Letter: Health care system’s true elephant in the room

Graphic by Lori Deaton

As regarding the noted opportunities, concerns and comments regarding the Mission Health sale to HCA: We should be mindful of the true elephant in the room. We have no choice but to face these kind of debates in a health care delivery system based on profit.

We’ll continue to chase our tails and flail about looking to deliver fairness and equity on par with efficiency and quality as long as profit is the driver. There are irreconcilable goals here. Those in the heart of health care, honorable and otherwise, know we can never deliver on the promises made and envisioned to improve the country’s troubling health care markers with profit as a primary driver.

Without a single-payer based model, the shell games will continue, and we’ll have a tiered model of delivery that benefits we-haves over the have-nots. We’ll as well continue to pour more resources into treating rather than preventing disease. For all the complexities of the former, it’s frankly proven easier than the latter in the era we’ve all lived.

We’re rightfully hearing more about making social determinants of health a priority. Will those who profit from our nation’s health infirmities find their priorities can align with this? I wish I could feel optimism here, but I don’t.

Finally, I take exception to Carl Mumpower’s recent diss of my Cleveland Browns in his letter to the editor regarding the Mission sale [“Mission’s Sale: One of the Greatest Local Political Cons,” Feb. 6, Xpress]. The analogy is a year late. Our formerly dismal Browns are now among the hottest teams and destinations in professional football. I would posit that a majority of devoted sports fans wouldn’t think of trading our Browns for the Patriots.

— Bruce Kelly, M.D.
Asheville

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25 thoughts on “Letter: Health care system’s true elephant in the room

  1. C-Law

    So “Medicare and Medicaid for All” it is then, Bruce, MD? Part of the everyone has a fundamental “right” to healthcare crowd?

    At the speed and velocity with which this evil Yankee Empire is heading to financial doom, I guess we might as well bring on the flaming asteroid of death and get it over with, ha!

    However, proposals such as Medicare and Medicaid for all is the sort of thing that will get an enormous percentage of the population killed if the government ever tried to enact such a policy.

    Something that someone else must labor to provide cannot be a “fundamental right”; such a declaration from a politician is a declaration of intent to impose slavery, and ought to be facially considered a capital felony.

    If there’s a list of “somethings” worth having a shooting war over slavery is almost-certainly at the top of the list.

    Rights can never be something another person has to provide; they can only be something another person can be enjoined from preventing you from doing.

    The Second Amendment guarantees the fundamental right to keep and bear arms. It does not compel someone else to pay for your gun and/or ammunition; it cannot, because in order to do so you would have to force someone else to make the gun for you at a cost to them which you choose.

    The First Amendment guarantees the fundamental right to free speech. It does not compel someone else to pay for your advertising in the media; it cannot, because in order to do you would have to force someone else to buy a printing press, paper, ink, video camera, web bandwidth or TV time.

    Medical firms commit daily felonies literally beyond the ability to count in the form of violating 15 USC Chapter 1. There is exactly nobody in the Federal Government or running for a federal seat who is doing anything about this, despite the legal authority and in fact mandate to arrest and prosecute being clear at both the state and federal level. Twice medical and insurance firms have gone all the way to the Supreme Court claiming immunity and lost both times — in the late 1970s and early 80s. For nearly 40 years both federal and state governments have ignored the literal daily financial gang-rape of everyone in America and allowed this venomous “industry” to destroy local, state and federal government balance sheets — never mind the financial health of virtually everyone in the United States.

    Worse, exactly nobody over that 40 years has gone into their garage and dusted off their pitchfork and torch. Nobody.

    Instead we have bleating about Medicare For All and in the last few weeks (from the likes of a freshman Congresscritter from NY who somehow has an Economics degree from Boston Univ., but obviously can’t perform simple arithmetic) Medicaid for all too — including illegal invaders — a literal “open door” for those who come to this nation to loot it.

    Sweet Asteroid of Flaming Death, may you both be large enough to get us all and smote DC right in the face! ha!

    But yeah, good luck with government run single-payer! Ha! Nice try and thanks for playing!

    • SpareChange

      While some do talk about wanting to create a positive “right” to healthcare, I find it interesting that Dr. Kelly does not seem to use the word, and makes no such assertion. While admittedly interesting in the abstract, this framework of negative vs. positive rights offers precious little guidance when it comes to important public policies which can make the difference between life and death for real people, living real lives.

      So, in order to advance the discussion, maybe we can just agree that healthcare is REALLY important in people’s lives. And that its importance is evident at numerous levels — to each of us as individuals, but also to our families, communities, and us as a nation. Then let’s say that given its importance, we might reasonably discuss and debate whether it is worth supporting people’s access to health care through our laws, taxes and public policies. This, after all, is the rationale behind supporting everything from stop signs, roads and education, to fire fighting and national defense. Including health care in the mix is a reasonable and defensible position in such a context.

      It does, as you make clear, still leave us with the very complicated policy problem of how to reform the current mish-mosh of cross-cutting political-economic interests and institutional actors, but at least we won’t be preventing ourselves from having the discussion simply because we allow ourselves to get stuck in the loop of an academic argument.

      • Lulz

        How can you enact single payer while also allowing those who buy food with EBT and WIC to purchase unhealthy food with it? The only people who will be held to any standards are those with a pre tax oncome set at a certain level. The other 50 percent of the nation that pays no taxes won’t be held to any,. Hence why the 3 trillion dollar a year costs will bankrupt the nation.

  2. Lulz

    LOL you think single payer is about fairness? LOL all it does is nationalize healthcare that’s still ran by big pharma. And they won’t be delivering top notch care for less profits. It’ll be the opposite. All you accomplish is take insurance out of it. Big pharma still lives and just like colleges with their student loan scam, actually increases cost because the money is guaranteed by the government. You end up with an even bigger bureaucracy, a bloated price structure, and less care.

    Do you even have a clue about supply and demand? Do you have the ability think that it’ll be nothing more than a wealth transfer scheme that eventually bankrupts the government? Cause that’s what it is.

    • luther blissett

      “Big pharma still lives and just like colleges with their student loan scam, actually increases cost because the money is guaranteed by the government.”

