Everyone is talking about healthcare – talking, but not communicating. To communicate successfully, we first need a common language.

In healthcare, people don’t agree about the meanings of simple words such as control, cost, cut, free, and charge.

The five phrases below are quotes taken from two recent online articles about our dying U.S. healthcare system. They epitomize the 2012 American Towel of Babel.

1) “Control the costs of medical care” starts our mass confusion. A payer, whether government or private insurer, does not control costs. They control their expenditures.

Most people define the word cost as “the sum of resources required to deliver a service or to offer a product for sale.” In health care, only patients can control costs, acting on advice of doctors. Government or private insurance companies control what they pay. They cannot control what things cost.

The true cost of medical services is unknown. That’s right! Neither your doctor nor your medical institution  knows the actual cost (defined as above) for the services they provide. When I asked two different hospitals the true cost of a cardiac catheterization and specified that cost should be measured as specific resources utilized, they both replied, “We do not account our costs that way.”

2) “Free care to poor patients” is another misnomer. Medical care may be free to (not paid by) a specific patient. Health care is never free. Someone has to pay nurses’ salaries, amortization on buildings, disposables, electricity, and the ever-popular liability insurance premiums. Medical care that is “free” to one patient must be paid by another, without permission. (Isn’t that called, ah, stealing?)

When it comes to modern technological medical care, “poor patient” refers to virtually all of us. If your household income is $100,000, you are in the lucky top 16% of the population. You could not begin to pay out of pocket the bill for your open heart surgery ($250,000) or the defibrillator pacemaker you need ($125,000).

3) The Service Employees Union of California has proposed that “hospitals would be limited [in what they are] charging patients.” But, hospitals already are. There are strict Federal rules governing how much a hospital or a doctor can charge. Further, they must charge the same regardless of payer source. This includes patients who have no payment source at all (unfunded care). So, they provide care and then charge, knowing they won’t get paid.

To sort out this mess, just remember two NON-relationships.

• Charges for medical care have no relationship to revenue received.
• Costs to provide medical care have no relationship to charges.

These two statements: a) Are absolutely true; b) Are not common knowledge; and c) Explain much of the confusion about money in healthcare, the system, as well as health care, the service.

4) “Charges [are] significantly more than actual costs.” Well, duh!? Any business – Ford Motor Company, your local hospital, your family doctor, or your family – either makes more than it spends or it goes bankrupt. Unlike the Federal government, the rest of us cannot print money. We either cover our costs or we go out of business (as many hospitals are doing).

The quote above (#4) about ‘charges exceeding costs’ was talking about individual patients, not overall finances.  It implied that patients were being ripped off because the charges the patient sees on the hospital’s or doctor’s Bill for Services Rendered are so much greater than what the patient thinks the costs are.

But recall that: A) No one knows the true costs of care per patient, and B) Actual reimbursements are only a tiny fraction of billed charges. When I do a cardiac catheterization in a critically ill baby, my fee is generally $4000-$7000. Want to guess the actual payment from Medicaid? Answer: $387.

5) “If a hospital’s charges…exceed [a] threshold for the year, the hospital would be required to issue refunds.” This proposal is nothing less than government-sanctioned theft. Revenue to hospitals and providers is always a small fraction of the billed charges, ranging from as high as 60% to as low as 3%. Do not forget mandated but unfunded care where the reimbursement rate is zero – no revenue at all, but plenty of costs that must be paid.

So, if a hospital’s charges (not revenue) exceed some arbitrary level, say 80% of last year’s charges, the hospital will have to refund the difference, money that it never received.  I can just see the Federal government enforcing a law where an undocumented resident needed and received emergency surgery; where the patient paid nothing; where the hospital was paid nothing; and where the hospital was required – by law – to give a “refund.”

Welcome to the Dictionary of Medical Terminology, 2012 Edition, written by the Mad Hatter (of Alice in Wonderland.)

• Cost ≠ cost. Cost = unknown.
• Charge >>> payment. Both are government-determined.
• Control and free care are meaningless terms.
• Cost cutting = reducing payer outlay. Cost cutting = cutting services.
• Consumer does not pay for what is consumed.
• Supply ≠ demand.

Is it any wonder that both healthcare and health care are drowning in red ink, and taking us with them?

Sick things – whether people or systems – need cures, not sedation, not palliation, and certainly not snake oil.

The Medicare program was sedation. It lulled us in thinking we could prepay the government for health care and then get whatever we needed when we needed it. Now, Medicare is going broke and Congress is “saving it” by cutting payments which means cutting services. They are saving Medicare by making care unavailable to seniors.

Both HIPAA (Health Insurance Portability and Accountability Act) and UMRA (Unfunded Mandate Reconciliation Act) were palliation. They made us feel better temporarily but fixed nothing. So, people don’t have an insurance portability problem, because they don’t have insurance. Unfunded mandates are still unfunded, so hospitals must steal from insured patients to pay for care they must give to the uninsured for “free.”

