Fixing Healthcare

Neither the ACA nor the AHCA address the real problem in health care.  The real problem is that healthcare costs too much.  Neither bill solves that, they just rearrange where the money comes from.

What is the real problem? A system that has no price transparency and no competition, so the marketplace can’t work.

You want to fix healthcare?  How to do it in a few simple steps:

1) Providers can charge whatever they want, but they must charge the same price for everybody. No PPO prices. No negotiated prices. One price for everyone, insured or not.

No more $10,000 hospital bills that they will chase the uninsured for with collection agencies, when the insured get a PPO price negotiated down to $3,000 or less. Every provider must offer services at the same price for the same procedure to everyone.

“You have money to buy insurance, so we’ll charge you less.”  What?

2) All prices for healthcare providers have to be posted on their websites by Medicare procedure number.

If it isn’t on their website, then it’s free. And if you prove it wasn’t on their website when you had the procedure done, and they charged you for it anyway, it’s triple damages plus costs.

3) Allow flat-rate pricing for major procedures, such as a price-per-stent-installed or per-knee-replaced, rather than a la carte for each Medicare procedure number.  Flat-rate pricing can eliminate guesswork for the patient.  The provider can spread the costs of complications across all procedures.  Simplifies billing.

4) Allow charity pro bono medical work.  Currently Medicare must be the lowest price, so doctors cannot charge the legitimately indigent lower prices.

5) Provide some broader method to cover indigent visits to emergency rooms.  Right now it is on a per-facility basis.  Combined with the “must treat” policy, this is driving hospitals out of poorer areas.  Either state-wide or federal sharing of these costs across all facilties, or outright federal reimbursement to facilities.

One solution would be to account these at the state level, and then reimburse them as part of Medicaid, or under the Medicaid organization.  Without some relief, hospitals will move out of poor areas.  Further, hospitals will have a hard time competing in an open market against providers who do not have emergency rooms, such as imaging centers, surgery centers, etc, since they must spread the indigent emergency room costs across other services.  So get rid of the unfunded part of the mandate and its hidden costs and get the costs out in the open.  Let the entire market share these costs.  One way would be federal funding.

The other things that’s strange about the current unfunded mandate is that emergency care for the poor is funded by other people who are sick and facing big hospital bills.  The healthy take no part in funding this care for the poor, which is of general benefit to society.  Right now it’s a tax on the sick.  Some broader funding mechanism seems appropriate.

6) Enable private healthcare fraud investigators with 10% or 20% bounties on finding Medicare and insurance fraud.  Let the private sector provide a more adaptive and more effective enforcement against fraud.

7) No 100% insurance coverage for anything.

The patient has to pay 10% or 15% or 20% of everything out of pocket, up to a maximum of $2000-$3000 per year. We can figure out which numbers work best later.  This incentivizes the patient to shop prices.

8) No deductibles on which insurance pays nothing.

The insurance company should have some exposure up until the deductible is met, to incentivize insurance companies to assist the patient in controlling costs.

7 and 8 could be combined into something like 50-50 insurance and patient payment up to $4000 (so insurance pays $2000 and patient pays $2000) before insurance kicks in at 100%.

9) Allow health insurance purchase across state lines.

Get rid of the exemption, granted by Congress to the states, that sidesteps the Commerce Clause.  No state insurance boards selecting which insurance companies can and cannot sell in their state.

10) Eliminate state and federal coverage mandates that force people to buy coverage they don’t want, and substitute a simple federal basic catastrophic coverage plan as the minimum health insurance plan nationwide.

11) Tort reform, to make costly defensive medicine unnecessary.

Limitation on pain and suffering damages.  Actual economic damages, wrongful death, etc. are not limited.  Perhaps the actual limit should be 150% of actual economic damages, so the plaintiff is 100% restored after the lawyers take their one-third contingency payment.

12) Insurance companies not allowed to drop you when you get sick.

