Category Archives: Healthcare/Insurance

The Case FOR Conservative Market-Based Universal Healthcare Reform


Not Only Possible but Preferable to Anything Put Forward to Date


Say what?  Again?  Universal coverage?  Is Bernie Sanders on to something?  Well, in a way yes, as far as good intentions go.  What will be explored here, is the possibility and preferability of achieving the good intention, not by methods of command and control central planning, but government policy that embraces market forces and trusts individuals, making free choices in their self interest, enticed, even when using the money of others, to act as if it is their own, thus avoiding the proverbial road to hell.

The Inspiration

The policy concept presented here, though original, does not deserve to be called The FreeMktMonkey Solution.  It is the expansion and adaptation of  a seed idea presented in the final chapter of David Hogberg’s 2015 book, Medicare’s Victims: How the US Government’s Largest Health Care Program Harms Patients and Impairs Physicians.  In deference to Hogberg’s brilliantly simple but arguably far too timid, solution to Medicare’s flaws, the idea of conservative universal as a replacement to Obamacare, will be presented as the Hogberg Solution, from which it arises.

Starting Points

  1. Just because it’s a policy of the central government does not preclude the possibility of protective legislation that insures and embraces natural forces of voluntary free exchange in the marketplace to achieve desired solutions superior to central control.
  2. The market best achieves optimal setting of prices, and allocation of scarce resources through the direct interaction of the seller and the buyer,  not via the seller and a third party agent of the buyer, who will never share the same level of self interest as the buyer directly.
  3. A person’s life and immediate need for necessary treatment to maintain and extend it is not the same as losing a car to a crash or a home to a fire, or investment to bad advice of a broker.  It’s a tough position for anyone of compassion, including conservatives to stand for denial of treatment in someone’s moment of need, when life is at stake, due to inability to pay.  Accepting this, is to make a strong argument for an individual mandate, that “shared responsibility payment” thing in Obamacare, as an acknowledgement of the implied responsibility of each individual to accept their part, to the limit of their ability,  to protect their neighbor from the potential to have to pick up after their inability to pay.
  4. Medical science has made very rapid advances over the last century.  There are many more treatments, medications and devices available that have drastically improved both quality of life and longevity.  This alone will involve more spending simply because of availability.  It’s sometimes hard to believe that routine use of antibiotics, did not commence until the early 1930s, still about 15 years from being one century ago.
  5. While condition of health is clearly within control for most, it is certainly not for all.  Thus the ability, by healthful living, to protect others from an obligation to have to cover one’s own inability to pay for treatment, is limited.  Sudden unexpected disease, injury, or congenital defects can affect anyone.
  6. As outlined in what remains a gold standard June 1994 study, by Stan Liebowitz, writing for Cato Institute, Policy Analysis No. 211, Why Healthcare Costs Too Much, central to the mess we have in costs of US healthcare, is overreliance on third party payment.  The illusion of free or almost free, in coverage of what can normally be afforded otherwise, adds significant cost by promoting overuse (that must be baked into premium) along with expense to interact, often combatively, with third party payers, to obtain payments that should be made efficiently, directly, at the discretion and choice of the buyer, in direct dealings that preserve the purity of the doctor-patient relationship.  The Cato study suggests the solution is utilization of the highest level of direct payment possible, by health savings accounts and catastrophic insurance.
  7. Only a small percent of healthcare spending is for emergency situations, where there is no time or opportunity to check prices or treatment options, and make informed choices on how to direct resources.  Even this Brown University study that claims previous reports of emergency spending have been far too low, at most estimates emergency spending does not exceed 10% of our total $2.6 trillion.  This argument is often made by those favoring a government single payer system as evidence of why a market in medical treatment cannot exist.
  8. In both the Medicare and non government civilian healthcare markets, use is heavily concentrated into a very small percent of the respective populations, with little of that being priced by normal market forces through the direct interaction between the buyer and seller of services.  This argues for insurance or some backstop protection for the big items, even as the vast majority in most years would have no trouble paying their entire bill without it, and over the long haul, most would be better off by banking premium otherwise spent.
  9. Only small minorities of buyers need to be active in finding the best deal possible to elicit response from sellers that benefits all market participants.  Hogberg notes this as the concept of “marginal consumers” that drive the market, producing price and quality benefits for the non-marginal majority.  This truth is central to the viability of Hogberg’s solution for Medicare (and its extension to universal).
  10. It may not be necessary for buyers to spend their own money to achieve the benefits of the marketplace,  if means can be employed to entice them to spend the money of others as if it was their own, through a system of rewards, that more effectively produces desired results than schemes of central planner bureaucrats.

The Solution

Hogberg comes to the conclusion in Chapter 8, after noting typical failed attempts to get a handle on Medicare spending involve politicians, bureaucrats, and all manner of experts, engaged in elitist planning, at the exclusion of spontaneous order that arises through market forces of individuals freely making choices in their best interest.  He states, “It never seems to occur to them that the best way to align incentives is to let the patient control the money that pays for the care.”  But how to do that in a way that does not promote waste and abuse when it may not be their money?

This is where Hogberg encounters sheer brilliance, that if not so timid with the idea, could have led him to propose an extension of his Medicare Solution pre-Medicare to the entire healthcare sector of our economy, opening the potential to achieve the universal coverage goal of the left in a way that does not make healthcare a right without obligation.