Snake oil used to be sold in the U.S. by smooth-talking salesmen claiming it could instantly cure all sorts of medical conditions, from abdominal colic through “men’s complaint” (erectile dysfunction) to rheumatism. Snake oil had no medicinal properties and the salesmen wisely rode out of town before their mendacity led them to the hanging tree.

Today’s snake oil – with which Washington is liberally dosing America – is PPACA (Patient Protection and Affordable Care Act). The supposedly active ingredients are the individual mandate to buy insurance and the health [insurance] exchange.

Discussing the individual mandate is a waste of time until the Supreme Court decides to uphold it or strike it down.

Health exchanges are touted as the use of market competition to reduce costs and improve access. The “American Experiment” called the U.S. proved that in a free market, consumers can get better or cheaper, usually both.

Look at what free market competition did for Lasik (corrective eye) surgery. Availability went up. Prices plummeted and the success rate now approaches 100%. The Washington salesmen promised We The Patients the same results from the health exchanges: better and cheaper.

Free market competition, emphasis on “free,” means that various sellers of products or services are allowed unrestricted competition based on quality, such as benefits, availability, or features, as well as on price. In a free market, consumers pay their own, hard-earned money for goods or services. Consumers decide for themselves what is their best value. By choosing some sellers over others, they decide on winners and losers in the marketplace.

A health [insurance] exchange is the exact opposite .

• Sellers (of insurance) cannot compete based on benefits. They are strictly regulated as to what benefits they can and cannot offer.
• Sellers (of insurance) are forbidden to compete across State lines. Imagine selling cars or potatoes under these circumstances.
• Sellers (of insurance) cannot compete on what they pay their suppliers (doctors). They follow the Medicare Reimbursement schedule. Thus, they cannot compete on price to the consumer.
• Consumers (of health care) have no data on which to judge value of goods and services they are buying. Imagine purchasing a car without knowing what mileage it gets, how much the maintenance schedule will cost, or what the resale value will be, what features the car has, or even what it will cost!
• Consumers (of health care) do not control (spend) their own money. Thus, the moral hazard applies.
• Consumers (of health care) cannot choose among competing insurance sellers. The sellers do not compete (see above). Most Americans get their insurance through their employer, which gives the workers a very short list of insurance options. For the unemployed, there is no “market” of competing insurers.

Since there is no free market competition, how can consumers – We The Patients – get better and/or cheaper? Answer: we can’t.

Wisconsin studied the PPACA exchange and found that PPACA constrains competition, makes consumers pay more for insurance, and 100,000 of their residents “will be involuntarily dropped from employer sponsored health insurance” (Press Release of August 24, 2011). No wonder Governors Walker (WI) and Susanna Martinez (NM) rejected implementing a health exchange.

Supporters of such exchanges have offered both carrot and stick. The carrots are sizable grants for the Federal government to defray set-up costs. The stick is the threat that States will lose their Medicaid funding if they fail to create PPACA exchanges.

Both the carrot and the stick are more snake oil. The grants are one-time allocations but the exchanges will have ongoing costs along with the “hidden tax” as described in the Gruber Report on Wisconsin and PPACA.

The sticks (punishments for failing to set up an insurance) are much worse. First, there is the threat of “loss of Federal matching funds.” Governor “Butch” Otter first announced that he had not only garnered $37 million in Federal funding for Idaho but also saved over $300 million in Medicaid money that would have been lost if he did not set up an exchange. Then quite publicly, he had to retract the latter because it just wasn’t true.

A second PPACA stick is suppression of competition. Each State exchange must follow Federal rules and regulations that virtually eliminate any real, free market competition. Governor Haler Barbour said on national television that his State of Mississippi already had a vibrant, competitive health insurance market, and that PPACA exchanges would destroy it.  .

Throughout the nation, private insurance premiums – already beyond many citizens’ ability to pay – are escalating an additional 30% or more. Employers are being forced to drop health coverage for employees.

So much for “cheaper” as a result of having health exchanges. What about “better?”

The bureaucratic costs of health exchanges are enormous, both for the States and for the Federal government. At the same time as it spends money (Medicaid grants) for set-up, Washington “saves money” by reducing payments to providers. This stick directly hurts patients.

Writing in January 2012, Jaime Leopold, the Director of the Arizona Breast Cancer Society wrote, “We have had over 45 people since September [2011] that have had their coverage cut mid-treatment.” That means money is being taken away from treating cancer patients to pay for new bureaucrats.  To whom should we complain about this grotesque cost – really revenue – shifting? Clearly PPACA exchanges fail to make health care either “better” or “cheaper.”

The State of Utah did set up a PPACA-like exchange. Of the over one hundred thousand people eligible to sign up for their State’s “free insurance,” five thousand did. Apparently, Americans know snake oil when they encounter it. Health exchanges are a liberal application of the smelly stuff.