13) No pre-existing conditions if you have been continuously insured.  No refusal of insurance to anyone.  One-year maximum exclusion of any pre-existing condition for someone who has not been insured.

14) An initial grace period with no pre-existing conditions and guaranteed acceptance even if you haven’t been previously insured, to get the system started.

15) Some sort of HSA system, where people can set aside tax-free dollars for the patient portion, and roll that into their IRA if they don’t use it. Can be inherited tax-free if it is rolled over into another HSA.

16) Tax deductions for all medical expenses, both for insurance premiums and the patient portion of expenses.

17) Get the AMA — the doctor’s union — out of the business of certifying medical schools, and using that to limit the supply of doctors.

How much would truck drivers earn if the Teamsters ran the DMV?  Would we have a shortage of truckers?  What would be the education requirements for truckers?  Would they be reasonable?

One solution is to split the AMA into a minimum of three associations — the BMA, CMA, and DMA — none of which can have more than 40% of the membership of all three taken together.  Any of the three could certify a medical school or a hospital.

18) Get rid of the residency requirement for doctors from other countries coming to the U.S. to be certified.

This could be on a country-by-country basis, but OECD countries should probably be specified right off the bat.

19) Get rid of certificate of need requirements for medical facilities.

The cheapest groceries are when Kroger and Marsh are across the street from each other, not when there is only one grocery in town.

20) If a medication has been approved and in use in another OECD country for five years, it gets approved here automatically.  No FDA requirements for approval.

21) Allow the free import of approved medications.

No more milking the American public in a closed market while selling wholesale overseas.

22) Change the dietary recommendations away from the discredited low-fat diet to a low-carb diet.

Obesity and Type 2 diabetes are being driven by the low-fat diet nonsense.  Jelly beans brag “Zero Fat!” on the package.  Order the FDA to abandon the existing food pyramid and dietary recommendations, and revise them in the light of current research.

23) At the end of every year, the government determines what the median Medicare spending per senior is for every age: 65, 66, 67, 68,….  Anyone of that age who had more Medicare spending than that, well, that’s OK.  That’s what it’s there for.  But if someone had Medicare spending below the median for their age, they get a check from the government for, say, 20% or 25% of the difference.

Example: Someone who is 65 had $4000 of Medicare spending last year, while the median spending in the age 65 group that year was $10,000.  In January, the Medicare system sends him a tax-free check for $1200, 20% of the difference of $6000.

What this does is encourage people to go to less expensive providers, and to not go to the doctor for every little thing just because it’s free.  It also encourages providers to charge less than the Medicare maximums if they can, in the hope of attracting more patients trying to save Medicare money. That is to say, it would restore market incentives even though the costs were reimbursed, which is the really tough problem to making Medicare pricing competitive.

Advice For The Young

Know that you will grow old. Age is merely the passage of time, and inside every ancient is a youth wondering what the hell happened.

Take pictures, of yourself, of your friends. Your children will never believe you were ever young, and you will need documentary evidence.

Avoid frivolous spending. A dollar saved and invested at age 23 will grow more than eight-fold in constant dollars by the time you are 62 and provide 40 cents in today’s dollars per year in income every year after that, while leaving the principal for your offspring.

Marry wisely. Beauty fades, and friendship is more valuable than sex, is more fulfilling, and can be enjoyed for many years longer.

Marry a spouse who prefers to save than to spend. No matter how much you make, it is possible to spend more; no matter how little you make, it is possible to save some. The former is the path to poverty, the latter the road to security. If your marriage partner does not understand this, you will always be poor regardless of your income.

Practice moderation in your vices. Beware what monkeys you invite onto your back. They are all cute when young, but grow into surly adulthood. Carrying them will affect your health, your savings, your family life, and your social relationships.

Slow down. Avoid the purposeless bustle of those around you. Learn to relax, to enjoy the moment, and not to chase ceaselessly after the next moment, and the next. Life is now.