Hogberg’s solution is simple.  Pay the patient, through incentive rewards, to do a better job than various schemes, by CMS, to fix prices, assess quality and value by questionable metrics, determine reimbursement, even direct treatment, all by artificial means far worse than a free market would accomplish on its own.

To do this Hogberg suggests, since we spend all this public money anyway, provide each Medicare beneficiary with 2 annual accounts: a basic account of $5000, and a major medical account of $70,000.  For anything not spent out of the basic account the beneficiary would be paid 10% at the end of the year to use for any purpose whatever.  For anything not spent out of the major medical account 1% would be paid to the beneficiary.

Here is where Hogberg makes a flaw, as he suggests the 1% from the major medical account would only be paid if that account was reached following total depletion of the basic account.  He recognizes the moral hazard of this in producing an incentive to spend out the basic account ($500 max rebate) to get to the $700 max rebate of the major medical account’s 1% rebate.  The obvious way to correct this would be inclusion of both rebates, so the individual who spent nothing in a given year would get $1200, with perhaps only the $500 going to any purpose and the $700 dedicated to an HSA for future medical expenses, also protecting future rebates.

He points out that in 2012 25.7 million of 37.7 million (68%)  Medicare recipients spent <$5,000, and only 3.9million (10%) spent over $25,000, with their average about $57,000; so a $75,000 total account would be more than adequate for most beneficiaries in any given year.  Expenses beyond that could be covered with a private personal $75,000 (or greater) stop loss policy.  This, due to its low cost due to low use, would likely attract widespread voluntary choice, thereby allowing limited government exposure without the need for rationing either by availability or delay.

Hogberg also missed, or was too timid, to entertain a logical extension of his concept pre-Medicare as a solution to the entire national system, unique in all the world, and compatible with extra governmental market solutions being developed and growing rapidly by efforts of pioneers such as Surgery Center of Oklahoma in transparent honest competitively priced surgery or Atlas MD in Wichita KS, leading development of models of Direct Primary Care, both now entering into direct cash relationships with self paying individuals and the approximate 60% of employers who self fund health benefits they provide their employees, bringing competition, quality and value as seen nowhere else.

Indeed, Hogberg’s suggestion of a demonstration project for Medicare, belies his otherwise strong faith in the power of market forces, such that it is Medicare itself that may better serve as the demonstration project to extend his seed idea to the entire healthcare sector of our economy.

Such an extension would also be compatible with the single best reform proposal of any to date that respects freedom, that of Cato’s Michael Cannon, with his 2008 Large Health Savings Accounts concept, or as published here in July 2014,  after noting the failure of Republicans or conservatives, now in almost 8 years following the election of Obama, to develop a plan of their own that doesn’t dictate purchase of a qualifying product to obtain benefits from the government or retain a large proportion of third party payment, the post “GOP Stuck in ACA Replacement ‘Plan Trap’ as Magic Bullet Solution Hides in Plain Sight“, written prior to any knowledge of Cannon’s proposal, but very similar in approach and expected outcomes.

The Hogberg Solution as applied to the whole US system, as presented here, would require modification to Dr Hogberg’s seed concept, but allow market based universal to become a reality that would significantly, instantly create a system of near ubiquitous direct payment.  This is the game changer, as no other proposal to date has suggested such a virtuous possibility exists, and assuming sufficient popularity, could allow for voluntary participation.

Here’s how it would work.  Every participant would be required to pay a percent of all income into a personal health savings account to a limit.  To start, then periodically adjusted for inflation,  this may be 7.5 of all income to a $50,000 balance, then 5% of all income to a balance of $100,000, which would from that point only have to be maintained.  Employers, as enticements, could agree to match employee inputs.  A national tax would be required to cover additional expenditures, but factoring in market induced competitive savings plus elimination of 3rd party payment processing expense, may be little more than total taxes required to fund Medicare and Medicaid currently, and would replace those taxes.

Hogberg’s suggested Medicare accounts would be modified for the universal system.  For working people they would be accessed, only after exhaustion of personal health savings accounts.  One modification would be the creation of three layers of account.  The basic $5,000 with 10% of any unused portion rebated for any use would remain.  Then an intermediate account of $25,000, followed by a $45,000 major account would apply.  Unused portions of these accounts would be rebated at 2% ($500), and 1% ($450) respectively, but not for any use.  These rebates would apply to the personal health savings account, both providing future protection to the public accounts and allowing reaching one’s mandatory individual funding limits sooner as well as protection of future rebates.  Of interest, $950 is sufficient to fund unlimited direct primary care at many of the growing list of doctors offering this choice.

For anyone still working who exhausts their mandated HSA and taps the government pool, continuing work related payments to their HSA would always precede any government pooled funds in paying for services as used and bills come due.

As percentages of any other government cash assistance transfers (welfare) would be directed into individual health savings accounts as well, both Medicare and Medicaid would be rolled into the new universal system.  Opt outs could be allowed but then initial entry or reentry would be have to be prohibited lifetime.  The idea in the mandate is a requirement to buy nothing, just forced budgeting to protect others in a system where we can agree no one will be left “dying in the streets”, as Donald Trump has stated.  It raises the question also if a tax is not a tax, when that set aside is available for that person’s and their immediate family’s exclusive use.