Henry David Thoreau wrote that, “All perception of truth is the detection of an analogy.” Let’s use analogies to comprehend the seemingly incomprehensible: healthcare in the U.S. Below, the word “they” refers to power brokers in Washington, on both sides of the aisle, and in the White House.

• They are concentrating on one vein on one leaf of one tree, while the whole forest is ablaze.
• They remain intensely focused on a tiny germ under a microscope while an earthquake is destroying the lab.
• They have precisely lined up all the deckchairs on their magnificent new, “unsinkable” ship – the Titanic.
• They are applying anti-acne cream to a patient with a brain tumor (T).

The basic truth described in these analogies may seem obvious to you and me, but apparently, it escapes people who work within the Beltway. They are focused on the trivia while the big problem gets worse.

The “doctors” for the critically ill U.S. healthcare system – our Representatives in Washington – are altering financing and expanding regulations, apparently without any understanding of why patient Healthcare is sick. As a result of their treatment, the patient is deteriorating. Indeed, patient Healthcare is dying, and when it goes, we will go with it.

The following is a list of Healthcare’s signs and symptoms. Every good nurse or doctor knows you don’t treat these.

• Spending too much, both individually and as nations
• Lack of health care goods and services
• Shortages of trained personnel
• Limitations in access
• Errors and adverse impacts
• Variations in both quality and payment for similar services.
• Medical bills were formerly the leading cause of personal bankruptcy in the U.S. until the 2009 real estate collapse. Medical bills have now “slipped” to second place.

The list above does not include the causes of patient Healthcare’s woes. Those are the things you do treat, like perverse incentives, action without evidence, spending that delivers no value, suppression of market forces, and preventing learning.

You cannot cure over-spending by spending even more, as does the PPACA (Patient Protection and Affordable Care Act, called “Obamacare”). You determine where the dollars are going – the “spending” – and decide which of those expenditures is “over-”, meaning which dollars we are spending that show a negative cost/benefit ratio.

The Beltway-doctors say they are “fixing” healthcare by infusing competition through health exchanges. Those exchanges actually expand government control of healthcare and thereby, they suppress the free market forces that give consumers better, cheaper, and quicker. Even as Congress promises lower insurance costs through Federally mandated exchanges, you and I see our insurance premiums skyrocket.

Congress reduces payments to providers and at the same time, they pay more to themselves. We get fewer doctors and nurses but more bureaucrats. Trillions are paid to healthcare – the system – leaving less and less for health care – the service. As Robert Moffit of the Heritage Foundation testified before Congress, “One cannot get more of something by paying less for it.”

The only people we can count on to act in our best interests is us, not as in U.S., but as in you and me, We The Patients speaking as We The People. What should we do?

Sick patients, such as Healthcare, should be treated by people who practice good medicine. The self-proclaimed healers of Healthcare in Washington repeatedly shout: “Trust me! I have your best interests at heart!! Pay no attention to who is funding my re-election campaign.” You can easily see how patient Healthcare is doing under their fine care.

The following are the basic principles of good medical practice, whether the patient is a sick person or a sick system. This is what the Washington-doctors are NOT doing.

1. Evidence based decision-making
2. Treat causes, not symptoms.
3. Long term (cost + risk) / benefits analysis
4. Partnership with the patient

What should We The Patients do? First, we must accept the job of becoming We The Doctors for patient Healthcare. If we wait for someone else, it won’t get done, and certainly will not get done right.

Next, we must accept the fact that the “system” we currently have cannot be adjusted, managed, tweaked, or reformed to make it efficient and effective. It is not just a broken system. It is no system at all. We need to create a real system, one that works…for us.

Congress is guilty of nanomanaging Healthcare, which is “a thousand times worse than micromanagement.” They substitute logic and passion for hard data and cost/benefit analysis. We must demand that all Congressional actions have evidence in advance of legislation. Such evidence must include, as the engineers say, both problem definition and proof of effect.

Finally, though we are temporarily acting as Doctors for Healthcare, we also remain We The Patients. It is crucial that we demand a partnership with the Federal government. We want the exact opposite of how we were treated with regard to PPACA.

Economist Robert Samuelson has declared that health care costs are “out of control.” Though one hesitates to disagree with a widely syndicated columnist, Samuelson is 180 degrees wrong.   Health care costs are IN control – very tight control – by Washington.

Health care as two words refers to goods and services delivered by hospitals and providers to be consumed by patients. The word costs, when referring to what providers and institutions must pay, is determined primarily by government regulation and bureaucracy rather than by labor costs, supplies, or MRI machines. Payments to providers and institutions –what the government calls costs – are predetermined by the government. The bill submitted by a provider is generally irrelevant.

Whether you describe excessive national expenditure of money as costs or as payments (reimbursements), spending is strictly controlled by the government. It is not “out of control” at all.

