An Apron & An Admission

 

There was something about the United States I once found extraordinary: the sense that the country was not reinvented every time someone new took possession of the White House.

Administrations changed, majorities shifted, and laws were rewritten, but underneath them remained something like a continuous manifesto, an imperfect and permanently editable playbook. The country seemed to understand itself not as property belonging to whoever happened to control it at the moment, but as an inherited civic project.

You received the Constitution, the institutions, the debts, the victories, the atrocities, the promises, the precedents, and the people already there. You could amend the project and fight bitterly over what it meant, but you could not plausibly wake up one morning and declare yourself the new owner of an empty house.

Immigration tests that idea.

A country has the right to control its borders, establish rules for admission and residence, and expect those rules to mean something. A government cannot maintain a credible immigration system if every restriction simply dissolves once enough time has passed.

But that is not quite the situation the United States created.

For decades, millions of people lived in the country without permanent lawful status while participating extensively in its economy. In 2023, an estimated 9.7 million unauthorized immigrants were in the U.S. workforce, about 5.6 percent of all workers. Unauthorized workers have represented between 4.4 and 5.6 percent of the workforce since 2003.

They were not invisible. They built houses, harvested food, cleaned hotel rooms, cooked meals, landscaped yards, raised children, paid rent, bought groceries, and, in many cases, paid payroll and other taxes. The Social Security Administration has long documented the peculiar fiscal consequence of this arrangement: unauthorized workers may contribute to the system through taxable earnings without necessarily receiving benefits tied to all of those earnings. For 2010 alone, SSA estimated that taxes associated with unauthorized workers exceeded benefits paid on their earnings by about $12 billion.

They were not, in the legal sense, invited guests. But once they were inside, America handed them an apron.

Imagine a dinner party with a door officially marked CLOSED. People nevertheless come through it. The hosts object periodically, argue among themselves about what to do, occasionally escort some people out, and then continue handing aprons to the rest. They put them to work, accept what they contribute, and go on living with their presence year after year. Their children grow up there. What they are never handed is a place card.

Then, years later, a new group of proprietors arrives and surveys the room as though it had stumbled upon a situation no one had noticed before. Who are these people?

Suddenly the apron counts for nothing. Neither do the rent paid, the taxes collected, the crops picked, the roofs framed, the children educated, or the years during which everyone knew perfectly well that the arrangement existed.

The new proprietors simply point toward the door.

There is a familiar refrain that appears whenever the human cost becomes difficult to look at: their parents should have thought about that before coming here.

It is usually offered as if it settles the matter. The parents made the decision; therefore whatever happens to the children is unfortunate, perhaps, but ultimately theirs to bear. Conversation over.

That sentence deserves more attention than it usually receives.

Thought about what, exactly?

That crossing a border or overstaying a visa might someday have consequences? Certainly. But what, exactly, were they supposed to predict after ten or fifteen years in a country where employers continued to hire them, governments continued to collect taxes from their labor, and their children went to American schools, spoke English, made friends, memorized state capitals, and grew up believing that the place outside their bedroom window was simply home?

Were they supposed to understand that all of those years were real enough to work through, pay through, and raise children through, but could later be treated as though they had accumulated no moral weight at all?

There is another uncomfortable aspect to that arrangement. Immigration status can make a worker unusually vulnerable. Federal labor agencies themselves have warned that employers may exploit immigration status to discourage workers from asserting workplace rights, and that workers can fear retaliation or immigration consequences for complaining about wages or conditions. Federal law protects many such workers regardless of status precisely because that vulnerability exists.

The apron becomes even more useful when the person wearing it is reluctant to challenge the host.

None of this means that every employer exploited undocumented labor, that every immigrant was mistreated, or that the United States secretly designed unauthorized immigration as an economic conspiracy. History is rarely that organized. The point is less cinematic and more uncomfortable: a dysfunctional system can persist when enough institutions learn how to function around its dysfunction.

Then come the children.

In September 2026, CNN reported from an immigration courtroom in Harlingen, Texas, where 25 migrant children appeared before a judge. A six-year-old pretended to fly an airplane. A three-year-old played with a microphone. Some children appeared without attorneys. Among them was Angel, a 13-year-old Honduran boy.