Take the time to stare out the window, to let the mind wander, to dream. All dreams cannot come true, but without dreams, none of them can.

Select your career with your heart: do what you enjoy. In today’s world of high-technology cars, air travel, and space exploration, one can still make a good living as a blacksmith or a buggy whip maker. A career that you can’t enjoy is a terrible burden.

Do not be mindful of what others may think. They don’t do it often enough to concern you.

Educate yourself. Go to school, read books, travel, work with your hands. You are your own most important asset, and your investment in this asset cannot be lost, taxed or taken away.

The value of your friendships is not determined by their number, but by their depth. Know who your friends are.

Category: Weird Thoughts About Why I Support Single Payer

I support single-payer. I bet that’s something you never expected to hear from me. But I do. I think the government should collect enough tax money, and pay all the bills. Costs will be less, and people will be better served. I believe that. I truly do.

Yes, I support single-payer software.

What did you think I meant? I’m a software engineer. I think having the government provide software free to everyone, as much as they want or need, is a great idea. I mean, who doesn’t need software? Everybody does. Why should it be provided haphazardly?

Did you know that some people don’t have as much software as they need? It’s true. Software is just too expensive. And lack of access to quality software is potentially deadly.

I mean, if you don’t have ABS brakes, or back-up cameras in your car, or lane-keeping that wakes you up when start to drift out of your lane, or any of the other wonderful things software provides, you could end up dead. It’s just not fair that the poor don’t have equal access to software.

And since I’m a software person, I think single-payer is great. I’ll always be busy, and I’ll always get paid. What’s not to like?

Oh, you thought I was talking about single-payer healthcare? Nope. Stupid idea. You say your doctor supports single-payer healthcare? Of course he does, just like I support single-payer software, and the Teamsters union guy who lives down the street probably supports single-payer shipping. As much as anyone wants, for free. After all, who doesn’t need shipping?

Don’t fall for it people. Healthcare used to be much cheaper. Then the government got involved. Did you know that government provides 53% of the healthcare in this country already? It’s true. Between Medicare, Medicaid, the VA, and health insurance for government employees, government already spends 53% of all the healthcare dollars in the United States.

So why would you think more government is the solution? Gin does not cure alcoholism, and single-payer won’t cure the problems with healthcare costs in the USA.

More of the problem isn’t the solution.

Category: Weird Thoughts About Music

When you get old, and retire, you learn all the things you should have known about yourself your whole life. I realized another one today.

I’ve been spending some time learning more about music history. Rock music history, to be specific. AXSTV has a lot of cool programs about the history of various artists. I’m not a fan of Dan Rather for a number of reasons, but his program, The Big Interview, is pretty good, and he gets good guests. Rock Legends is also a good program.

At the same time, Wendy has been taking piano lessons for a number of years, and she practices every single day. She’s become good at it, but only plays for herself. I only hear her play because the garage and the music room are in the same building (the house is actually two separate structures joined only at the edges, which makes the music room soundproof) so I hear her playing when I come or go. Playing classical pieces I know. She’s really very good.

One thing that strikes me about music is the sheer, numbing repetitiveness of being a musician. Do you have any clue how many times somebody has to play a piece of piano music before they get any good at it? Or how many times a rock band has played their signature piece? And you see one of these guys on stage, singing a song for the thousandth time, and they put such energy and emotion into it. Again.

Actors are similar. How many times has someone delivered that monologue in a five-year run on Broadway? It’s like eight shows a week, right? Every night plus a matinee once a week. Call it two THOUSAND times. Even for movies. I have heard an actor say that some director works really fast, and seldom does more than six or seven takes.

I feel like Daffy Duck in that Bugs Bunny cartoon, Hunting Season. “No. I insist that you shoot me now.”

Honest. If I were an actor and had done ten or eleven takes of a scene, and the director said, “OK. Let’s do it again. This time I want you to…,” I would kill him. With my bare hands.