Note first that when the PPAHCA (“Obamacare”) reduced Medicare “costs” by 21%, they cut Medicare payments (to providers). Therefore, they cut services to patients. As Robert Moffit of the Heritage Foundation testified before Congress, “you cannot get more of something by paying less for it.”

Meanwhile, PPAHCA increased spending ON – the costs OF – the federal healthcare bureaucracy by six whole new agencies, hundreds (? thousands) of bureaucrats added to the payrolls, and multi-thousands of new rules and regulations. So the government controls and increases spending to/on itself, while it controls and decreases spending on patients.

Need proof? Of all the money spent on “healthcare” in 2010, 40% – that is over $1 trillion – …disappeared. It went in to healthcare but provided no health care. That statistic was before PPAHCA, which could raise the disappearing dollars to half (!) of all healthcare spending.

Samuelson goes on to use the recent OECD (Office for Economic Cooperation and Development) report to explain U.S. overspending: steep prices and abundant provision of expensive services. Hogwash! As Dr. Samuelson knows, “price” is meaningless in healthcare in terms of what gets paid.

As a doctor, I can charge whatever I like for doing a cardiac catheterization in a baby. The actual bill can read $2000, $4000, and sometimes over $5000. Regardless of what you call my price, charge, or bill, I get $387. That is what the government pays. So the price may seem steep but the payment is peanuts.

For Medicare, just as for my caths, payments are now lower than the cost-of-doing-business. So if you want to know your Medicare doctor can no longer see you and is not accepting new patients, it is because she gets paid less by Medicare than her costs to keep the office doors open.

How much of healthcare spending is for administration and regulations? No one knows because no one measures. Government administration guesses at how much it directly pays itself, and conveniently ignores the costs – to providers and the public – of the ever-expanding mountain of regulations.

Samuelson rightly asserts that, “the system needs a fundamental overhaul to deliver more value for money.” No one disagrees…except those in charge. In order to determine value, one must measure cost, measure benefit, and compare the two. Does the government measure either the benefits of health care or the benefits of healthcare? The answer is a resounding No!

So how can you-the-consumer, whom I call We The Patients, assess value? If you only know part of the numerator and none of the denominator of a cost/benefit ratio, you can’t.

Finally, Professor Samuelson practices really bad medicine … on healthcare. He jumps directly from symptom identification (overspending) to treatment plans (vouchers or single payer) without going through the critical step of root cause analysis.

If you want to cure anything, whether it is a sick person or a sick system, you must treat the cause(s) of illness. Overspending is only one part of the sickness in healthcare. If we try to fix it without resolving its root cause as well as the other causes of illness in the system, we are certain to fail, just as Obamacare – with its expanded control – is certain to make healthcare, We The Patients, and America sicker.

A town hall meeting was held about healthcare at the Albuquerque Art Museum, Albuquerque, New Mexico. The meeting had two parts.
• First, there was a screening of the film “Sick and Sicker,” written and produced by Logan Darrow Clemens. The film analyzes the Canadian healthcare system based on the assumption that full implementation of the PPAHC (Patient Protection and Affordable Health Care Act, also called “Obamacare”) in the USA will produce a system similar to Canada’s.
• After the film, there was an unstructured, free flow open discussion about healthcare among the 47 attendees, moderated by Deane Waldman, author of “Uproot U.S. Healthcare.”

QUESTIONS (ITALICS) AND RESPONSES

Doesn’t it make more economic sense to spend our limited healthcare money on the young and not on senior citizens who won’t live that long and will not be as productive as the young? [Note: The questioner appeared to be at least 65 years old.]

In a purely rational economic sense and speaking only for the nation not the individuals, the answer was yes: spend more on those who can contribute more.

Waldman the moderator then offered a different approach. He claimed that we had enough money to care for both young and old, but only if healthcare money actually went to health CARE. Forty percent of all our healthcare spending goes to the bureaucrats and insurance company CEOs rather than to doctors and nurses who serve We The Patients. In 2009, that was over $1 trillion “healthcare” dollars that produced no health “care.”

You talk about the need to balance demand with supply: unlimited demand with limited supply. Who should do the balancing?

There are only two choices for the “balancer” of supply and demand. It is either the government by decree who rations health care, or the individual through the market forces who balances his or her demands for care with his or her own healthcare dollars.

Insurance companies are bad: they totally get in the way between doctor and patient.

Several responders in the audience immediately agreed. Waldman agreed as a physician saying doctors frequently cannot do what the patient needs because of insurance companies, but also because of the government as an insurer (Medicare and Medicaid). However, he continued, it is fundamentally a system problem. We do not reward the outcomes that people want: good health and long life. The system rewards – with profit or power – those who give the least care.

In the flow of conversation, the moderator asked a question of his own. “Let me have a show of hands. If you could throw out all 535 members of Congress, no exceptions whatsoever, plus the occupant of the White House, would you do it?”

In response to that question, almost before the final words came out, the vast majority of the audience enthusiastically raised their hands.

