hospitals didn't have room for the preemies in their neonatal units.

"It's a big number and bigger than the previous capacity of the system to deal with it," said Adrian Dix, a British Columbia legislator, told FOXNews.com. "So when that happens, you can't have a waiting list for a mother having the baby. She just has the baby."


The mothers have been flown to hospitals in Seattle, Everett, Wash., and Spokane, Wash., to receive treatment, as well as hospitals in the neighboring province of Alberta, Dix said. Three mothers were airlifted in the first weekend of October alone, including Carri Ash.

"I just want to go home and see my kids," she said from her Seattle hospital bed. "I think it's stupid I have to be here."

Canada's socialized health care system, hailed as a model by Michael Moore in his documentary, "Sicko," is hurting, government officials admit, citing not enough money for more equipment and staff to handle high risk births.

Sarah Plank, a spokeswoman for the British Columbia Ministry of Health, said a spike in high risk and premature births coupled with the lack of trained nurses prompted the surge in mothers heading across the border for better care.

"The number of transfers in previous years has been quite low," Plank told FOXNews.com. "Before this recent spike we went for more than a year with no transfers to the U.S., so this is something that is happening in other provinces as well."

Critics say these border crossings highlight the dangers of a government-run health care system.

"The Canadian healthcare system has used the United States as a safety net for years," said Michael Turner of the Cato Institute. "In fact, overall about one out of every seven Canadian physicians sends someone to the United States every year for treatment."

Neonatal intensive care units in Alberta and Ontario have also been stretched to capacity, she said.

The cost of these airlifts and treatments, paid to U.S. hospitals by the province under Canada's universal health care system, runs upwards of $1,000 a child.

"We clearly want to see more capacity built in the Canadian system because it’s also expensive for taxpayers here to send people out of the country," Dix said.

The surge could be due to women giving birth later in life, and passport restrictions and family separation adds to the stress.

"I think it’s reasonable to think that this is a trend that would continue and we have to prepare for it and increase the number of beds to deal with perhaps the new reality of the number of premature babies and newborns needing a higher level of care in Canada," Dix said.

British Columbia has added more neonatal beds and increased funding for specialized nurse training, Plank said.

"There is an identified need for some additional capacity just due to population growth and that sort of thing and that is actively being implemented," she said."

Darwin said...

Incidentally, I should qualify that on the immediate occasion of this discussion, the S-CHIP expansions bill, I honestly have not studied the matter enough to have an opinion for or against. I don't have a principled stand against extending government healthcare to a particular group -- and children who can't otherwise be covered seem like a pretty good group to do better on.

What I'm more concerned with at the moment, however, is this idea that because a human life should not be assigned a specific worth in dollar terms, that therefore the possibility of saving even one human life makes the spending of any amount of money by the government a moral necessity -- the the refusal to do so constitutes "killing children by refusing health care". That attempt at more reasoning strikes me as deeply wrongheaded -- though certainly emotionally appealing from a certain point of view -- and that's what set me off.

Kate said...

Darwin

"Single-payer" does not necessarily mean centralized. The locally owned clinics in my home town stayed locally owned, Drs in Canada are payed fee-for-service, and the hospitals are private. The gov. is involved insofar as it collects the tax money federally (4% of federal taxes, roughly), and negotiates and distributes amounts proportional to need to the provinces (here Canada has a real advantage over the US, inasmuch as you can put all 10 premiers, the prime minister and the ministers of health and education in a room for a week to work out budget issues.) The provinces each administer their own provincial health insurance plans, which may or may not cover the same things or work in the same ways. These provincial organizations negotiate fees with the doctors and nurses unions.

This can (and is) done with remarkably little overhead. I'm well-prepared to believe that the US is incapable of running as little overhead. I just don't understand why Americans aren't more interested in reforming a governmental system where government waste seems so endemic. Even when it becomes an election issue, nobody seems to really believe that change will come about. I don't know what the solution is, but I'm surprised there isn't more active discussion of large-scale reform.

I'll believe there are better ways for the US to 'fix' health care than go to a single payer system, but someone has to put them forward!

(Really though, isn't insurance most affordable when the expenses are spread over the largest population? And it would have to be a non-profit of some kind if you want people to actually get the benefits for the cost, since for-profits are, by definition, more interested in keeping their (your) money than in promoting health - better (more cost-efficient) to wiggle out of covering you or paying for coverage than to actually pay for care).