I can see this when I look back on my career. I always wanted to do the things that you did once, then they got multiplied. Things with leverage. Write a piece of software, then send out thousands of copies. Design an electronics circuit, draw up the PC board pattern, then put that sucker in production. Even now in retirement, what is my hobby? Writing science fiction. Write the novel, upload it to Amazon, and sell a thousand or two thousand copies.

How these actors on Broadway do it, I don’t know. How musicians do it, where they go on tour year after year, and play the same song again and again, because that is the one song everybody really wants to hear, I don’t know. I couldn’t. I’d play the song in the studio, record it, press a million records, and be done with it. You want me to play what? No, I did that already.

Can you imagine if Kansas didn’t play Dust In The Wind? Or if Aerosmith didn’t play Dream On? Or Allman Brothers didn’t play Midnight Rider? Fans would riot.

And people screaming out “Freebird!” in Lynyrd Skynyrd concerts became a cliche.

I just couldn’t do it.

Author is good, though. Write a book once. Publish it. Done. Now write another, different book.

That I can do.

In Memory of Mr. Shelley

When I was very young, our neighborhood was a safe place. There was a cross street missing on our block, and there were about thirty kids within a few years of me living on both sides of the street of the double-long block. The grade school I attended was three blocks down the street, and we all walked to school and home every day. Most of us walked home for lunch and back as well.

About five doors down the street from our house toward the school, on our side of the tree-lined street, was a white-sided frame house with a front porch. The spring I was seven, I think — so that would be 1960 — an old man started sitting in a rocking chair on the front porch of that house during the warm part of the day. Walking back and forth to school at lunch, or home in the afternoon, I would wave at him and say “Hi!” because, well, because that’s who I was. He would wave and say “Hello there!”

School let out for the summer, and I missed saying “Hi!” to him, so I walked down there of an afternoon to say “Hi!” He was out on the porch, and I walked up the walk and introduced myself, and he introduced himself. He asked me how things were going, and I told him, but the doings of a seven-year-old weren’t terribly interesting. I asked about him. He had nothing much going on right now either, but he told me some story or other of his life.

This set a pattern for the summer, and, when the weather was nice, I would walk down there, and he would be on the porch, sitting in his rocking chair. I would sit on the steps, and he would tell me his stories. The lady of the house, his daughter-in-law, would often bring us out some lemonade and cookies, but she would retreat back into the house and leave us to talk.

Late in the summer, he stopped appearing on the porch. I went down there to look, and, though the weather was nice, he was not out. The second or third time this happened, his daughter-in-law came out and asked me if I wanted to see him. Of course, I said. So she led me into the house. In the dining room, the table and chairs had been pushed to one side and there was a hospital bed in the bay window. He was there, in the bed, with an oxygen tube in his nose. She pulled up one of the dining room chairs for me, and I sat by him.

He told me he was dying. His heart was failing. Apparently his son and daughter-in-law had taken him in for his last months, and his time was now short. I told him I was sorry, and must have looked terribly sad. He told me not to be sad, that he had lived a very long and happy life. He had had a wonderful wife and they had been tremendously in love for many years until she had passed. He had children and grandchildren who were all healthy and happy. He had lived a full life, the stories of which he had shared with me that memorable summer.

He said not to grieve for him, but to celebrate the wonderful life he had led and enjoyed so much, and to remember him.

We said goodbye for the last time that day. It was only a few days later that I saw the hearse parked in front of the house. I watched as they wheeled out his body on a gurney for the trip to the funeral home down the block.

I told my parents this story decades later. I had forgotten his name, but I remembered him, and I remembered that last talk in the sunny bay window of the dining room where he died. My parents were surprised, as they had known nothing about our relationship, but they knew his name. They called him “Old Man Shelley.”

I do remember you, Mr. Shelley, as you asked, even now, six decades later. I find your memory comforting as the years pile up.

When I see you next, maybe I can tell you some stories.