      Also, apples are oranges. But thanks for telling us that “how healthcare systems are run” is another thing you feel compelled to opine on despite knowing nothing about it.

      • Lulz

        LOL funny but it seems there was a tax passed a while back that was supposed to go to AB Tech. The people against it tried to tell the mob that the money would be wasted away. And lo and behold, where did it go? Tax and spend big government crony goons don’t know squat. And neither do single payer big government crony goons. 3 trillion a year in projected costs is a recipe to ruin. So why don’t you just like tell us all how you’ll manage that? What you’re calling for is communism. So trying to explain the reality to the people who make the followers of Jim Jones look sane is all for naught.

        • luther blissett

          “3 trillion a year in projected costs is a recipe to ruin.”

          Total annual healthcare costs in the US right now… $3.5 trillion. Hmm.

          Just under half of that — about $1.7 trillion — is Medicare, Medicaid, CHIP and other public spending. What separates the US from the rest of the developed world is the amount spent on price-gouging, kickbacks, pharma ads, private insurers, PBMs, for-profit hospital chains like HCA and the rest.

          Thanks once again for demonstrating what you don’t know.

  3. J

    It’s ironic that our politicians are very proud to give America’s finest “Veterans” socialized healthcare; yet when the debate is brought up with regards to socialize healthcare for all (here in this country) it is quickly demonized .
    As someone who grew up on the Canadian single payer system, then the US military for 5 years… and have been utilizing the VA since 2000…. AND now a physician who struggles in a for profit system…. yes I said struggles! Nobody knows a variety of healthcare systems better than I…..we may have he best healthcare here in the US, but when over 1/3 don’t have access to “the best”; due to enormous costs.. including Medicare and Medicaid due to low payouts…. what’s the point? Why are we the only industrialized nation to NOT implement healthcare for all?

    • C-Law

      J,

      You can want to promise “the best healthcare for all” and spend to infinity, but you will never solve the mathematics of the problem, beyond the immorality of you trying to force me to subsidize the self-destructive lifestyle idiocy of others through the fruit of my labor! Typical progressive BS–giving out charity to the undeserving with other peoples’ money. You may be a physician, but you don’t know squat about economics or liberty. Math doesn’t care about your politics or good intentions, it just is.

      Let me spell out the issue and the fix for you and any other MtnX readers that may stumble upon this…

      We can’t solve the crisis through any combination of cutting spending, tax-shifting in other areas or taxing our way out of this. Not mathematically possible.

      Collapsing price is the ONLY way out of this that doesn’t lead to economic implosion and utter collapse. Now why has the price of medical care gone to the moon in the last generation? Monopolistic practices in the medical and health insurance industries allowed with the full approval of Federal and state governments, run by the national “uniparty” system. The Ds and Rs have been thick as thieves in the whole multigenerational scam the whole time.

      This, and only this, is why health care costs are so high. Between prescription drug importation bans (a monopolistic practice Congress created out of whole cloth, and thus Congress can repeal) to CON laws to refusal to post and quote prices to practices such as a differential billing (which is responsible for Michigan having car insurance that’s 3x as expensive as states without it for starters) this has utterly disappeared. This is the issue that must be addressed and this act must take place NOW or our nation dies fiscally within the next four to five years.

      This is not a maybe, it is not a possibility, it is not political rhetoric it is immutable mathematical fact.

      The Federal government spent 37% of every dollar it spent in total on Medicare and Medicaid last fiscal year. This rate of spending is increasing by roughly 9% a year. Within four years that will result in roughly $2 trillion a year of spending on these two programs alone and blow an additional $600 billion a year hole in the federal budget. For scale $600 billion is roughly the size of all defense spending and that’s the additional amount we will try to tack onto to what is already being spent today. This is not due to people getting older, it is due to medical monopolies that in any other line of work would land everyone involved in federal prison under 100+ year old law found in 15 United States Code.

      Remember that socialist medicine in most of the developed world manages to deliver better health care outcomes than we have at half the cost per person. Capitalism always outperforms socialism for the simple reason that a capitalist system adds an incentive to bash your competitors over the head with price right up to the limit of excess margin. That is it adds price discovery as an incredibly powerful cudgel and drives incentives to remove inefficiencies and improve productivity, thereby allowing competitors to undercut one another on price even further. This means that a capitalist system minus the existing monopolies would wind up delivering health care at one fifth to one tenth of today’s cost and also deliver superior outcomes! If you think this is impossible then explain the $95 MRI you can buy today in Japan (which is not a third-world country) .vs. the same scan that costs $1,000 or more here.

      Again there is only one way to solve this problem and that is to collapse Medicare and Health spending by 80%. You can only resolve the problem by collapsing the medical and health insurance monopolies, forcing everyone to publish a price for everything and charge everyone the same price, where said price must be handed out before service is provided, along with telling everyone involved that for any and all conditions in which a lifestyle change will remove the need for treatment government will pay zero unless the person in question makes that change.

      The trend is not improving and it is not “The Next Generation” that will have to deal with this.

      This has to stop right damn now or it will blow up before we get through the next Presidential term — and no, you cannot tax your way out of it either. The people in Washington DC — Congress and the President — must be held personally and politically responsible for their refusal to deal with the only way to put a stop to it, which is to destroy the medical monopolists using existing, 100+ year old law, and to do it right damn now.

      And if they refuse we the people must enforce our demand for them to do so. They will refuse, I remind you, unless forced by the people — and there are peaceful and lawful means to do exactly that (e.g. a general strike.)

      Nothing less than the literal existence of this nation as a Constitutional Republic is at stake.

  4. Jay

    We are headed into Financial doing because of the fact that we spend 12 times the amount on our military as the preceding seven governments combined….
    RUSSIA our “biggest threat” has 1 base outside their country…. we have over 250…
    Very ignorant “proposals such as Medicare and Medicaid for all is the sort of thing that will get an enormous percentage of the population killed if the government ever tried to enact such a policy.”
    Considering ALL other countries with universal healthcare…. ARENT mass murdering their people/patients…

    • Lulz

      LOL because the USA is there to protect them. You folks raise a stink if Trump presses NATO to pay more.