Angel told the judge that his mother and almost his entire family were in the United States and that he believed it was too dangerous to return to Honduras. The judge concluded that his answers did not establish eligibility for asylum and presented him with the legal alternatives: voluntary departure or a removal order.

Angel answered, “I don’t know.”

Then he cried. Later he said, “I have no one. I have nothing.”

There is something grotesquely clarifying about the scene: a child young enough to need the accommodations of childhood is nevertheless expected to sit inside the machinery of immigration law while adults determine which country he may call home.

This is where “their parents should have thought about it” begins to sound less like an argument about immigration enforcement and more like something considerably older.

What makes the argument feel Hammurabian is not the severity of the consequence but the inheritance of blame. The parent committed the wrong; the child absorbs the consequence. Modern immigration law may treat the child as having an immigration status of their own, but the social defense of the outcome often rests on something older: their parents should have known better.

We consider inherited punishment primitive in almost every other context. We do not imprison children because their fathers committed fraud, nor do we seize a child's future because her mother violated a contract.

Indeed, the Supreme Court confronted a remarkably similar argument more than forty years ago in Plyler v. Doe, when Texas attempted to deny public education to undocumented children. The Court emphasized that children could control neither their parents' conduct nor their own immigration status and rejected placing the burden of parental misconduct on them as inconsistent with “fundamental conceptions of justice.”

This precedent does not establish a right for every undocumented child to remain in the United States; it addressed education, not removal. But the moral principle behind it survives that distinction: the child did not choose the border, the visa, or whether the family should remain after it expired. A toddler did not evaluate asylum doctrine. And a child brought somewhere young enough may eventually possess a passport from one country and memories almost entirely from another.

Law can preserve a status for thirteen years. Life cannot.

This is why the contemporary immigration debate feels strangely ahistorical.

One side of the ledger remains remarkably legible: the illegal entry, the overstay, the missed hearing, the unsuccessful application, the parent’s decisions. The system remembers them all. But the obligations accumulated by the society that employed the worker, taxed the paycheck, educated the child, and benefited from the labor are somehow reset to zero, and the rest of us are expected to forget they ever existed.

The child inherits the parents' mistake. The nation inherits nothing.

That is a peculiar conception of national continuity. We are quick to say we when the country gets something right. We inherit the victories, the inventions, the constitutional breakthroughs, the wars won, the moon landing, the cultural achievements. But when the inheritance is a failure, the pronoun suddenly changes. Then it becomes they: past administrations, past Congresses, previous generations, the immigrants themselves.

A nation is not a landlord who purchased an occupied building last Tuesday. It does not acquire only the assets it likes. If America is a continuous civic project, then today's country inherits yesterday's border, certainly, but it also inherits yesterday's wars, treaties, debts, laws, and constitutional obligations. National pride is collective; strangely, national responsibility is often outsourced.

Why should it alone be permitted to disclaim the human arrangements produced by yesterday's policies?

There is a legitimate answer from the other side: allowing long residence to create an automatic right to remain can reward unlawful entry and undermine immigration law. Enforcement postponed indefinitely can become indistinguishable from abandoning the rule itself.

That objection deserves to be taken seriously. But taking it seriously does not require pretending that ten years equal zero.

Time may not automatically create a legal right, but it can still create a moral claim.

That distinction becomes hardest to ignore when the person absorbing the consequence is a child.

An adult made the decision to migrate. Other adults wrote the immigration laws, decided how vigorously to enforce them, hired the labor, collected the taxes, and spent decades failing to agree on what to do with millions of people living somewhere between economic inclusion and political exclusion.

Eventually, another adult, this one in a black robe, looks down at Angel, thirteen years old, and asks whether he wants voluntary departure or a removal order.

He says, I don't know.

Perhaps that is the most rational answer anyone has given to the American immigration system, because he did not create the contradiction.

He merely inherited it.

The Bluff-Fueled Price Spiral

 

How American Health Care Prices Itself Out of Reach

Game theory is often presented as the study of strategic advantage: how one player anticipates another player’s move and responds. More revealingly, it is the study of traps—situations in which every participant can behave rationally and still produce an outcome almost none of them wants.