Category: Weird Thoughts on Repositioning a Book

We published Wendy’s first novel this year, in April. “Becoming Mia” is semi-autobiographical, in that it draws heavily on her experiences in the latter half of the 1960s, but it is not really about her. The most important part of the book for her is the Vietnam War backdrop, the resulting politics, and the struggle against gender bias in the STEM fields.

It also has a lot of romance in it.

So we positioned the book as historical fiction/biography. The categories, the keywords, the cover blurb, the Amazon blurb, the ad blurbs.

The eight months since release have been illuminating. When we look at “people who bought this book also bought,” we get a slew of romance novels.

Wendy’s book was also picked up by several local book clubs. She was invited to those meetings to discuss the book. And they talked primarily about the romance part of it.

One defining moment was when one of the women there, noting the book was somewhat autobiographical, asked Wendy what happened in her life after the book ended. Wendy answered that she had used her graduate degree in mathematics to have a very successful career in the computer industry.

“Yes, dear, but did you marry him?”

“Who?”

“Chip. Did you marry Chip?”

So it’s a romance, even though Wendy doesn’t think of the book that way. She’s a little nonplussed by it, but I told her the romance segment is much bigger, and they read a lot, so she should count her blessings.

The biggest challenge in marketing a book or author is finding your readers. Once you know who they are, you can target them. Absent that, you’re at sea.

And so, for 2019, we are changing the ad blurbs, and the Amazon blurb, and the back cover blurb, the categories, the keywords, and even the cover of the book. That’s the whole package that attracts readers — or doesn’t — to buy the book and read it.

The book itself hasn’t changed at all. We’ll see what repositioning the book brings.

 

Category: Weird Thoughts About Death

[First published on Facebook on February 11, 2017]

I’ve lost a number of close friends lately. Also, Wendy and I lost all four parents between 2000 and 2010. And there’s something that I have noticed again and again both with ourselves and talking to the families of friends who have died.

Guilt.

It comes in many forms. These appear to be the most common:

1) Survivor’s guilt. Why them and not me? This is usually with a spouse or someone else the same age.

2) “If only” guilt. If only I had pressed harder for the other treatment option. If only I had nagged more about getting a colonoscopy. If only I had <done this or that thing to change the outcome>.

3) Relief guilt. When someone is terribly ill, and suffering, we feel relief when their suffering is finally over. The next thing that sets in is guilt for feeling relief instead of grief that they have passed. And the corollary: Am I really relieved that their suffering is over, or am I a selfish shit who’s relieved that I don’t have to be their caregiver any longer?

4) Relationship guilt. When we think back over someone’s life, we also recall all the times that we weren’t the best version of ourselves. We feel regret and guilt for not having been a better spouse/child/sibling.

The common theme here is guilt. It seems to be a natural reaction to the death of a close loved one, and it hangs itself on the most convenient nail of the above.

There are some things that are important to realize here:

1) Guilt seems to be a natural human reaction to the death of a loved one. You aren’t unique. You aren’t alone. Based on my experience, this happens to almost everyone.

2) You most likely didn’t actually do anything wrong. Sure, there are outliers, just plain shit human beings who ought to feel guilty, but they probably don’t anyway. What I am talking about here are good people, who lead good lives. We are all human, and our relationships are human endeavors. The departed also fell short of the best version of themselves. Most of us do the best we can. As for “Why them and not me” it’s just the luck of the draw. In any case, there’s nothing to feel guilty about.

3) Our departed loved one, could we but ask them, would tell us that they don’t want us to feel this guilt, to punish ourselves with it. We loved them, and they loved us, as best we knew how, and that’s something to be celebrated, no matter that we both sometimes fell short of our own goals.

4) This artificial guilt gets in the way of remembering our departed loved ones with fondness, and of getting on with our lives.

Realize that the guilt you feel is very common in these circumstances — that it is wired into the way humans think, and feel, and love — and set it aside.

Celebrate what you had, remember them with fondness and love, and move on.