Government paid (universal health care) systems tend to have one thing in common - the recognition that better and more widely available wellness care REDUCES the total costs of health care by preventing more expensive conditions. I think if you asked me whether I'd rather have better over all health and quality of life or have a poorer quality of life and over all health and have marginally better chances of surviving serious illness or surgery, I'd take the better wellness care and quality of life. Thanks. :-)

As it is, when our income increases, we'll probable look for a combination health savings account/catastrophophic health insurance combination. It would be nice, after all, to see some of the money we'd be paying actually being used for medical bills, should we lose the bet and never suffer a health crisis.

Tony said...

I was listening to Alan Colmes the other night (not my usual fare but he's friendly and reasonable to listen to).

He was talking about how SCHIP was necessary for even middle class people who can't afford health care.

I wanted to call in for fun and tell him that it was a good idea, because if I didn't have to pay insurance premiums for my children, I could afford a new 60" flat panel TV.

It's all about choices we make. And the "poor" in this country have cars, multiple TVs, cable and cell phones.

I don't believe I ought to pay for your necessities while you are buying luxuries.

m.z. said...

Some quick hits:
- Donald picks on BC and Calgary. Unmentioned is the population boom presently occuring there due to oil. I could make a remark about the South not being able to meet demands for milk during the winter and claim that capitalism is a failure. I won't. It is however stealing a base to claim a system is inherently dysfunctional when it is operating under conditions that were unanticipated when it was constructed. The dairy industry in the south will adjust, and the western provinces will adjust. I should also add that when my grandfather was in Vegas, he had difficulty getting into a hospital due to the shortage they have there.
- People who have insurance do not pay for their own health care. Their care is payed for out of trust administered by an insurance company and funded by its members. Fundamentally there is little difference between that and a trust administered by the government.
- Anyone (tony) who claims that the health care industry can be cured by eliminated TVs, videogames, cable TV service, and/or cell phone service does not understand the numbers involved.

Lotar said...

m.z.

Catastrophic Medical Insurance costs on the order of $50 a month. More comprehensive plans can be easily found in the $100-200 range. They not the best, but they will keep you from dieing of cancer, or loosing your house over a broken leg. A cell phone bill is easily generally around $50 a month, and cable is at least $50-100 a month. A second car will cost you in repairs, maintenance and insurance premiums, that alone can easily add up to the cost of medical insurance.

Kate,

Recently Canada was forced to airlift maternity cases to US hospitals because they had no beds left. There are cases in the UK of people dieing of easily treated illnesses and injuries in hospital waiting rooms.

I heard on NPR the other day that 20% of Medicare's budget goes to scams. No, I don't trust any government with my families healthcare.

Insurance increases in effectiveness in larger populations, but what we are talking about is nationalized healthcare. Everything is payed by the government, not just emergency situations. That is not efficient. Canada was able to lower prices by setting the prices, not due to effeciency or effectiveness. That causes pressure on supply and limits innovation (thusly, airlifting women giving birth to the States).

I personally don't see why 4% of my wages should be taken from my family in order to subsidize people who are too lazy and/or lack the foresight to get health insurance.

Donald R. McClarey said...

A link to an opinion piece in the Times Online regarding the British Health Service. The comments pro and con following the piece are interesting.


http://www.timesonline.co.uk/tol/comment/columnists/camilla_cavendish/article2633529.ece?ILC-EVYcomments&ATTR=Camilla

CMinor said...

We spent some time in Germany, and you'd be amazed at some of the services covered by the government there--spa visits, for example, and a monthly stipend for each child under 18. The tax rates, of course, were jarring and unemployment was a problem at the time. Most people took whatever they were entitled to because darn it, they'd paid for it.

We have covered most dental and optometry and all orthodontia (not optional, in our case)for years. Our kids' ortho wasn't sure how to deal with us at first--almost everyone else in her practice uses insurance. I guess most folks either use it just because it's covered or do without. I remarked to her at the time that I figured the others were paying for it one way or another. At least when I write out the check, I know what it's costing me.

It's too bad some insurers are unwilling to cover homebirth--it would save them considerably if they supported it. Unfortunately, charging CNMs (who are seldom sued) the same malpractice rates as OBs (who often are) raises even those costs. In some parts of the country midwives can't even get malpractice coverage to do homebirths anymore, which moots the issue. I was acquainted with quite a few disgruntled midwives and would-be midwives who were forced to helplessly watch their practice opportunities dry up--this was about 15 years ago.