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A Budget of Paradoxes

By Dr. Julia Frank
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Great fleas have little fleas upon their back to bite 'em
And little fleas have lesser fleas, and so ad infinitum 

Who knew? This famous couplet, which the mathematician Augustus DeMorgan apparently expropriated from the poet and social critic Jonathan Swift, comes from a book whose title originally (and now again) captures the essence of complex interdependency, a “budget of paradoxes”. The lines came to mind unbidden during the recent government shutdown, when I learned that in DC, where I teach and practice, hospitals were surviving on reserve funds the city tapped to pay bills normally covered by the federal government under Medicaid. By the early part of last week, those funds were nearly tapped out.  

Republicans in Congress seem inclined to treat those depend upon the federal government to pay its debts as no more than pesky fleas. But for DC hospitals that provide care to a large Medicaid population, the threatened interruption of reimbursement was of great concern. Our local hospital system is already under enormous stress. With a shortage of beds, patients are “boarding” in emergency departments, sleeping on stretchers or in recliners in hallways for days on end. At my own hospital, our once beautifully appointed space now resembles a train station waiting room, with nurses, physicians, and social workers clacking away at keyboards and pleading on telephones to find places for weary patients-in-waiting. From the halls of congress to the hallways of the emergency department is a very short step, at least in this city.

Many municipal hospitals operate on a slim economic margin. If the government had defaulted on its obligations, hospitals would not have been able to pay their staff or suppliers on time. Like the bigger and lesser fleas, this process would have transferred the economic burden inexorably down a line that begins with businesses and professionals and lands squarely on the backs of patients. Delay in reimbursement would have meant more beds would close, and the people now crammed into hospital hallways would have been sleeping, or dying, in  homes, attics and on subway grates.

The infinite regression of suffering that would follow from a governmental failure to pay its debts, like the bites of fleas, is something none of us, but especially those of us involved in healthcare, can ignore. 

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