While I agree that insurance companies are a cause of the rising costs, there is also the practice of defensive medicine.

There were many nodding heads and several mumbled about tort reform but no one responded aloud.  So Waldman spoke up, saying that we do not need tort “reform.” We need tort replacement. We need to dismantle the adversarial malpractice system and create one that will do what we want: compensate the injured and improve outcomes. (He then made a plug for his book “Uproot U.S. Healthcare,” which describes how we might do that.)

We need to restore the [direct] doctor-patient connection.

Everyone agreed with this statement. The moderator then reminded the audience that part of such a connection was direct payment. The audience seemed to have no problem with doctors making money. It was the government taking and controlling their money that rankled them.

What is the next step if Obamacare is repealed (overturned by the Supreme Court)?

Again, there was silence, with the audience expecting Waldman to answer, so he (I) did. Repeal of PPAHCA or not, either way healthcare is terminally ill and needs radical treatment. We cannot keep tinkering with a system that does not work and can never work. We The Patients – homage to We The People – need to become doctors for sick healthcare. “Uproot U.S. Healthcare” shows us how – it gives us power.

What happens if the Supreme Court strikes down the financial requirements in Obamacare but the Federal Government keeps the mandate to provide care regardless of payment source?

This was addressed specifically to the moderator. Waldman said, “So what? Nothing changes.” Either way, hospitals and doctors are legally bound to provide care for people most of whom cannot pay. Though care is federally mandated, the government does not pay.

Waldman brought up the question of illegal residents and health care for them. Discussion followed including the history of numbers (of uninsured “Americans”) as well as how European healthcare systems handle illegals (they don’t). The audience then demanded that Waldman give his personal opinion on what should be done.

I answered as follows. We as a nation should decide this important question. We The People should not accept what the pundits say or the President (or I, Deane) think is right. WE as a People should have a national dialogue, and then we should decide what is right.

I am a veteran and was injured in Vietnam just as our soldiers are now coming back injured from the wars in Iraq and Afghanistan. What is going to happen to health care for Veterans?

Nothing good. As shown in the film Sick & Sicker, the Province of Quebec now spends over 40% of its entire budget on healthcare and yet people are dying waiting in line for services. When those in power, “the system,” must decide between paying the providers or paying itself, guess who gets the short end of the stick. With limited resources, care services (and patients whether veterans or not) suffer, while the bureaucracy survives and thrives.

Medical school enrollment is down; people are leaving the healthcare profession. How common is this? How bad will this be for us?

As the film Sick & Sicker showed, the Canadian government aggressively pared down the number of physicians in its efforts to control costs. This resulted in millions who simply cannot find a doctor. From 1995 to 2006, applications to U.S. medical schools fell almost 20%. There are currently over 500,000 unfilled nursing positions in the U.S.

“How bad will it be for us?” The moderator had nothing optimistic to respond. He reiterated that We The Patients must become active in our own self-interest and fix healthcare.

What will I do if Medicare reimbursements fall below the doctor’s cost and the doctor won’t see me anymore?

Medicare reimbursements HAVE fallen to below financially survivable numbers for doctors, and doctors are refusing to see Medicare patients. The film showed what will happen: people will wait, people will suffer, and people will die.

At the back of the meeting room there was a poster advertising moderator Waldman’s book and asking people to post question to be answered on this website. One such posted question was the following. “What are the strategies for a successful medical model after we find Obamacare unconstitutional?”

The answer is, as emphasized in “Uproot U.S. Healthcare,” to practice good medicine on healthcare. That means We The People must agree on a set of principles that will govern healthcare and then demand a new system based on those principles. That model and only that model will work.

CONCLUSION

People with different views exchanged their opinions. There was difference.  There was honest exchange of divergent ideas. People demanded evidence when other people spoke out.

This was quite different from the staged events in 2009 that called themselves town hall meetings. This town hall was a great success because it was real dialogue. It was a small (okay, a tiny) step in the right direction – the path toward consensus.

The Rio Grande Foundation plans to hold more such town hall meetings around New Mexico. We urge other think tanks throughout the nation of whatever persuasion to do the same.

The parallels are worrisome, even frightening. In many ways, people now living in the United States of America have returned to circumstances of our revolutionary forbearers. Hopefully, George Santana was not referring to us: “Those who cannot learn from history are doomed to repeat it.”

In 1776, there was an hereditary British aristocracy that was totally out of touch with the everyday class, in fact preying on it. Today we have an elite class of professional politicians with apparently lifelong tenure in Congress and their minions in a massive bureaucracy that controls the populace by overseeing regulatory compliance.

In 1776, the ruling class protected and extended their power using a military often built through impressment. Today, the power elite fosters a class of government dependents who, in order to protect their government handouts or bailouts, keep the elite in power through the ballot box.