      Military budget us 800 billion. Single payer is 3 trillion a year projected. You do the math.

      • J

        You folks? Wow… so typical of “You folks” to generalize…. and that’s 3 trillion considering how much the entire healthcare industry CHARGING; NOT GETTING PAID! Coupled with the insane profits top brass Hospital administrators and stock investors get…. must I remind you that converting from a for profit to a nonprofit healthcare system; won’t cost us nearly as much as what our corporate GOP elected officials ( sellouts) are telling us… So nice try on to inflating the numbers to discredit a system that AGAIN! every other industrialized nation uses and has a much better success rate than we do …

        And for what it’s worth there is no liberal; that is opposed to getting other countries to pay their fair share on military spending !

          • J

            Again….. ARE U SUGGESTING THAT ONLY BECAUSE THE US defends other western powers; is the reason these same allies can afford universal healthcare!? How come no body’s answering me about this? Again; how is it that EVERYOTHER industrialized nation provides ubviseral healthcare and we CANT/DONT??

      • luther blissett

        3 trillion a year is cheaper than the status quo. Thanks for playing.

        • Lulz

          LOL the entire budget is 4 trillion. Where you going to get the money? All the illegals? LOL the insanity on display is priceless.

          Jim Jones is jealous.

          • Tim P.

            When someone thinks they’re the smartest person in the room….it might be time to a new room.

          • luther blissett

            “Where you going to get the money?”

            Where does the money come from for the current arrangement?

            It’s okay to be ignorant. Everybody’s ignorant about certain things. But the cure for ignorance isn’t more ignorance.

    • C-Law

      It’s okay Jay, you misunderstand the part about getting people killed if such a policy were attempted to be enforced…

      Side note–I totally agree with you…The Evil Yankee Empire’s bloated and corrupt military occupation overseas on every continent I find to be intolerable! Especially when the Federals drag out the flag and claim they are killing and oppressing poor brown people overseas for my “freedom.” Or they set up the next false flag attack/black swan event to further the globalist agenda. The Yankee Empire…bring death, destruction, and “order out of chaos” world-wide since 1861. Aggressive abroad ad despotic at home.

      But, no the deaths pursuing and fully enforcing a Medicare/Medicaid for All program will cause death and destruction here stateside because:
      1. It will utterly destroy the domestic economy and likely be the final breaking point for the corrupt and thoroughly rotten to the core Yankee Empire. Devolution to feudal/regional scale society and economy may sadly be the best-case scenario…sadly several much worse outcomes are just as, if not more likely.
      2. It will require working class people like myself and millions of others to further become wage slaves/debt peons/21st century sharecroppers. We will reach a point of shutting down our traceable economic output to feed our families and ideally starve the government.
      3. If .gov attempts to forcibly confiscate our property or prosecute us for choosing to withdraw from participation in the economy, there are millions of us, bearing millions of arms and hundreds of millions of rounds of ammunition. In an economic collapse/civil society major disruption event, when we have nothing to lose…well, nobody wants to see that. You, me, nobody! We’d better off if the Sweet Flaming Asteroid of Death smacked us right in DC just as Yellowstone erupts and “the Big One” unzippers Cali!! Haha!

      • J

        Then please express to me in a truthful and rational way why is single payer healthcare system works in every other industrialized nation….. EVERYOTHER!!!! And please please do not tell me that innovation is only spurred by the highest paid…. Israel; a country that provides universal healthcare to its citizens; has just announced that within a year virtually every cancer will be cured in a very cost-effective way….

        Bottom line; if it works successful in so many other countries… there is absolutely no way that it will not work here…. I don’t disagree that it may be politically unpopular for some …. but then again look at who we have sitting in the oval office ( they’ll get over it )

        • C-Law

          Hi J,

          Read my response to your original remarks and that will get you on the right track as far as what the real problem with healthcare delivery in America is, and I offer up the fix for it as well. The bottom line is that current system is the express route to systemic destruction, however, we don’t need government run single payer either. It may be better than the corrupt system we currently are under, but I can give you a better fix than that.

          Bear with me and check this out below here…(if MtnX mods are kind enough to indulge the length)…I will lay out the parameters for a bill which could easily be turned into formal legislative language. Maybe someone could forward on to Mark Meadows and any and all members of Congress you can think of?

          Anyhow here is what I humbly (ha!) call my : Bill to Permanently Fix Healthcare For All

          All providers must post, in their offices and on a public web site without any requirement to sign in or otherwise identify oneself to access it, a full and complete price list which shall apply to every person. This instantly allows customers to compare pricing between providers for services and products in the medical realm.

          •All customers must be billed for actual charges at the same price on a direct basis at the time the service or product is rendered to them. This immediately and permanently decouples “insurance” from the provision of care. The current system of an “explanation of benefits” that often features a “negotiated discount” of some 90% is nothing other than an extortion racket and is arguably felonious — threatening to bankrupt someone if they don’t buy your “insurance” through a threat to charge them ten times as much certainly appears to be a criminal enterprise and, given that more than one entity is involved, looks like it meets the definition of Racketeering. Insurance coverage may well cover some, part or none of a given bill, and nothing prevents an insurer from telling you in advance of your visit how much they will pay (if anything) for a given procedure or drug. Indeed you should demand that information from them and use it as part of choosing where to obtain treatment but the bill still has to be rendered to you, you have to be the one to file the claim and everyone must pay the same price to the same provider for the same kind and quantity of product or service.

          •For a bill to be valid and collectible it must be affirmatively consented to in writing, with a disclosure of the actual price to be charged from the above schedule for each item to be provided whether good or service, prior to the service being performed or the good furnished, subject only to the emergency exception below. A bill that is increased, has items added to it after consent is obtained, which contains any open-ended promise to pay without an actual price listed for each service or good prior to customer consent or is issued with no consent at all (including having a customer sign a consent form while under the influence of drugs the facility gave them as occurs in virtually every instance today while you’re being wheeled into the OR) is deemed fraudulent and void. This instantly stops “drive-by” doctor charges in hospitals as just one example. It also prevents charging $20 for an aspirin; nobody would tolerate being billed by the square for toilet paper in a hotel! Hospitals will of course squawk that they cannot operate like this as they “can’t” figure out what is required until after-the-fact but that’s false; nothing prevents them from advertising “Appendectomy: $2,000” and that being the soup-to-nuts price. In fact that’s exactly what the Surgery Center of Oklahoma does today so quite-clearly it both can and does work. In addition this change will permanently and immediately put a stop to the ridiculous practice of defensive medicine (read below for the explanation.) You would never accept a gas station that only displays the cost of your gasoline after you pumped it and varied that price based on who your car insurance was bought from or a grocery store that had no prices posted at all and only gave you a total after your groceries were taken out of the store and the transaction could not be refused.

