**6.3 Balanced budgets**

The United States has held a privileged position in the world (militarily, financially, and societally) since the end of the second world war. Financially the U.S. has been able to borrow money both domestically and through foreign funds as the US dollar has been held as the global reserve currency. At times, such as during the Clinton presidency (1993–2001) there was economic prosperity and balanced budgets, at which time you see a leveling off of healthcare expenditure by %GDP (**Figure 1**). However, the vast majority of years the U.S. Congress has not been able to pass a balanced budget. This has allowed the U.S. to spend more on healthcare then there is money for, putting this debt on future generations. Perhaps the electorate would demand more of their elected officials if when economic successes were conveyed in the media they were scaled by how much debt was taken on to achieve them. For example, if healthcare coverage was increased by spending \$X more for services, but that was during a year where the deficit (or borrowed money) was 20% higher than revenues, then the reported success should only be in funding a 80% \* \$X increase in healthcare support. The U.S. Revenue has been around 17% of GDP for the past 30 years, while spending has averaged about 20%. While congress has historically worried about deficits in the capital-B range (Billions) of US dollars, during the covid-19 pandemic both the Trump and succeeding Biden administration had relief packages in the capital-T (Trillion) dollar range. The fact that states generally keep balanced budgets, since they don't have the legal means to print money like the fed, has kept future medical debt from being much worse.

## **6.4 Surgical decisions**

Hospital administration, physicians, and patients can choose a very expensive procedure/surgery based on a perceived outcome which does not match the scientific outcome data. This misalignment can occur when a decision needs to be made quickly, the intervention has a positive short term outcome compared to longer term issue (such as reducing immediate pain), or for financial reasons if the hospital stands to benefit from a procedure covered by insurance. An example is the increase in the United States of C-section deliveries, compared to vaginal births, which rose from ~20% in the late 1990s to over 30% 15 years later [51]. In 2010 cesarean deliveries were 40% more expensive than vaginal deliveries, \$9,905 versus \$7,089 respectively [52]. Cesarean deliveries can reduce the incidence of pelvic floor disorders

(PFD), namely stress urinary incontinence (SUI) and pelvic organ prolapse (POP), but the future savings do not offset the larger increase in delivery costs. The rate of SUI and POP after a vaginal birth are 13% and 14% respectively, but drop to 7% and 5% respectively after a cesarean birth. While the cost of surgeries for POP and SUI are expensive (\$6,878 and \$10,600 respectively) the relatively rare occurrence causes the average savings (\$344 and \$742 respectively) to be dwarfed by the higher delivery cost (\$2,816) [52].
