Bill to Permanently Fix Healthcare For All

(I found this proposed bill here and am re-posting because it is awesome.)

The Bill to Permanently Fix Healthcare For All

  1. 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.
  2. 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.
  3. 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.
  4. 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….)
  5. 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!
  1. 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.
  2. 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.
  3. Auxiliary services (e.g. medical or dental Xrays, 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.
  4. 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 hereand 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!)
  5. 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.
  6. 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.
  1. 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.
  1. 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.
    • 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.
  2. 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.
  3. 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.
  4. 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 billback 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.

Different Ways to Define Success

Small Beginnings

When I started my software company, I didn’t even realize I was starting a software company. I’d been in the PC service business for a couple of years, and had a customer with a particular problem. I figured I could solve it for him. (Solving problems: that’s one way to define success.)

So I bought a compiler with a built-in templating language, taught myself to program and built the solution for him. He liked it so much he told some other folks in his industry about it, one thing led to another, and the next thing I knew, my PC service company had morphed into a software company.

I knew I needed help, so I agreed to partner with a guy who was better at selling than I was. (In retrospect, I must’ve been pretty good at selling too, since I didn’t know how to program when I started. The most important person to sell is yourself.) Anyway, Ron got on the phone and started dialing for dollars while I worked on making the program better.

Riding the Blue Whale

Ron was hardcore. He’d dial that phone 100 times a day talking to leads, turning them into prospects, converting them to customers. I know I couldn’t do that. Cold calling is hard work. But he seemed to be able to do it without it destroying him. He was one of the most relentlessly optimistic people I have ever met. Nothing seemed to get him down.

One time, we packed my giant Chevy van, (the Blue Whale), with computers and tables and banners and floppy disks, and drove halfway across the country from central Texas to San Diego for a trade show.  (I think the distance is roughly a jillion miles.)

Since the van was so big, we just took turns driving and sleeping. He’d lay down on the floor in the back and sleep while I drove, then we’d switch and just keep on trucking. I don’t remember much about the trade show, but I do remember that stretch of I-10 from San Antonio to Tucson seemed to go on forever.

A Marketing Misfit

We kept growing, so we needed to hire more salesmen. Then we needed tech support. Then we needed office help. It all just kind of snowballed. And there I am, coding my brains out, writing user manuals and trying to manage a roomful of crazy salesmen. Oh, and marketing.

What I didn’t know about marketing could fill an airplane hangar. If it had to do with marketing and was something you should know, I didn’t know it.

I have always been a little bit of a misfit, always a little more skeptical than most folks. I was also convinced that I was more rational than most people. (Guys who write code always believe that about themselves.) As it turns out, I am exactly as irrational as the rest of the population – most of the time. I just occasionally have moments of pure logic in the ocean-fog of instinctive click-whirr behavior which is the bane of humanity.

So I sucked at marketing. I was the guy who layered on the description of features, completely unaware that people don’t give a rip about features. No one buys the color of a car. They buy the feeling they get when they look at that car color.

All those lessons though were in the far distant future.

Booze & Mr. Metaphor

My tech support guy Ken wasn’t very technical, but he had a vocabulary somewhere between Shakespeare and Miriam Webster. He had this soothing way about him that the customers seemed to appreciate. (I was singularly lacking in “soothingness”.)

I called Ken “Mr. Metaphor.” Bizarre metaphors poured out of him like water over Niagara. (See, that was a simile. He would have done a metaphor and it would’ve been way better.) Ken had a weird, sad childhood that I think scarred him permanently. I considered him a friend and he seemed to look up to me. Years later, after he moved back to California, he asked me to be in his wedding. When he passed away, I wept.

RIP, Mr. Metaphor.

One salesman was a raging alcoholic. He was destroying his second marriage when he worked for me. Some days he would show up sober and could talk the ears off a donkey. I always thought his form of salesmanship was little more than hucksterism. But, (I told myself), he was better than me.

I realize now that he wasn’t.

I dropped by his house one day to check on him late in the afternoon, and he had already emptied his first fifth of vodka for the day. He was a marvelously talented and skilled deceiver, as are most addicts. He’d spent his entire adult life abusing his body with some form of chemical or another. Before I met him, it was drugs. When I knew him, it was booze. Today? I dunno. Food maybe.

It was from him I learned the very valuable lesson that you cannot care for someone else’s life more than they will care for it themselves. That is a recipe for utter frustration.

Youth, Beauty & Great Hair

Another salesman was this kid who had moved to central Texas from the wilds of New Jersey. Never had a father in his life and I guess he looked up to me as a father-figure. Which was pretty hysterical because I was in my early 30s at the time and had barely figured anything out. But I guess in the land of the blind, the one-eyed man is king. He paid an inordinate amount of attention to his hair. I thought he probably had a future as a hairdresser.

He was a beautiful person, extremely outgoing and pretty good on the phones. I could tell he desperately wanted approval and I tried to give it to him. I recently saw where he is quite a successful real estate agent. He has a beautiful wife and a lovely family and I suspect has made a good life for himself. I like to think I had a tiny part in that.

But my best salesman by far was a teenager named Andy. I hired him because I needed more salesmen and his sister was already working for me.

You know how some people just seem to have been dealt a raw deal in life? Andy was the opposite of that. Andy was charismatic, gorgeous, physically strong, outgoing and had that “it” factor that just made people want to listen to him, look at him and do whatever he said. It broke my heart when Andy left, but honestly, he was destined to be the leader of his own pack, not just a sled dog in mine.

Take You By Surprise, Make You Realize

I guess perhaps my favorite person though was the woman who was our bookkeeper/office manager. Her name was Amanda, and she was the wife of a friend.

She was one of those people who was born to manage the affairs of other people. And I mean that in the best possible way. She had no need to be The Boss. She was just very, very, VERY good at putting things in order and keeping them in order. Fortunately for her, my partner and I were very good at making messes that she cleaned up. She used to bitch and moan about the state of affairs, but I think she actually enjoyed converting chaos to order.

She completely overhauled my files and made it so that I could find anything in an instant. I actually used her filing system for years after that. She took my books and turned them into something that a real company would be able to use, rather than piles of receipts stuck on a nail.

And she loved to play. I can remember standing at one end of the long hall that ran down the middle of our office and whipping a foam ball at the back of her head. She sat with her back to me in the big room at the end of the hall, and when her door was open, I could fling that ball down the hall while she was sitting at her desk.

For me, the challenge was to try to throw it straight enough to get through the door. Bonus points for hitting her.

Most women would probably have killed me, but Amanda would just fling it right back. She had a wicked sense of humor, and a vocabulary to match.  I can remember days where it seemed all we did was laugh, and Amanda was the biggest instigator of those laughs.

Lord, did we ever have fun.

All True Stories End in Death

My partner and I eventually split the company in two. He had a vision for taking it one direction, I had another. I spent the better part of the years since then thinking that I had failed in that company. But looking back, I can see that I succeeded almost beyond my dreams. (Almost…)

I was working with people I loved, doing something I loved, somewhere I enjoyed being, in an industry I loved. The only thing I would have changed is the amount of money I generated from it. That could have been better. But frankly, I had way more success than I realized at the time.

Perhaps that is why meditation has become so important to me. I am learning to Be Here Now.

Thinking back on those days, I was so greatly blessed and so blissfully unaware of it because I was focused on the bank account and the future. I missed the Now.

No, it didn’t last forever. Nothing real ever does. Yet if I had to define success, I think I would say that being surrounded by friends all day every day is at least part of it. And I counted all those people as friends. Not merely employees, but friends. I got to work with my friends all day, every day.

That’s pretty cool. And pretty successful.