          •No event caused by or a consequence of treatment, can be billed to the customer. This instantly aligns the interest of the customer in not having such an adverse complication (e.g. MRSA, etc.) with the medical provider. As it stands right now hospitals actually have an incentive for you to have a complication since they make more money if you do. If you call me to fix your roof and I drop my ladder causing it to crash through your picture window I get to pay for the glass I broke through my ineptness. The same must apply to medical providers. For those who claim hospitals and similar can’t adopt such a model I point to the OKC surgery center, which does exactly this — and has a lower complication rate (gee, I wonder why when they have to eat it if they cause it….) The exception: A unavoidable and pure-chance side effect of a treatment or medication that (1) is less harmful than the disease or condition treated, (2) fairly and objectively disclosed in comparison to the original risk of the condition being treated and (3) thereby consented to with informed consent. In other words you can’t give informed consent to an MRSA infection acquired in a hospital but you can give informed consent to the risk of taking a drug, if and only if you are in fact provided the truth about the treatment and it’s scientifically-documented risks and rewards. Note that if those scientific facts are later proved to be bogus you have a cause of action against everyone so-involved in deceiving you.

          •All true emergency patients, defined as those who are unable by medical circumstance to choose where their treatment is to take place and require immediate medical intervention to either stabilize their condition, prevent severe permanent impairment or death (e.g. transported by an ambulance, unconscious with no person with medical power of attorney at-hand, having a heart attack in the ER, etc.) must receive the same price for the same service as a person who consents to said service. For a bill to be valid for a true emergency documentation must be maintained and presented showing that the customer was unable, due to exigent circumstances at the time they presented to the provider, to provide consent prior to services being rendered. Any medical provider who attempts to bill any service or product above that price to a person in exigent circumstances forfeits 100% of their invoice and is guilty of consumer fraud. Note that this does not prohibit a hospital from having a published price list that charges more for services rendered through their Emergency department, those that are provided at 3:00 AM, etc. so long as those who walk in, are conscious and able to consent get the exact same price as someone who is unconscious and flat on a gurney. If you demand that an A/C repairman or plumber come out now at 3:00 AM he most-certainly can charge you more than if you call and ask him to show up during normal business hours!

          •All medical records are the property of, and shall be delivered to, the customer at the time of service in human readable form (a PDF provided on common consumer computer media such as a “flash stick” shall comply with this requirement.) Any coding or other symbols on said chart must include a key to same in English delivered at the same time. No separate charge may be made for the provision of a contemporary record of a medical visit or treatment other than a reasonable charge for physical media if the customer does not have same with him or her. The obvious way to do this is for the customer to bring a flash drive to which the human-readable chart is written. If the customer doesn’t have one the office can certainly maintain a small supply of $10 flash drives and charge the $10 to their bill.

          •All surgical providers of any sort must publish de-identified procedure counts and account for all complications and outcomes, updated no less often than monthly. Consumers must be able to shop not only on price, but also on outcomes. Because outcome odds do vary with the seriousness of the presented case providers may classify severity as well provided it can be done in an objective way. Complications must be broken down as to type (specifically identifying any that are not due to presentation but rather the facility via infection or error), severity of injury (including death) and additional time and/or drugs and procedures to resolve on a ratable scale commensurate with the original prognosis.

          •Auxiliary services (e.g. medical or dental X-rays, lab testing, etc.) may not be required to be purchased at the point of use. If you wish to buy your tests from the lab down the street (which also must post a price) that’s up to you. If you wish to have your bitewings taken at the imaging center across town, that’s up to you. The dentist or doctor cannot require that you buy those services from them; they must compete for them like everyone else.

          •All anti-trust and consumer protection laws shall be enforced against all medically-related firms and any claimed exemptions for health-related firms in relationship to same are hereby deemed void; for private actions all such violations proved up in court are entitled to treble damages plus a $50,000 statutory civil penalty per impacted person. If the government won’t bring these charges (and we know they won’t since despite not one but two US Supreme Court cases here and here making clear anti-trust laws apply to medical providers of all stripes not one charge has been leveled against any of the medical firms) let’s make it damn attractive for individual private suits by making the price of losing such a suit for a medical provider ruinously expensive (and lucrative for the attorneys bringing them!)

          •Any test or diagnostic that carries no exposure to drugs or radiation, nor is invasive beyond a blood draw, may be purchased without doctor order or prescription. If you want an A1c or CBC you thus need nobody’s permission to have one. Same for an MRI. For those tests and procedures in which exposure to drugs or radiation are involved, or are invasive (e.g. internal biopsies, etc.) requiring some sort of chain of evidence of need due to that risk is reasonable. But for most diagnostics this is demonstrably not true. There is a clean argument to be made that for young, outwardly healthy adults a metabolic panel and CBC might actually be more useful in catching incipient serious disease than an annual physical which typically is nothing more than 5 minutes of observation and no checking of metabolic parameters beyond blood pressure and pulse rate! The former can be had for $10 while the latter is often a $100+ charge. Let the people and evidence show which is superior on a cost-benefit basis; after all it’s my ass on the line from my decision not yours.