The game changing nature of this extended Hogberg Solution should be obvious.  Price transparency would happen organically overnight as well as huge savings just from elimination of the cumbersome third party payment mechanism in place now.  Providers of treatment and devices would be instantly responsive to concerns of price and quality.  Even well past normal working years for many, into what are Medicare years now, carried HSA balances would continue to protect the government pooled funds, themselves limited without the need for rationing, by personal stop loss private insurance.  Any remaining HSA balances at death could be transferred to a beneficiary.

Private insurance protection expense beyond the government pool could be further lessened in cost by allowing stop loss policies in excess of $75,000 by including other personal sources, such as one’s HSA balance or other assets willing to be spent first.  Thus a person with $100,000 in their HSA and $25,000 in other assets available for medical expenses, along with the $75,000 government funds, would only need a personal stop loss policy to cover expense exceeding $200,000, very unlikely and very inexpensive.

By trusting individuals with control of the money, acting freely in their self interest, and having faith in the predictability of their response to properly presented economic incentives and constraints, along with a system of rewards, we can create a government devised system that respects the marketplace, innovation, and choice, while keeping government command and control decision making out of the equation.

Does Obamacare Contain a Serious Violation of the 14th Amendment?


Is another challenge in its future?

While I’m neither a lawyer nor a legal scholar I do have an interest in things legal.  I also have an interest in the healthcare issue and have posted many original articles and op-eds on this blog.  So when I noticed something at that seemed weird and just not right it stuck in my mind.  I bounced my thoughts around with friends and organizations via social media.  Finally when Pacific Legal Foundation tweeted that they were combing through the issue and would address it in a weekly podcast, I felt validated, humbled and eagerly await their opinion.

So what is the issue and could it eventually provoke a fourth (more on that later) Obamacare challenge to reach the Supreme Court?  From the home page of, rolling over “Get Answers”, then under “Coverage for…”, finally clicking “American Indians and Alaska Natives” a story of unequal special treatment for one group over others unfolds.

The level of special treatment is shocking in regard to our Constitution’s 14th Amendment which requires equal protection under the law for all citizens.  Qualification comes with membership in a Federally recognized tribe or being an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.

American Indians and Alaska Natives most favorably have no closed season under the ACA.  They can sign up for a health plan on the exchange anytime they want and even change plans once per month.  They can choose to have no insurance at all without paying the tax penalty.  On top of that, up to 300% of federal poverty level (up to around $70,650 for a family of 4) they pay ZERO copay or deductible.  How is this equal treatment under the law?

Every other group not exempted from the law by provisions in the law, generally based on religious beliefs, is subject to the same rules governing the exchanges as anyone else.  This includes a closed season three quarters of the year, a hefty tax for choosing to go uninsured, and reduced copays and deductibles only up to 250% of the federal poverty level on silver plans.

Closed seasons, when there’s guaranteed issue as with the ACA, prevent gaming the system exactly as the special provisions for American Indians and Alaska Natives allow.  No closed season opens the door to only signing up for insurance after the discovery of a serious illness.  This is precisely why employer provided health benefits, which have long been guaranteed issue, have an annual open season for about a month each year, barring specified life event exceptions.  For such plans to work time commitment at all times must be required of everyone.

There is an Indian Health Service already on reservations where Indians can get free healthcare from Indian healthcare providers or others if referred by one, but discusses advantages of additionally obtaining plans in the exchanges, suggesting better access to programs not provided by other Indian health programs.  They also suggest this will help the tribe by allowing more services to others, suggesting tribal programs run on a globally limited budget.  Think rationing of services or extended waiting times that accompany such approaches and perhaps the ineptitude of the Veterans Administration as well.

This raises questions of possible reasons if American Indians and Alaska Natives could or should be treated unlike ordinary citizens under the Constitution.  Are they citizens at all?  Aren’t Indians sovereigns within our country, nations within a nation?  The answer seems to be to a point.  The “FAQ” section of the Bureau of Indian Affairs website provides many clues and answers.

First let’s consider eligibility.  Described in the FAQ, membership in a federally recognized tribe is determined by each tribe.  It makes clear that “there is no single federal or tribal criterion or standard” and eligibility for membership “will differ from tribe to tribe”.

If this doesn’t seem loose enough, the FAQ tells us that “blood quantum” is not the only means by which a person is considered, including “how strongly a person identifies himself or herself as an American Indian or Alaska Native”.  As it’s becoming popular to identify outside one’s race or even gender, it appears any of the 561 recognized tribes could open membership to anyone willing to learn the history and customs and believe enough, perhaps even paying a hefty entry fee in the process, thereby granting them special benefits under Obamacare too!

Even among those with sufficient blood quantum, estimated by the Census Bureau to be 4.5 million in 2007, enrolled tribal members are around 2 million, less than one half.  Of the total population more than half do not live on reservations, and can be integrated into the larger society to any degree, while still maintaining tribal membership.

It’s worth noting some of the other facts provided in the FAQ as follows:

American Indians are citizens of the United States and the states in which they reside, and have been so, generally, since 1924.

American Indians have the right to vote.

American Indians can run for and hold any public office as any other US citizen.

American Indians do not have special rights different from other US citizens unless based on treaties or other arrangements.