Imagine a patient who needs a scheduled procedure. Let’s call her Laura. There is not an emergency. No one is unconscious. The surgery is six weeks away, which should be enough time to answer a question that precedes the purchase of almost anything else: What will this cost me?

The surgeon’s office can quote the surgeon’s fee, perhaps, but not the hospital’s. The hospital needs the procedure codes. The insurer needs the codes, the facility, and every participating provider. The anesthesiology group cannot say how much time will be required. Someone may send tissue to a laboratory that has not yet entered the story. Each answer is individually defensible. Together, they leave Laura with a date, a consent form, and the financial equivalent of a blank check.

Laura would not buy a $600 television this way. Yet she may undergo a procedure capable of generating tens of thousands of dollars in charges without knowing whether her own portion will be $800, $3,000, or much more. The care arrives first. The price jumps out later like a jack-in-the-box.

This is not an exceptional horror story. It is a recognizable feature of the system. Anyone acquainted with American health care knows the ritual: call the provider, get referred to the insurer, get sent back for billing codes, discover that one estimate excludes two other bills, and eventually make a medical decision without the information that would make it a consumer decision.

The Unknown Price

The first problem is uncertainty. Before receiving care, patients often cannot obtain a reliable estimate of what they will owe.

Instead, the number changes according to who is asking, who is insured, which insurer covers the patient, whether the provider is in-network, how the service is coded, how much of the deductible has been consumed, and which part of the transaction the speaker wishes to emphasize.

The federal transparency rules make this multiplicity explicit. Hospitals must publish gross charges, discounted cash prices, payer-specific negotiated charges, and minimum and maximum negotiated charges. They must also provide a consumer-friendly display or estimator for at least 300 services that can be scheduled in advance, according to the current Centers for Medicare & Medicaid Services requirements.

This is useful regulation. It is also accidental conceptual art. A normal market does not require the government to compel every seller to publish several incompatible answers to What does this cost?

Nor did the rules instantly produce ordinary transparency. In its October 2024 review, the U.S. Government Accountability Office reported that stakeholders had encountered inconsistent file formats, complex pricing, and data perceived to be incomplete or inaccurate—problems that impeded price comparisons across hospitals. CMS had initiated 1,287 enforcement actions from 2021 through 2023. Requirements introduced in 2024 standardized the files and required hospitals to attest to their completeness and accuracy, but the need for those repairs tells its own story. Opacity was not a rare software glitch. It was the inherited condition.

There is an especially revealing asymmetry in the No Surprises Act. Since 2022, an uninsured person—or an insured person choosing to self-pay—has generally been entitled to a written Good Faith Estimate when scheduling care or requesting one. Congress also created an advance-estimate process for insured patients, in which providers would send expected charges to the health plan and the plan would produce an Advanced Explanation of Benefits showing expected coverage and patient liability. Yet more than four years after the statutory deadline, the federal government’s 2026 regulatory agenda still listed the implementing regulation under “Proposed Rule Stage.” In its December 2024 implementation update, CMS reported that commercially insured participants in its consumer research expressed “a general uneasiness about navigating their insurance coverage and understanding their health care costs.” Participants overwhelmingly supported receiving cost estimates before treatment and identified an accurate estimate of their out-of-pocket cost as the most important feature.

Complexity Is Not an Alibi

Some uncertainty is real. A surgeon can encounter complications. An operation can take longer than expected. Emergency care cannot wait for a comparison-shopping expedition.

But uncertainty is not the same as enforced ignorance. It does not explain why a scheduled service can be delivered with no credible range, or why the party with the least information and the least ability to walk away must absorb the surprise.

This is where the game-theory explanation stops absolving everyone equally. Defensive behavior may explain how opacity developed. It does not justify preserving opacity as a business practice. Pricing secrecy has no legitimate place in a transaction the patient is expected to navigate as a consumer.

A market cannot call the patient a consumer while withholding the one piece of information without which consumer choice is impossible: the price. Informed consent that excludes reasonably foreseeable financial exposure is only partial consent.