          •Wholesale drug pricing in the United States must be on a “most-favored nation” basis. The impact of this would be to force a level price across all nations for drugs produced by any pharmaceutical company marketing both in the US and anywhere else in the world. Violations, including attempts to “offshore” via subsidiaries to evade this requirement are deemed criminal and civil acts. The civil penalty shall be 300% of the difference paid to the customer who got screwed, and another 300% for each instance of a prescription filled at an inflated price paid as a fine to the government. This would drive drug prices down by at least half in the United States and for many drugs by 90% or more. It would instantly and permanently end, for example, the practice of charging someone $100,000 for scorpion antivenom in Arizona when the same drug from the same company is $200 for the same quantity 40 miles to the south and across the Mexican border. Since all prices must be posted at the retail consumer level for both goods and services controlling the drug pricing problem at a wholesale level is both simpler and sufficient since competition will already exist at the retail pharmacy level.

          •No government funded program or government billed invoice will be paid for medical treatment where a lifestyle change will provide a substantially equivalent or superior benefit that the customer refuses to implement. The poster child for this is Type II diabetes, where cessation of eating carbohydrates and PUFA oils, with the exception of moderate amounts of whole green vegetables (such as broccoli) will immediately, in nearly all sufferers, return their blood sugar to near normal or normal levels. The government currently spends about 25% of Medicare and Medicaid dollars on this one condition alone and virtually all of it is spent on people who can make this lifestyle change with that outcome but refuse. If you’re one of the few exceptions and it doesn’t work in your case you have the burden of proof. Nobody has the right to light their own house on fire on purpose and then claim FEMA benefits for same. This one change alone will cut somewhere between $350 and $400 billion a year out of Federal Spending and, if implemented by private health plans as well, likely at least as much in the private sector. That’s more than three quarters of a trillion dollars a year that is literally flushed down the toilet due to people being pigheaded and refusing to do things that would not only save the money but also save their limbs, eyesight and ultimately their life.

          •Health insurance companies must sell true insurance to sell any health-related policy at all. A true insurance policy is defined as one that (1) does not cover any condition you have received treatment for over the last 24 months (in other words, p != 1.0), (2) if an adverse event does occur your obligation to pay any further premium ends with regard to coverage for that event and all consequences thereof while the company is required to pay reasonable costs of treatment until and unless the condition has been resolved without limitation on the necessary amount or duration of said payments and (3) does cover, with a selection of deductibles available to the buyer, all accidental injuries and truly life-threatening emergency medical events (yes, this means the “exceptions” medical insurance firms write into policies for victims of crimes or terrorism will be unlawful and unenforceable.) Medical underwriting is permitted for such catastrophic policies but once undertaken is transferable to a new company without a new round of underwriting provided no interruption in coverage of more than 60 days occurs. Such a policy may exclude intentional acts (e.g. acute drug overdose by other than non-consensual consumption), perhaps with an exclusionary period (such as that for suicide on life insurance.) A common policy of this sort with the above reforms would cover things such as heart attack, cancer, liver failure by other than alcoholism, rare diseases and similar and would be very inexpensive. For a young person of normal weight the cost of such a policy might be $100 a year. For a 50 year old, maybe $300 a year. If you’re overweight or obese (or worse, have a high A1c) then it’s going to be considerably more-expensive because your risk of heart attack, for example, would be much higher. Ditto if you’re a smoker. To protect against fraudulent misconduct by insurance companies with regard to rescission of policies after an event, which used to be quite common, the only grounds for rescission is evidence that you actually underwent medical treatment for the condition that is medically proved as the underlying cause of the claim or fraud in the application (e.g. claiming to be a non-smoker when in fact you are.) The two-year “no treatment” period balances sufficient protection against anything that (1) is degenerative and emergent and (2) would otherwise lead to a claimable event against the abuse of rescission against the possibility of a customer attempting to rip off the insurance company (and thus all the other policy holders) by buying a catastrophic policy after a serious event has become evident to them.

          •All health insurance providers selling true insurance, in whole or part, must provide within their “true insurance” the ability to “replace like with like.” This is the premise of insurance, subject to policy limits. If you wreck your car you’re not entitled to a new car, but rather either (1) repair of the one you wrecked to “as before the wreck” condition or (2) its current value in money. To the extent reasonably possible health insurance for “true insurance” events (as above) must therefore cover the provision of services and goods to return “like for like” within the area where you are at the time the event occurs, or to where you are involuntarily transported in the event you are incapacitated.

          •Medicare becomes just another insurance provider. There is no “special” Medicare-accepting doctor list; it is simply an insurance plan and one that does not pay for routine physician visits and similar but rather covers unexpected insurable expenses. In other words Medicare Part “A” will continue as-is along with Part “D”, but Medicare Part “B” will be deleted. Since Medicare was sold to the public as an “80/20” plan (the customer bears 20% of the cost of care) this change represents no violation of that promise. In addition Seniors can still buy “Medicare Advantage” plans should they wish that covers all medical costs (with possible deductibles and co-pays) as is currently the case.

          •Medicaid is repealed entirely. No, we’re not leaving the poor out in the cold. See the next point; the poor will in fact obtain better care than they have now as they will have full access to the entire body of physicians, hospitals and facilities.