American Indians do pay taxes like everyone else with the exception of state taxes when living or conducting business on a reservation.

Laws that apply to non Indians also apply to Indians except on reservations where only federal and tribal laws apply to members.  Only state laws do not apply to members when living on a reservation.

American Indians do serve in the armed forces of the United States.

So what is the takeaway of all this?  It seems proper application of the 14th Amendment would back and provide standing for any uninsured non Indian to be exempt from the individual mandate and its tax or require American Indians and Alaskan Natives to be subject to it.

It also seems that any uninsured non Indian tribal member who encounters a serious illness outside the open season without a qualifying event, would have standing to claim harm by being denied immediate access to insurance on an exchange as is afforded American Indians or Alaskan Natives primarily as a result of their ethnicity.  It’s with this I await what the legal minds at Pacific Legal have to say.

Pacific Legal Foundation, which has been defending against government impositions on property rights and liberty since 1973, is involved with another Obamacare case, Sissel vs HHS, that could invalidate the entire law as a violation of the origination clause, and is now under appeal to the Supreme Court.  If accepted it will be the 3rd challenge, hence the chance a possible violation of the 14th Amendment outlined here could eventually become number four.

Pacific Legal produces a weekly podcast each Wednesday and maintains an informative website, both with stories and updates on the many fascinating cases they agree to accept.  Importantly and impressively they represent every client and every case at no charge.  Liberty minded individuals would do well to consider supporting them with a donation.

King v Burwell, Marijuana, and a Path to Marginalize Obamacare in its Presence


States Should Start It / If Weed is Worth it……..

Short of repealing Obamacare the next best thing would be finding a method to marginalize it in its presence.  Oddly King v Burwell, along with 23 states plus DC that approved medical use of marijuana and three plus DC that approved recreational posession and use of the plant, may provide a path to doing just that if King prevails.

King v Burwell is the case challenging whether government subsidies can apply to qualified health insurance sold on exchanges run by the federal government.  Proponents of King, led by Michael Cannon of Cato Institute, and Jonathan Adler of Case Western Reserve University School of Law, contend the law is clear that subsidies can only be applied in exchanges established by the states.  As the issue was raised, the IRS simply declared that federal exchanges too are eligible for subsidies.

Four separate but related court cases challenged this IRS decision, and in November the Supreme Court agreed to hear King.  The case is scheduled to be heard March 4th, with a decision sometime in June.  In the event King prevails, most agree there will ensue chaos of a sudden affordability vacuum if the approximately 5 million people who own qualified health insurance bought in states with federal exchanges lose their subsidies.  This will likely bring intense political pressure to find a fix, even as businesses, relieved of penalties triggered by employees obtaining subsidies will argue for other remedies.

In addition, many individuals will find the cost of unsubsidized ACA triggering plans now exceed 8% of their income, relieving them of the individual mandate and its tax for not buying insurance, except they will then either have to scrape to find the unsubsidized premium or be left uninsured with no other choices.

Several Republican governors of federal exchange states, including rising star Scott Walker are feeling nervous about a King win, and don’t seem to know what they may be able to do.  At a National Governors Association event, they took to saying that it’s Congress’s job to deal with any fallout.  None expressed any ideas of what states may be able to do short of somehow restoring the subsidies.

So what if federal exchange states, rather than looking to Congress, switching to a state exchange or piggybacking on another state’s successful state exchange, as has been suggested, would simply make alternate, non ACA qualified, more affordable choices available off the exchange?

Since I had never seen evidence to the contrary and had been told by both Andrew Schlafly, attorney with the Association of American Physicians and Surgeons, and Oklahoma Attorney General Scott Pruitt, whose name is on one of the other three cases, that they knew of nothing in the ACA to prohibit states from making available non ACA qualified choices off the exchange, I heretofore thought this was possible and within the law.

My take had been that the ACA only defined what must be in health insurance plans to be on the exchange, qualify for subidy, and avoid paying the mandate tax, making possible, with or without King, state provision of a parallel free system along side the government control system, allowing states, with their retained authority to regulate insurance through their insurance departments, the potential to allow or even require the availability of alternate choices off the exchange, understanding non qualified plans would not avoid the mandate tax.

I thought this may be especially attractive to those individuals discovering low cost direct primary care arrangements, where an increasing number of primary care physicians are offering unlimited care for a monthly fee.  Here is a rapidly growing need for pure catastrophic insurance as a compliment, that ACA qualified plans have shut down.

I believed all this.  Then, February 9, in a twitter exchange with Phil Kerpen, President of American Commitment, he sent me a link indicating otherwise.  There is indeed federal code that prohibits what I thought was possible.  The office of my Congressman, also previously unaware, identified it as a law from the 1940s that had been amended by Obamacare.  Talk of leaving no stone of iron fisted control unturned!

So what to do now?  State offer of non ACA compliant health insurance off the exchange, no matter how welcome, or as immunization against the affordability aspects of a King win in 37 federal exchange states, would run afoul of Federal law.  It would be an act of defiance, but isn’t this what 23 states plus the District of Columbia did when they approved the medical use of marijuana?  Taking it further, isn’t this what Colorado, Washington, and now Alaska and DC did by approving the recreational use of marijuana?  So far, for those state actions, the feds have chosen to stand down.  If legal weed is important enough to risk federal admonishment, how is offering citizens, still willing to pay the mandate tax, the choice of affordable non ACA qualified options off the exchange not?  It would seem.