Three nights ago, I moderated a town hall meeting on healthcare. [That meeting will be described shortly on this web site.] In the course of our dialogue, I called for a show of hands asking, “If you could, how many of you would vote out all, repeat all, 535 members of Congress?” Instantly, almost the entire audience enthusiastically raised their hands.

In 1776, King George III dictated to a group of colonies, separated from him by great distance. Today, we have an elected monarch (President) who preaches at (not even to) us, who is totally out of touch with reality. Like King George, the President is separated greatly from his subjects but Obama’s isolation is because of ideologic blinders.

The President blames the rich – not his own policies – for all our national woes. He wants to control the nation in order to redistribute its wealth. We The People want to be independent and free. We, the creators of wealth, want to become rich, not destroy them. As true liberals and therefore followers of John Locke, we deplore being dependent on the government, resent control by the government, and like the Founding Fathers, we will resist.

In 1776 (actually it was 1765), the Stamp Act was imposed on us. It took our money without our consent. As colonists, we declared it unconstitutional. Today, we have “Obamacare” or the PPAHCA, which is similar, almost identical.

The cry of taxation without representation and using our own money against us seems all too appropriate today. Think of our involvement in foreign wars, job-killing legislation, the favored handling certain (campaign contributor) groups, bailouts, and Solyndra.

In 1776, the monarchy – the government – controlled our lives, our liberty, our property, and our precious honor. In response, we declared a Bill of Rights, which was not a list of RIGHTS at all. It was a list of constraints against the government imposing its will on us. Our nation was founded in defense of one single right for Americans: to be free.

There is one huge difference between 1776 and today. Then, we were powerless unless and until we took up arms. Today, we do have power: the power of a single vote multiplied by hundreds of millions.

This is not a call for another armed, bloody revolt. This is a cry for bloodless revolution, called democratic change.

As “government is the problem, not the solution,” We The People should change our government. We must throw out the current power elite: 535 members of Congress plus the White House. We need to depopulate the bureaucracy and force the regulators and overseers to do something productive instead of confiscatory. Then, we should repopulate the Beltway with people who remember what we did and why we did it 235 years ago.

Do you wonder why you cannot find a doctor or nurse to care for you? If you are one of the 15% of Americans who are uninsured, you assume it is your lack of health insurance. If you are in the 85%, you…just don’t understand at all.

Everyone knows that health care providers are in short supply. And the shortage is getting worse. While low pay is a factor, it is not the main reason why people are either leaving health care or not going into it at all.

In 1993, social scientist Carl Weick wrote an academic paper titled “The Mann Gulch Disaster” in which he described a “cosmology episode.”

That is the answer to the question, Why can’t I find a nurse or doctor?

While there are numerous reasons why people choose to work in healthcare, one stands above all others: moral clarity. From the boiler room through the operating room to the Board room, people in healthcare know – without question – that what they do when they go to work is good and noble: they are helping others.

So why, they cry, does it seem to get harder and harder? Why do people in healthcare feel under constant attack? Are they paranoid or is the attack real? The explanation is cosmology episode.

According to Professor Weick, every person on earth functions with certain basic, subconscious assumptions that make the world understandable. The cosmos is not arbitrary or capricious: it follows rules. The sun always rises in the east. If you throw a ball up in the air, it will come down. If you hold your head under water long enough, you will drown.

But…

What if you watch the sun rise from the south? How do you explain a ball that never comes down or someone who can live under water? You can’t. A world where there is no gravity or where you can breathe water…makes no sense. The cosmos is not following the rules. You are in a cosmology episode.

Now imagine that you are a health care provider, and you experience the following.

• The system that is supposed to help you help others, called healthcare, actually makes it difficult-to-impossible for you to do your noble work.

• When a patient has a bad outcome, you instantly change from fiduciary to perp.

• Even though you are working harder and patients are doing better, payers have reduced your revenue below a level where you can stay in business.

• As the number of nurses, doctors and other care providers keeps dropping, the number of overseers, regulators, and bureaucrats continues to rise. There seems to be unlimited money for them and no money for you.

Providers who experience the above are having cosmology episodes. They think they are dreaming a nightmare, but it is worse. They are actually awake and living the nightmare.

There is overwhelming evidence of provider shortages. Professional satisfaction has gone from 95% to 20% in thirty years. Forty percent of doctors over 50 years old are considering early retirement. Over five hundred thousand nursing positions are unfilled in the U.S.A.

Maybe, you muse, things are better in countries with universal health care. Unfortunately, they are even worse. In Canada, people are dying in line waiting for care that was approved but cannot be provided because of the shortages. In Great Britain, within three years after finishing training, doctors are looking for ways to get out of healthcare.

The Democrats’ “fix” for healthcare, disingenuously titled the Patient Protection and Affordable Health Care Act (PPAHCA or “Obamacare”), is making a bad situation worse. Insurance premiums are soaring, making insurance unaffordable even for those with jobs or money.