          •For those who have no means to pay and find themselves with a need for medical attention the following provisions shall apply:
          1. EMTALA is hereby repealed.
          2. The provisions of this section, bearing on those who cannot pay for medical services, shall apply only to US Citizens and lawful permanent residents. This instantly puts a stop to the “uncompensated care” problem for illegals and the “come here pregnant and poop out a kid” expense issue as well. No medical provider shall have any liability, whether civil or criminal, for their refusal to provide care for which they are unable to secure payment when furnished to other than lawful permanent residents or Citizens. Other nations that wish to negotiate a bill-back provision for their citizens in order to insure that payment is secured may, of course, do so but under no circumstance shall a person who is not a citizen or permanent resident obligate any provider to provide services without payment, nor may they avail themselves of the backup payment provisions of this section, nor does any cause of action in favor of any person arise in equity or law for a provider’s refusal to provide care to a person who is not a citizen or permanent resident without sufficient guarantee of payment for medical goods and services.
          3. For those with true emergencies (as defined above) and who are lawful permanent residents or citizens and thus can identify themselves as such but are unable to pay the treating hospital/ER shall bill the US Treasury for the lawful charges incurred under the above framework and shall be paid within 30 days. All provisions of the above shall apply for what constitutes a lawful and payable bill and shall be provided to the customer at the time of service along with the fact that same has been forwarded to the US Treasury for payment.
          4. For those with non-emergency conditions who are (1) US Citizens or (2) lawful permanent residents and who assert they are unable to pay the medical provider shall bill the US Treasury for the lawful charges incurred under the above framework and shall be paid within 30 days with the provision that government billing shall not be available for any condition, drug, device or treatment for which a lifestyle modification that the consumer refuses to make will alleviate any or all of said expense and need for medical goods or services. Again, all provisions of the above shall apply for what constitutes a lawful and payable bill and shall be provided to the customer at the time of the service being provided. Treasury shall provide a means of rapid verification of citizenship or permanent resident status for the use of medical providers, with access to same restricted for this exclusive purpose so as to allow validation of such claims at the time of service (if we can have a background check call-in number for gun sales we can certainly verify citizenship status for those who claim to be indigent and in need of medical care!)
          5. Said charges under (3) and (4) will, when submitted to Treasury, result in an invoice being sent to the taxpayer in question and may be settled within 90 days of submission at no penalty. This allows a person who temporarily cannot pay or who is misidentified as not having a means of payment (whether insurance-based or otherwise) to make payment directly to the US Treasury without risk of an adverse tax action. If said bill(s) are not paid in full within 90 days then they become a tax lien subject to collection exclusively from any or all of (a) refundable tax credits, which may be garnished at up to 100%, (b) tax refunds, which may be garnished at up to 100%, (c) other entitlement checks excluding Social Security retirement which may be garnished at a rate of no more than 25% (e.g. social security disability, general assistance, etc) and (d) windfall amounts in cash or property that cumulatively exceed $10,000 in a rolling 12 month period from any source (e.g. inheritances, lottery winnings, gifts, etc.) that may be garnished for payment up to their full amount. Statutory interest at 110% of the current 1-year Treasury bill rate, with the rate adjusted on the last business day of each calendar quarter, shall be applied on any remaining balance until paid in full. This will be vastly cheaper than Medicaid — about 10% of what is spent today, in fact, and a good part of it will be recoverable over time.
          6. At death if a tax lien exists for unpaid medical bills it shall be treated as any other tax lien for the purpose of claim against the decedent’s estate except that in the case of a married couple with a surviving spouse who’s marriage pre-dates the medical expenses in question any such claim shall not be recoverable during the surviving spouse’s remaining life but rather shall become a claim against said surviving spouse’s estate at the time of their death. Remarriage, creation of a trust or other estate-planning vehicle after the event(s) giving rise to the medical tax lien shall not modify or defray this liability and may not be used to shield the assets of the surviving spouse from an existing claim.
          7. Any provider of service that falsifies billing under this section, bills at inflated prices or otherwise violates the provisions of this law in regard to any bill submitted to the US Treasury for payment shall be deemed guilty of a criminal felony for which the punishment shall be the forfeiture of three times the billed amount and each individual who has caused such an invoice to be issued, transmitted or otherwise participated in same shall be subject to a fine of not less than $1,000 nor more than $10,000 and imprisonment of not less than 2 and not more than 5 years. Each fraudulent invoice shall constitute a separate and distinct offense, all penalties shall be consecutive and additive, and liability for same shall be joint and several.
          8. Misrepresentation of citizenship or permanent resident status for the purpose of obtaining health care to be billed to the Treasury shall be deemed a criminal felony punishable by not less than one and no more than ten years imprisonment and a civil penalty of three times the amount of the charges incurred. Upon conviction said individual shall also be immediately deported and suffer permanent exclusion from the United States; said penalties may not be decreased or waived irrespective of other circumstances.

          •ALL provisions of the PPACA and other public health related laws contrary to the above, whether in law, CFR, Internal Revenue Code or otherwise are declared contrary to public policy, void and unenforceable, and all State Laws and Regulations contrary to same are preempted, void and unenforceable since medical care inherently involves commodities that travel in interstate commerce and thus the sale of such goods and services fall under the Commerce Clause to the US Constitution. Rather than go through and strike them all (which of course Congress could do) that one sentence will take care of it until the necessary clean-up can be performed on a chapter-by-chapter basis. Yes, this means the taxes, mandates and similar — all gone.

          Now let’s look at what you could expect under such a system.

          Let me first note that such changes would drop Medicare expenses in the budget by at least 75%. Again, 25% comes off from changing how we handle Type II diabetes alone; these are not “pie in the sky” numbers. This results in a complete deletion of the federal budget deficit on an instant and permanent forward basis and as a result everyone in the country becomes richer every year because their purchasing power of money stops going down and starts going up.

          The CBO is out with their latest estimate on the detonation of our federal budget, and it’s not pretty. They point out what I’ve said repeatedly on the budget and “entitlements”: Social Security is not the problem and in fact will start declining in share of the budget in 2028; politicians speaking of “entitlements” lumping Social Security in with Medicare and Medicaid are lying. The entire problem is in medical spending and if current trends are not reversed — not just “adjusted” over time — will destroy the federal budget and economy. We will not get to 2037 before it happens either; in fact, if we do not act we’ll be lucky to get through the next four years as the markets will figure out that neither political party will take this issue on and resolve it. Simply put we must solve this problem and we must do it now.

          If we don’t the federal government will try to ramp debt to infinity…That will fail because it must; infinite exponential expansion of debt is impossible to sustain and will result in a fiscal crisis. Since this is being entirely driven by health care spending the only means to avoid collapse of the government will be forced rationing or even collapse of both Medicare and Medicaid — an immediate disaster for everyone dependent on them.

          We must act now to stop this, and the above plan (or something substantially identical to it) is the only workable means to do so.

          Fixing Health Care prevents the destruction of the Federal Budget and prevents you from losing access to medical care — especially if you’re a Senior Citizen or poor. If we do not pass this bill or something substantially identical to it and you are either a Senior Citizen or poor within the next five to ten years you will face forced rationing of your health care or the government will collapse.

          This bill will materially increase access to doctors, clinics and similar by Medicare customers since there is no longer any discrimination between who does and doesn’t take the program — Medicare is simply an insurance payer just as any private program is, and will list its payable amounts for care just as will any private party insurance does. This also leaves the Medicare Advantage programs, for those who decide they like that program better, fully intact. For those Seniors who have medical expenses that exceed what Medicare will pay they will wind up with a tax lien just as will any other citizen.