More likely, on an Obamacare challenge, the feds would push back hard, but states would have arguments in defense, as well as significant public support that may even exceed weed, especially if King prevails, subsidies are lost, and a sudden affordability vacuum ensues.  While the stand down on marijuana would mean nothing in a legal sense, it may help state defiance on Obamacare play well in the court of public opinion, giving state officials more backbone to act.

States can point to their continued regulation of health insurance where the feds have found it convenient to not supplant them.  State coverage mandates in excess of ACA essential minimum coverage rules still apply, as do their definitions of regional pricing zone boundaries.  They can question also why their regulation of all other types of insurance remains intact, without federal meddling.

There’s the argument McCarran-Ferguson 1945 still gives states the authority to offer alternatives, so long as they don’t attempt to eliminate the federally designed plans.  They could claim restriction only to such limited choices represents overbearing federal imposition and violates the Constitutionally protected freedom of their citizens to contract.  They could point to a long standing tradition of state regulation of insurance in return for insurance being exempt from federal antitrust law.

Perhaps as important, since the ACA unquestionably allows doing absolutely nothing upon payment of the mandate tax, any opposition would be forced into the absurd argument that doing something substantially more than nothing in protecting others from one’s potential inability to pay their medical bills should be prevented, so long as the tax is paid.  In fact, Congress, seeing this argument play out, may be motivated to specifically allow non ACA qualified offerings and reduce or eliminate the mandate tax for buyers, in recognition of their obvious reduction in potential liability to others by their actions.

If only one state or a few, federal exchange or otherwise, would boldly take this course of action, we would present, at least the opportunity to embark on a path to marginalize Obamacare in its presence.  A parallel free system, alongside the government control system could be created, and repeal would no longer be necessary as people could freely choose which system they prefer.

The sudden chaos of a King win would be the perfect time to have alternate choices available, as the potential to quickly attract sufficient numbers to spread the risk enough to insure viability would be most opportune.  If weed is worth it………

Don’t Be Like Me…Resolve to Get That Colonoscopy!


Now over two weeks into 2015, those well intended resolutions, often centered around taking better care of one’s self, are no doubt already beginning to be forgotten.  Gym attendance is likely already on the slide.  Diets are being forgotten.  Tobacco revenue is recovering.  All as accepting return to the status quo proves easier than determined vigilance for many.

Most of us can take better care of ourselves and should keep tabs on the state of our health.  As I’ve learned the hard way, having that screening colonoscopy, especially after age 50, in spite of a family history, is one diagnostic test not to be avoided.

Not being one to worry or “run to meet trouble”, as an old friend used to say, for the 13 years that it has been available at no cost to me, I’ve avoided and made excuses for getting this most important procedure.  In spite of reminders and urging from my wife, as well as the fact that my mother had polyps removed, I took the position that only a small percent of those who don’t bother to get checked, will actually develop colon cancer.  While this assumption is true, I’m now facing what should have been caught in its earliest stages, likely as a  precancerous polyp, years ago.

The trouble with colorectal cancer is that it can grow without pain or notice until it becomes very serious, causing a bowel blockage or spreading to other organs.  Nor do tumors always bleed.  Fortunately mine did.  A couple months ago, when I noticed blood in my stool, I knew something was amiss.  I went to a primary care physician for only the second time in my adult life for a head to toe checkup.

Of course when I described the symptom that motivated my visit, a diagnostic colonoscopy was arranged a week later, on Christmas eve.  An “ulcerated mass”, confirmed as cancerous by pathology inspection, was discovered along with a polyp showing cancerous attributes.  A surgical resection of part of my colon was suggested.

Three days later I had a lower abdominal CT scan and chest x-ray that fortunately showed no obvious spread of my cancer to other organs.  Although that’s great news, if the cancer is found in surrounding lymph nodes that will be harvested and inspected during my surgery, I’ll certainly be facing chemotherapy follow up to try to attain a cure, often considered 5 year cancer free survival.  My odds of achieving that outcome are about 65%.

So, yes, my negligence to have regular medical exams, and a screening colonoscopy in particular, may yet prove a fatal choice.  I can’t begin to explain the feeling of personal complicity and stupidity that comes with my situation, nor the impact this has on friends and loved ones.  My hope, in writing this, revealing the details of my medical condition, is to spare others.  Don’t be me! Resolve to get that screening colonoscopy!  Don’t make excuses!

Even for those without insurance coverage there are options.  Healthcare Bluebook is a great resource to find fair prices in your area, that can be used to negotiate with providers.  In the Harrisburg, PA area where I live, the fair price for a screening colonoscopy, that amount normally accepted as insurance payment by network physicians, is listed as $1609.  This is broken down as $676 facility fee, $413 physician fee, and $520 anesthesia fee.  Also, colonoscopies can be, and sometimes are, done without anesthesia.

Another option is MediBid, a medical brokerage service started by a Canadian immigrant, Ralph Weber, to connect patients and physicians for specific procedures nationwide.  As one notable example, KATU, Channel 2, Portland, reported in September, 2013, the story of a Chicago man without insurance, looking for a colonoscopy.  Through Medibid he found a physician in McMinnville, OR.  His cost for the procedure, including airfare, lodging, and a rental car was less than half the average $3500 best price he could find in the Chicago area.