Payments to doctors are repeatedly being cut, forcing them to do one of two things: either 1) “make it up with volume,” meaning even less time per patient, or 2) leave healthcare altogether. Meanwhile, the bureaucracy is massively expanding with thousands of new rules and regulations (just what we need!)

If it is possible to exacerbate a cosmology episode, PPAHCA is doing it and making the shortages even more critical. Yet, PPAHCA is not the root cause. The problem started long ago, when the healthcare system grew without principles, guidelines or plan.

Healthcare is a system that is not a system. It works against the best interests of both patients and providers. Because it is contradictory and perverse, the healthcare “system” – or lack thereof – is root cause of cosmology episodes.

Assigning blame won’t work. There is no simple solution or quick fix. Until we replace the whole system – from tort reform through the financing structure to the culture of health care – cosmology episodes will become more frequent, and as a result, patients will suffer.

Would YOU voluntarily work in an industry where the pay is low and getting lower; where the rules and regulations are stifling, incomprehensible, and constantly multiplying; where the government steals all your resources; and where your customers (patients) blame you when they need you the most?

I did and I regret it.

(This article was excerpted from the book Uproot U.S. Healthcare.)

Deane Waldman MD-MBA is Adjunct Scholar for the Rio Grande Foundation, and the author of “Uproot U.S. Healthcare” as well as “Not Right! (January 2012).

E.D. Kain’s blog on Forbes Online titled Why Healthcare Reform Matters to Occupy Wall Street should not be allowed to stand uncorrected. It is a combination of accurate assertions with incomplete and often erroneous statements.

Kain is right to label what desperately needs reform as “healthcare” (one word). As such, the word refers to the system. U.S. healthcare is very, very sick. It is a “system” in name only: it is not systematic. Further, all systems including the so-called universal health care ones fail to meet public expectations.

Health care as two words means a service relationship between a patient and a provider. A healthcare (one word) system exists in order to facilitate (two words) health care and the well-being as well as longevity of people.

Kain’s first sentence is incorrect: well intended but wrong. He wrote, “Nearly every country in the developed world has some form of universal access to health insurance.” Most nations with so-called universal health care offer access to insurance and therefore care to citizens only. If you are not a citizen, even if you are one of nearly two million Turkish invited guest workers in Germany, you do not have access to “universal” health care.

Secondly, the care you can access is not what your doctor says you need. Care is limited to whatever the government says you can have. In other words, universal health care is rationed by the central government, always. People are literally dying in Canada waiting inordinately long times to gain access to care that has been approved.

Writing about the market for health care, Kain remarked about “the way capitalism works – and doesn’t work – in America.” The flaw in his comment is this: there is no market, certainly no free market, for health care in the U.S.A. Let me prove that statement.

Within the so-called healthcare market in the U.S.A. there is a monopoly: a single supplier class called licensed providers who do not compete with each other on price. Within the so-called healthcare market in the U.S.A. there is a monopsony: a single purchaser called government who sets the amount of [fixed] payment. Insurance companies simply follow suit.

Any “market” that lacks price competition among the suppliers and that lacks price variability among purchasers is not free. The free market has not failed in American healthcare: it does not exist, and never did.

In place of a free market, healthcare has a controlled, contradictory, and perverse financing arrangement. We should not even call it a market but for convenience below, I will.

The market is “controlled” because payments are fixed and non-competitive. The market is “controlled” because suppliers do not compete, and most particularly, because consumers and suppliers – patients and providers – are disconnected.

If you go to McDonald’s for a hamburger, you consume it and you pay for it (in the reverse order of course). McDonald’s offers its hamburger at a certain price. If you are willing and able to pay that price, you pay and consume. If the price is too high, you go elsewhere, where a competitor offers a burger for less.

In healthcare, the patient/consumer does not pay the provider/supplier: a third party does. In healthcare, the supplier/provider does not determine his or her price: a third party does. That is called micro-economic disconnection, which can function only when the third party payer (government) both rations the supply and fixes the payment in advance.

The market in healthcare is internally “contradictory and perverse.” Ostensibly intended to promote health and longevity, the supplier (government) encourages sickness, viz., subsidies to tobacco farmers and to grain producers. The current system rewards NOT giving care (insurance profits) and rewards providers when patients are sick, called “pay for performance” but not when they are well.

Mr. Kain’s solution is as follows. “A single-payer healthcare system works so well [1] because there is one very large risk pool with an enormous amount of bargaining power. [2] You can’t match that bargaining power in a fragmented system like the one we have, comprised of myriad regional insurers with de facto monopolies over their area.” [3]

[1] Single payer systems do not work “so well.” Just check out deaths in Canada, England, and Spain, or the necessary rationing of care in Greece. Check out the administrative waste of all of these systems. Yes, the U.S. is worse in terms of administrative healthcare costs, but that does mean that single payers “work well.”

[2] Bargaining power of the single-payer is absolute: it is in fact price fixing by the government. When Italy thought that pharmaceutical prices were too high, they simply decreed low prices. Result: the destruction of a previously vibrant Italian pharmaceutical industry.