          This bill will make customer choice not just a function of price but also of outcomes. Today there is no accurate way for a person seeking a procedure to compare the success rate between various providers of a given procedure. This must be fixed immediately if we are to have true competition as some doctors are outstanding, some are excellent, many are average and some are poor. There is literally no way for a customer today to know, other than by anecdote, which category a physician falls into.

          The bill will also destroy PBMs and the outrageous extraction of funds they commit by forcing price transparency and decoupling price from “insurance.” You will be able to call or go online to look up drug prices from any pharmacy and they will in turn have to honor the same price for all retail buyers. Competition will return at the retail level and the practice of “gagging” pharmacists, which is arguably illegal as it is done for anti-competitive purposes, will end immediately.

          If you’re unable to pay or accrue medical expenses in your Senior years (or otherwise) that wind up being paid by Treasury then when you die they go “poof” (Treasury eats them) to the extent that your estate is unable to pay them off as ordinary debt prior to distribution through probate (will) or trust. If you’re married then your spouse cannot be punished for said debt during their life should they survive you despite some (or all) of your assets being titled in common, but your joint assets cannot be shielded when the surviving spouse dies against your medical claims nor can you marry after incurring such expenses as a means to prevent recovery from your assets. This prevents “serial marriage” or late trust-creation gaming of the system yet also protects a surviving spouse, which will be particularly important for poor couples and will prevent some of the nastiest situations that occasionally arise today (where long-married couples are essentially compelled to divorce for economic reasons due to medical expenses and collection efforts.)

          Medicaid goes away entirely on a formal basis however poor people actually acquire superior access to health care. The amount spent by Treasury would drop by at least 80% instantly. A fair amount of the remainder would be, in future years, recoverable as some people leave the ranks of the poor and if and when they do their accumulated medical debt would be recovered over time.

          This bill stops the detonation of all of the state public pension fund budgets — a catastrophe that has been driving property tax increases and threatens to destroy all of the state budgetary systems. That all ends in one day.

          It deletes all state Medicaid spending immediately (the states may choose to use said funds, or some part of them, to pay for low-income clinics and similar for residents in their states, much as County Health Departments do today in the States.)

          It makes bilking the government by submitting false or inflated bills to the Treasury a severe criminal offense. The poor and disabled are the least able to press their own claims and fraud is rife in both Medicare and Medicaid today. This puts real teeth in the anti-fraud provisions for those individuals who, most of the time, cannot reasonably bring their own suits. It also protects the poor and disabled from improper tax liens while at the same time recovers from them the cost of their care should their financial situation improve in the future.

          An often-repeated claim is that medicine is “highly variable”; the person who presents to the hospital or ER has an unknown expectation for complications and follow-up requirements. But this is true for car repair as well. I remind you that it was not that long ago (if you’re old enough you remember) that the practice in car repair was to put your car on the rack, get a blanket authorization, rip it apart and tell you what the bill was when they were done. This often led to vehicles being literally held hostage and outrageous bills that nobody would have agreed to in advance. That was made illegal and during the debate over these laws all the car dealers and repair shops said they “couldn’t” accurately estimate and would go out business if forced to do so. They lied; the dealers are still there but the racketeering they used to engage in and the rabid screwing the consumer used to take is gone. Car dealers dealt with this by introducing a “flat rate” book. The “flat rate” for repairing your front brakes is $400. This includes a set of pads and rotors and the labor to install them along with a margin for expected and possible complications; the dealer has no idea what sort of condition the vehicle is in other than that it needs brakes when he takes it into the shop. The flat rate book gives him the expected time to perform the procedure including a margin for possible complications. In some cases the dealer will take less time to fix the car and in some cases more. That doesn’t matter; what does matter is that on average that’s what it will take with a reasonable profit for the dealer, and in addition the dealer typically adds a “shop charge” that is a flat 10% of his repair price for small and hard-to-itemize things like shop towels, grease and similar. If he gets it done faster and cheaper, he wins. If he runs into complications, he loses. The book gets released with each new model and can be updated as actual service history is fed back to the manufacturer.

          The “must post a price” model, incidentally, does not mean that providers cannot differentiate between customers who have objectively-measurable differences in presentation. For example a provider could charge 25% more for someone who is morbidly obese but must do so for everyone who is, and must post that up front on their price list. There may well be a higher complication rate for such a person in that practice’s history. If a provider is willing to come in at 3:00 AM to take care of something urgent but wants to charge double to do so rather than waiting until the morning they can, provided they disclose it up front in their price list. Likewise, perhaps some practice has a lot of available appointments in the afternoon and wishes to offer a 10% discount for appointments between 1-4 PM. No problem. Competition once again comes into play; if some provider figures out how to get rid of the additional complication rate caused by said obesity they can then undercut the other guys on price and gain that business. If one provider is more skilled than another and thus has a lower complication rate they can undercut their competitors which is good for everyone except the lesser-skilled provider. Who do you want practicing their medicine on you — the better guy or the lesser one? This is how progress is made folks. It’s also why the shop charge to change an alternator in one make and model of car is different than the same job done on a different make and model; one may have easy access from the top, the other does not.

          Likewise insurance companies employ a whole bunch of actuaries for the purpose of figuring out the odds of a given thing happening and what it will cost if it does. To do this they analyze previous events. After this change in law hospitals will be no different; the hospital has access to fine-grained data on all of its previous procedures done, for example, to perform a coronary artery bypass. It knows on average how many sutures must be laid, how many scalpels are used, how many units of blood get consumed, what drugs and in what amounts are consumed, how many hours in the operating theater and so on. It knows that X% of the operations go without a hitch, Y% have some minor complication and Z% are a disaster requiring other major interventions because of unforeseen complications — some of which are avoidable (e.g. infections acquired in the hospital) and some of which are not. From all of this data the hospital can compute an average and that’s the price they set. Just like the car dealer does not know if your car has frozen bolts that will have to be chiseled off in order to change your brakes or a caliper that will have to be swapped out because when it is reset it starts leaking fluid the hospital does not know all of the possible complications that may arise from a procedure when you are admitted. By mandating a quoted pricing model competition comes into the game and the hospital now has an incentive to find ways to reduce the complication rate and waste. The complication rate is very important to you as a customer since avoidable complications (e.g. MRSA infections) are severe consequences that you suffer and a good part of the time it happens because they screwed up. It is utterly essential if we are to improve the quality of care that the incentives align for the provider and customer in this regard and if the hospital across town (or across the state!) can reduce the infection rate, for example, that also reduces its average cost for a given procedure and thus said provider can offer a cheaper price. That’s called innovation or, if you prefer, productivity enhancement and it is the driver for progress in your quality of life both personally and economically.