Three days from now I’ll be in surgery, beginning the process of trying to stop what could still prove fatal, and likely could have been prevented.  Again, don’t be me!  Resolve to get that screening colonoscopy!  NO excuses!

Stolen Health Data Threatens Pennsylvanians/Others With Identity Theft


Chinese Hackers implicated

Monday August 18 CNN Money reported Community Health Systems, headquartered in Franklin, Tennessee, announced it’s 206 hospital system, spanning 29 states, had been hacked, exposing critical personal information of 4.5 million patients of its affiliated physicians.  Anyone who used the services of a linked doctor in the past five years, even if never seen at a hospital, is potentially at risk.

Pennsylvania is one of seven states identified as having the most significant presence in the Community Health Systems network, operating 20 hospitals in the Commonwealth.  As a rough estimate, 20 of 206 hospitals is 9.7% of the hospitals in the network.  9.7% of the reported 4.5 million patients suggests about 436,500 Pennsylvanians could be at risk.

It’s reported that the hackers, identified as Chinese, did not get any information related to medical history or credit cards, but information critical to obtaining credit cards and stealing the identities of those at risk, including names, social security numbers, addresses, birthdays, and telephone numbers.  Community Health Systems has said it will be offering identity theft prevention services when it notifies individual patients.

Spokesperson Jason McSherry, representing affiliated and affected Memorial Hospital in York, PA, provided the following statement, shared here in its entirety:

Limited personal identification data belonging to some patients who were seen at physician practices and clinics affiliated with Memorial Hospital over the past five years was transferred out of our organization in a criminal cyber attack by a foreign-based intruder. The transferred information did not include any medical information or credit card information, but it did include names, addresses, birthdates, telephone numbers and social security numbers.

We take very seriously the security and confidentiality of private patient information and we sincerely regret any concern or inconvenience to patients. Though we have no reason to believe that this data would ever be used, all affected patients are being notified by letter and offered free identity theft protection.

Our organization believes the intruder was a foreign-based group out of China that was likely looking for intellectual property. The intruder used highly sophisticated methods to bypass security systems. The intruder has been eradicated and applications have been deployed to protect against future attacks. We are working with federal law enforcement authorities in their investigation and will support prosecution of those responsible for this attack.

Many American companies and organizations have been victimized by foreign-based cyber intrusions. It is up to the Federal Government to create a national cyber defense that can prevent this type of criminal invasion from happening in the future.

In discussion with McSherry, he emphasized that stolen information resided in connected doctors offices rather than the hospitals.  For this reason, he does not think anyone using a hospital directly for emergency or any other reason would be at risk.  The Memorial Hospital website currently lists 267 affiliated physicians.

McSherry also said that not all network hospitals are affected by the breach.  For instance, the affiliated nearby Carlisle Regional Medical Center, although part of the Community Health Centers network, uses a different information system.  He did not know how many different information systems are used by Community Health Centers.

Back to the provided statement, it’s interesting that Community Health Centers looks to the Federal Government to “create a national cyber defense that can prevent this type of criminal invasion from happening in the future”.  There may be some justification to their position, as it’s the Federal Government that’s been dictating so much of what has been happening in medicine.

HIPAA, the 1996 Health Insurance Portability and Accountability Act; ASCA, the 2001 Administrative Simplification Compliance Act; HITECH, the 2009 Health Information Technology for Economic and Clinical Health Act; PPACA, the 2010 Patient Protection and Affordability Act all, along with regulations promulgated under them, address, in various ways, requirements concerning electronic medical records, their use, protection and transmission.  While purported to be money saving measures or patient protections, this maze of imposed regulations, with cost of compliance and threat of substantial penalties, has been driving doctors out of independent practice to hospital employment or out of the profession entirely, while exposing patients to hacking risks, as we’ve seen here.

In addition, can the same Federal Government that runs the Post Office or Veterans Administration really ever do more than stay one step ahead of hackers in protecting us, as the cost of the attempt must be born by all?

Note: This article shared to WatchdogWire-Pennsylvania

GOP Stuck in ACA Replacement “Plan Trap” as Magic Bullet Solution Hides in Plain Sight


Best Plan is NO Plan

Whether by reaction to charges from Obamacare supporters on the Left, or by their own lack of faith in freedom over planning, Republicans, not one of whom voted for the Affordable Care Act, along with conservative allied groups, think tanks, or prominent individuals, are, by last count, now promoting close to a dozen different concepts of how to replace one version of federal government planning with another less abrasive one.  Despite many replacement proposals, Republicans in congress seem unable to coalesce around any one approach, still leaving the impression they have none.

Some of the proposals are introduced bills. Others are wish lists of items to be in bills.  All have myriad suggestions that either move money around by extending tax deductions or refundable credits, allow formation of small business associations, require price transparency, reform medical malpractice, enhance health savings accounts, shuffle money to states for high risk pools, or various changes to Medicare and Medicaid, among others.

Far away the most popular inclusion is selling health insurance across state lines, itself a dangerous (and here) invitation to Federal micromanagement under the twisted  modern interpretation of the Commerce clause.