The Bluff Behind the Price

Laura still faces a second problem. When the price finally arrives, it is often inflated. No single villain is required to build the machine that drives it upward.

Providers set high opening charges in anticipation of negotiated reductions, delayed payment, denied claims, and uncompensated care. Insurers build networks, prior authorizations, and cost-sharing in anticipation of high provider prices and unnecessary claims. Employers keep buying increasingly expensive coverage because dropping it would expose their workers and make hiring harder. Patients keep paying premiums because facing the system uninsured can be ruinous.

Each move is defensive. Each becomes the next player’s reason to defend.

The provider’s opening price justifies the insurer’s restrictions. The insurer’s restrictions justify higher charges and more billing staff. Administrative growth raises costs. Rising costs raise premiums and deductibles. Patients then delay care because they fear the bill, sometimes allowing manageable problems to become expensive ones.

The chicken and the egg take turns being first—simultaneously.

This is why the system resembles a bluffing arms race. Every participant exaggerates or fortifies a position in anticipation of the others doing the same. No one can safely disarm alone. A provider that begins with a modest price may be reimbursed below viability. An insurer that stops policing claims may be undercut by competitors. An employer that withdraws coverage transfers enormous risk to workers. A patient who refuses to play may lose access to the insurer’s negotiated rates and protection against catastrophe.

The system survives not because everyone believes in it, but because no participant can safely stop playing.

And so a prediction becomes self-fulfilling. The system does not merely respond to the expectation that care will be unaffordable. Layer upon layer of rational self-protection helps make it unaffordable.

When Laura’s bills finally arrive, the price does not appear as a single number. It multiplies into several prices for the same care.

The provider submits a billed charge. The insurer applies the negotiated allowance. Part of the allowance becomes the insurer’s payment and part becomes the patient’s responsibility. The difference between the opening charge and the allowance appears as a discount—as though the first number had been waiting at the cash register for an unsuspecting shopper.

The discount can be real. An in-network contract may prevent a provider from collecting the full billed amount, and that protection can be extremely valuable. But the presentation remains theatrical: the supposed savings are measured against a price the provider never seriously expected to collect and the insurer never expected to pay in the first place.

And all of this happens after Laura has already paid premiums to enter the system—and may still face a deductible and coinsurance to use it.

Dental coverage provides a useful illustration of how a “good” plan can remain expensive at the moment of use. For example, under the 2026 Blue Cross Blue Shield Federal Employee Program dental plan, an adult member using an in-network dentist pays 50 percent of the plan allowance for major Class C services—including endodontic treatment—under the High Option. Under the Standard Option, the member pays 65 percent. Those percentages still do not answer what a root canal will cost. The allowance must be known, and the final restoration may be a separate service. “Covered” describes a relationship among charges; it does not reveal a price.

The broader medical market shows how far commercial prices can diverge from a public benchmark. The latest large RAND comparison, published in 2024 using 2022 claims, found that employers and private insurers paid hospitals an average of 254 percent of what Medicare would have paid for the same services at the same facilities. That does not prove that Medicare always pays the correct amount, or that every dollar above it is excess profit. It does show that the same services are routinely delivered under a substantially lower public payment schedule, complicating any claim that commercial rates simply reflect the irreducible cost of care. 

A Bluff That Became Real

The trap is durable because every participant can point to a different number. Providers point to the discounts they granted. Insurers point to the charges they defeated. Employers point to the premiums they subsidized. The government points to the share paid through public programs. Patients point to the amount removed from their bank accounts. Every number can be accurate while the account of who paid what remains strangely incomplete.

The first reform is conceptual: stop pretending that all these numbers describe the same thing. A billed charge is not an allowed amount. An allowed amount is not an insurer payment. An insurer payment is not the value of the policy. A patient’s bill is not the patient’s total cost. An employer contribution is not free.

Only then can the famous discounts be judged honestly. Until then, the system will continue performing its favorite trick: inventing a price no one was expected to pay, reducing it to a price the patient was not allowed to know, dividing that price among parties who have already paid one another, and presenting the result as evidence that the machinery works.

The bluff did not conceal the price. Eventually, it became the price.