          One of the often-repeated claims is that much testing today is undertaken for the purpose of “defensive medicine” in the form of preventing malpractice lawsuits (or at least making them harder to win.) Forcing the doctor ordering said tests to present a price to the customer and obtaining their consent before the test is done ends this instantly. If the customer refuses to consent to spending the money on some diagnostic then the result of doing so is on him or her.

          “Poof” goes the defensive medicine problem in a puff of smoke because the customer made the choice rather than the doctor! Physicians often claim we need “tort reform” and that they order tests by the bucket-full as a means to defray lawsuit risk. Various advocates, for their part, want to outlaw bringing such suits. The problem with so-called “tort reform” is that sometimes lawsuits are appropriate — the classic example is when the doctor amputates the healthy foot or hand leaving the diseased one attached! The best, easiest and most-equitable reform when it comes to the “tort lottery” game played today is to replace the current “order 10 tests” paradigm with informed consent and shift consent along with the cost and potential benefit analysis to the customer. If the doc says “I want you to take a CT scan because I suspect X and it costs $200” and I say “No” because I don’t want to spend the $200 then if it turns out that the bad thing would have been discovered by the CT I cannot sue because I was offered but refused the test! Customers need to become the decision point, not doctors; they must be presented both the cost of such procedures along with the expected benefits — including the odds of either proving up or refuting a possible diagnosis. My ass, my choice, my expenditure, my risk. That permanently resolves the entire tort lottery problem yet leaves the legal system intact for the outrageous cases where consumers should have redress in the courts.

          Ok, who gets hurt?

          1. The lobbyists. They lose big. In fact virtually all of them wind up out of business entirely.

          2. The administrators who aren’t needed and are very expensive. Many, maybe most, get fired. The hospital becomes a place full of doctors and nurses but damn few administrators since now their cost can’t be shoved off on others — it’s overhead, and is subject to competition from the hospital across town or in the next town over. Not only does this reduce employee cost at said hospital dramatically it also reduces the space the hospital uses for overhead which makes their per-person cost for actual procedures go down further since a larger percentage of their space goes to actually treating customers. Yes, those former administrators will lose their jobs. The good news is that the economy will expand due to greatly improved cost structures, so there will be new jobs in other fields available to them.

          3. The drug reps. Gee, what happens when you can’t be a pusher any more and have to price on a level basis? The rest of the world’s prices go up some (there’s many billions of “them”) while ours fall like a stone (because there are only 330 million of “us”)! That’s math; take the amount of revenue necessary to make the drug and a profit and divide by the number of users; there’s the price. Guess what — forcing the US consumer to pay for the development cost of drugs used worldwide ends in a day. This costs us hundreds of billions of dollars a year today.

          4. The PBMs. All gone. These organizations are all quite-arguably committing unlawful acts on a daily basis in any event under 15 USC Chapter 1; using market power to restrain trade and fix prices is per-se illegal. These firms appear to be nothing more than a racket — and one that was tested in 1979 at the US Supreme Court with the drug firms losing their appeal.

          5. Anyone who refuses to change their lifestyle and instead demands everyone else cover their willful acts. That’s a tough nut to swallow, but it must be swallowed. If you can control a condition for zero cost you have no right to demand someone else pay tens of thousands of dollars a year to you every single year because you refuse. There are millions of Americans who do exactly that costing upwards of $350 billion every year just between Medicare and Medicaid and every penny of that expense must end right now.

          That’s a good start.

          The problem isn’t that health care is “expensive.” The problem is that it’s a rip-off and is laced through with fraud, theft and arguably even racketeering from top to bottom. You can find myriad examples of what competitive prices look like for health services and products if you bother to look around, even in the United States, and since we know what those prices look like what I laid out up above isn’t a fantasy-land dream — it’s a reality we can have right now and forevermore into the future.

          To do it we must demand that the politicians put a stop to the scam and back that demand up with whatever political and economic action is necessary until and unless they do so.

          Perhaps we should all start showing up at town hall and campaign events with a simple plastic spork and wave ’em in the air from start to finish. They’re obviously not weapons but the message ought to be pretty clear when it comes to what the people might, at the point the economic and political system collapses due to all the fraud and theft the political class is enabling through medical scams, choose to eat first.

          So Jay, and anyone else…read, digest, let me know what you think!

          I’ll take your single-payer, and raise you an even better solution that is a uniquely American fix for a uniquely Yankee-Imperial fascist/crony capitalist created mess. Not bad for white male Southern redneck! Ha! Probably just doomed any chance this idea had of succeeding! ;)

          • Susie-Danzen

            You go so far as to state perhaps the largest misconception about the entire subject of “healthcare for all” when you say: “This bill will materially increase access to doctors, clinics and similar by Medicare customers ”

            In it’s simplest form, when the supply of a commodity remains unchanged (in this case the number of doctors available to meet market demand) and the demand for this commodity increases nearly 100-fold by consumers, the price of the commodity increases.
            Plain and simple.
            Everything else you state is pie in the sky that will never happen here. And I’m not saying it’s all untrue, I’m saying it will never happen.

          • J

            Wow!!!! Now you’re talkin Like a liberal!!!!! Although I’m truly having a hard time keeping up with you but from what I gather you’re certainly not a Republican or a Democrat if you are awoken regards to this… Rep. Ilhan Omar had the balls to call out Israel, but was quickly tagged an antisemite by both sides of the isle, cuz their both so dependent on AIPAC MONEY

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