Such is the pressure and propensity for government to “do something” that bears on both sides of the political spectrum.  This is the plan trap.

Rarely is there a peep from anyone suggesting that no plan is the proper path, that simple policies to promote, restore, and support the proper functioning of the free market, usually by removing government intrusion rather than supplanting it, should be the goal.  One lone voice, Association of American Physicians and Surgeons past-president Dr Alieta Eck, GOP candidate for the 12th Congressional district from New Jersey, wrote an article defending freedom over planning in January 2014.  She opens:

We constantly are told that “while ObamaCare might not be perfect, the right has not come up with a better plan.” Is it possible that we do not need a “plan” at all?

Think about it. Has the federal government set up a food plan for all? A housing plan? Is the Secretary of Whatever empowered to decide what and when we eat? What kind of house each of us lives in? Of course not. We work, we plan and we buy what we need, saving up for the big-ticket items. Government does not control us, nor should it.

Yet one element contained in a few of the plans and wish lists can be the basis for a market revolution.  Unfortunately, no one seems to have grasped the power of its singular focus.  Had Dr Ben Carson simply stopped at Step 1 of his still in progress 5 step plan he would be almost completely there.

Relatively simple modification, enhancement, and expansion of tax policy surrounding HSAs, done right, has the power to be a true game changer by its potential to encourage employers to drop their long standing provision of health insurance in favor of a defined contribution approach.  It is the magic bullet.  It hides in plain sight, and here is how to get there:

Please follow these simple policy modifications:

1) Decouple HSAs from the requirement to be attached to any insurance policy.  While HSAs could still be attached to insurance (suitable for many), anyone should be allowed (and perhaps even required) to have an HSA.  Monies in HSAs receive rare triple tax advantage and protect others from the owner’s potential inability to pay for needed medical services.

2) Allow the purchase of health insurance or medical services through an HSA.  This establishes favored equal tax treatment without the need for separate legislation.

3) Greatly expand contribution limits to allow #2 to happen.  The HSA can be the tax advantaged conduit for all medically related purchases allowed under it.

4) Allow employers to contribute pre tax to an employee’s private HSA.  This is the crucial trigger for a spontaneous move of employers away from policy provision to defined contribution.  Resulting individual ownership solves portability and suitability issues for those who choose to buy health insurance in the open market through their HSA.  Employers could offer direct contributions or matches to employee HSAs.  Contributions from several employers could be combined, as well as HSA assets among family members’ accounts to purchase one insurance contract if desired.

5) Establish a permanent mechanism whereby Americans can look to each other rather than government for assistance by allowing gifting from one HSA to another both within and beyond family connections.  This is similar to the medical sharing ministry concept without the structure of membership or formal organization.  Any groups could pledge to come to the assistance of each other as needed. Such transfers could keep some people away from Medicaid, where access problems are well known or safely allow lower cost policies with higher deductible amounts.

6) For those in need fund a portion of all government assistance transfer payments into personal HSAs to be used ahead of Medicaid.  The power and influence of ownership is stronger than artificially concocted restrictions on use.  Funds from HSA extend dignity of choice and equal access until exhausted

Nothing more at the federal level may be necessary.  States would have to do their part by discovering their proper constrained regulatory role, requiring sufficient reserves to pay claims and enforcing rather than defining terms of health insurance contracts buyers and sellers find right for them.  All this, of course, requires and follows total Obamacare repeal.

While the benefits of defined contribution in a free market (not to escape or game Obamacare) have been recognized (tops list in American Doctors for Truth Plan) and discussed, no one has suggested a good way to transition. Less attention has been paid to the damage done by employer provision of health insurance, which itself was propelled by government tinkering with wage controls in World War II.

Frank Chodorov, in his 1959 book The Rise and Fall of Society, provides clues to understand why employer provision has been the enabling force of most of our problems.  He argues that a natural law of human behavior leads men to seek the highest degree of satisfactions with the least expense of labor to thereby pursue limitless desires, in order to obtain even greater gratifications.  This leads to efficiencies of effort and specialization of tasks via cooperation with others in forming societies.

Unfortunately this natural inclination also presents a weakness to seek something for nothing.  Such is the case when the employer provision of health insurance disconnects the employee from its cost.  As soon as the employee disassociates health insurance with being a part of his employer’s total cost of his employment, rather than realizing he is really giving his employer permission to spend his money in ways that may be against his best interest, he’s in trouble.  He will request or even demand more, without consideration of alternatives that would be likely choices if he was paying directly.

This then is the source of a gradual movement away from direct payment, even for that normally within the ability to easily afford otherwise, to prepayment schemes that defy the normal purpose and function of insurance to protect assets from expenses that are beyond the ability to pay.

This excess third party payment itself bolsters the illusion of getting “covered” services for free or almost free, even as the premium includes the incentivized overuse of others when not getting one’s own.  It is through these false satisfactions that we accept in healthcare what we don’t see anywhere else in our economy, a situation where almost every transaction involves, at least in part, someone else’s money, driving overuse from both the consumer and provider side along with the associated administrative costs to accomplish it.

It’s not hard to imagine how employer provision of car insurance over time would look just as ridiculous.  Oil changes would require a small copay and many other services would be “covered”.  The brake lobby would have used safety as an excuse to convince legislators to require brake “coverage” in every policy issued, all as employees, under the illusion of something for nothing, would keep asking and demanding more “generous coverage” from employers.

On the other hand, employees reconnected to cost through defined contribution, sparked by simple modification of tax policy related to HSAs, in states that likewise get government out of the way to allow multiple market choices, will make wise decisions that fit their specific financial needs.  The abuses of excess third party payment will naturally end and the free market magic bullet solution some say cannot exist will be a reality.  No one thing can accomplish so much by doing so little.

Note: This article shared to Watchdogwire-Pennsylvania

Illogical Response to Simple RTK Request – Pennsylvania DPW Digs in on Healthy PA


Healthy PA is Pennsylvania Governor Tom Corbett’s idea for unconventional optional Medicaid expansion that would require a waiver from the Federal Government.  As part of the process the Department of Public Welfare held a series of hearings around the Commonwealth, soliciting public comment via strictly limited three minute turns at the microphone.  Written comments were accepted at the same time or separately through January 13, 2014.  This video is the Power Point presentation that preceded public comments at each meeting.

I was able to get a total of nine minutes to comment by attending three of the eight hearings.  At two of the hearings I spoke unscripted and at the Harrisburg hearing January 9, read a prepared script which I then left as a written submission.

My intention was and is to publish some observations on the hearings.  I took notes but made no recording, especially since the presenter’s comments were being transcribed either by manual input or voice recognition and appeared on a large screen facing the audience in real time.  DPW says they intend to publish a summary of the comments with responses prior to the waiver request submission, but I wanted the verbatim account in the transcripts, both to read comments of others and publish my own unscripted remarks as they were presented.

I called DPW to let them know what I wanted.  They said I would have to go through Right to Know to get records they never suggested do not exist.  So that is what I did in a simple straightforward request.  Today, within the required period, I got an answer.  My request is being delayed for up to 30 more days for the following reasons:

    • Your request is under legal review to determine whether a requested record is a “public record” for purposes of the RTKL
    • The extent or nature of the request precludes a response within the required time period.

I simply cannot buy either of these excuses.  How can they solicit public comment, which anyone had the right to record, obviously make a direct transcription of it, and then suggest it may not be part of the public record?  Then too, why would it take longer than a week to give the records to anyone who properly requests them?  Would the fact that they know me to be a detractor from Healthy PA have anything to do with their response?

Also I wonder why any of this should be necessary.  Yes, I did have a right to record the event but chose to not do it.  That said, how much trouble would it be to require all public meetings to be voice recorded (if not video also) and posted within hours online so anyone unable to attend in person could listen?  It seems that would be a very easy but very significant improvement to our Sunshine Act and Right to Know laws, greatly improving transparency, as well as saving costly clerical efforts in situations like this.

While I’m waiting for bureaucratic determination involving legal experts, what follows is my prepared text I read at the final Healthy PA hearing in Harrisburg on January 9.  Among what mostly amounted to various interest groups slithering up to the Federal money trough, or those objecting in favor of unaltered Medicaid expansion, or those complaining of any suggestions whatsoever of personal responsibility (as exist in Healthy PA), or even one arguably socialist Republican house member passionately pleading to not delay grabbing Federal money one more day, there was this:

Comment to PA DPW hearings on Healthy PA

Despite its good intentions Healthy PA is a misguided and dangerous additional step in the direction of fiscal insanity.  First let’s think about the insidious lure of “Federal” money.  Federal money IS our money.  It comes from the pockets of Pennsylvanians or is imposed as a crushing debt on our children. 

While Healthy PA is not exactly an expansion of the existing failed structure, we know there are better approaches to the entire Medicaid program.  We can see the results of situations where people are empowered with ownership of accounts they control.  We know how spending one’s own money can control overuse, encourage wise use, and reduce fraud.  Healthy Indiana showed how money can be saved by giving it away-such is the power of ownership! Knowing this we should insist that any expansion only be considered after first changing how we run the existing system, using savings wrung from it, except in this “partnership” arrangement the rules only go in one direction, from the Federal Government top down.

We also know of suggestions to boost the number of and participation in free charity clinics, where doctors can operate outside the crush of burdensome regulations.  We’ve passed Act 10, and HB1760 sits in our Health Committee and would not need a Medicaid waiver.

While any state would put itself at an extreme financial disadvantage by exiting the Medicaid program entirely, we also know that if every state did so we would all be better off.  The added layer of Federal bureaucracy and administrative expense could be used to treat needy sick people. 

Think then where we are today.  Here we stand asking a powerful central authority to give us permission to do what should be the absolute right of free sovereign states and people under a constitution unique in the history of the world.  This is America upside down.   This is a great nation in decline.  Healthy PA is further participation in that decline, and it’s time we stop allowing it to continue and expand. 

Rather than making a stand for commonsense solutions we do understand, by becoming leaders for freedom, educating our citizens to what really would work to the extent they understand and demand it, we succumb to expediency, dare I say, political expediency, in an election year.  It’s time we act like the sovereigns we are and end this bowing to a powerful central authority in Washington DC that is changing the fabric and face of America.  Thinking beyond ourselves to generations yet to come we would set Healthy PA aside and choose a different path.

Submitted January 9, 2014

Todd Keefer, York County

Note: This article shared to WatchdogWire-Pennsylvania 1/27/14