[3] While there may be on paper a “myriad [of] regional insurers”, they follow a pre-determined (fixed) payment schedule that comes directly from the government (Medicare). There is no competition among suppliers (providers) on price. As stated above, healthcare – with both monopoly and monopsony – is no real market at all.

Fortunately, Mr. Kain ended with a completely true statement. “The lack of universal access to healthcare in this country actually hampers business. It makes capitalism more risky for workers, and the cost of healthcare weighs down workers and businesses. The economic cost is huge, and makes American firms less competitive and American workers less secure.”

Business leaders such as Andy Grove (Intel) and Lee Scott (WalMart) have both said publicly that the U.S. healthcare non-system is the major drag on U.S. competitiveness. As a nation, we spend way too much on the healthcare system: 40% of all healthcare spending does not produce health care. With a less healthy and less long-lived populace, we are less competitive. The regulatory burden just adds to the drag.

Even ignoring the ethical advantages, it is in the financial best interests of individual persons, of U.S. companies, and of the Nation to cure – not palliate or sedate – our sick healthcare system. Curing requires treating causes not symptoms. Cure entails replacement, not reform.

“It is just a semantic difference” generally implies a meaningless academic argument over words, a distinction without significance, such as saying someone is disingenuous or mendacious instead of just calling the person a liar. Unfortunately, politicians now so distort semantics that “war is peace, and ignorance is strength,” to quote George Orwell’s book 1984.

People in the Beltway now routinely pervert* commonly used words and phrases so that their meanings are inverted. Subsequent decisions and actions then produce the opposite of what was promised. *(To pervert means to “distort or corrupt what was originally intended.”)

Semantic are now distinctions with great significance. They are differences that very much DO affect us.

Consider the following examples.

The President quite rightly said that the U.S. is spending too much on healthcare. Then he pushed through a Bill – the PPAHCA (Patient Protection and Affordable Health Care Act)  – that will spend $1-2.7 trillion over the next ten years. How does the President reduce spending…by spending even more? Answer: semantic perversion.

President Obama admits that the deficit is a huge problem and must be reduced. A deficit is defined as “expenditure in excess of income.” The only way to explain his spending $1-2.7 trillion dollars that we do not have (thereby increasing the deficit) is…you guessed it…semantic perversion.

In the commercial and financial worlds, proper accounting methods and due diligence are phrases with precisely defined, accepted meanings. A business that fails to account its finances properly is punished, by law. Businesses either employ proper due diligence before they spend money, or they go broke.

Due diligence apparently means something different in Washington than everywhere else. Case in point: the CLASS Program.

After doing what passes for due diligence around the Potomac, Congress promised us that the CLASS Program (Community Living Assistance Services and Support), a component of the PPAHCA, would reduce the national deficit.

Congress then engaged in wishful, even magical thinking. It assumed that millions of healthy younger Americans would sign up for CLASS and pay in lots of their hard-earned money for many years without getting anything for it. Why should they? Would you?

These non-existent CLASS premiums were predicted to produce $80 billion over ten years. The projected income was then accounted as if it were real money in the bank.  According to Congress, that “revenue” (semantic perversion again) was going to provide 56% of the deficit reduction promised from PPAHCA.

Robert Bixby of the Concord Coalition quite rightly (and kindly) labeled such accounting “phantom savings.” He called the program a “budget zombie.” Personally, I might call it semantic perversion, but a more accurate term is fraud: “wrongful or criminal deception intended to result in financial gain.”

How should we respond when the U.S. Congress utilizes the same ethics as Enron and Bernie Madoff? What should we say when our Congressional Representatives take lessons from Carlo Pietro Giovanni Guglielmo Tebaldo Ponzi, after whom the pyramid or “Ponzi” embezzlement scheme was named?

Then there is Congressional proper accounting procedure. Solyndra, a solar-panel manufacturer, was so credit-shaky that both the private investment community and  Congress before 2009 rejected their requests for financing.

With the Obama ascendancy in 2009, “proper accounting procedure” became simply a matter of color: “green” (eco-friendly) was – by definition – good practice. No further study, diligent or otherwise, was required. The Obama administration with a Democrat-controlled Congress quickly granted Solyndra $535 million in loan guarantees.

Less than a year later, the company filed for Chapter 7 (go out of business), not even Chapter 11 (reorganization). They took a half a billion of our tax dollars with them. This failure could have been (and was) predicted.

Proper accounting procedure as well as due diligence are two more victims of Washington’s semantic perversion.

Imagine if we could get people in the Beltway to use words only in the ways the rest of us use them. Imagine if they used proper business and financial planning, instead of substituting political correctness and flights of magical thinking.

If Congress stopped perverting semantics, over spending would cease to be a problem. They might even restore our faith in the word “Representative,” which has long been a victim of semantic perversion.

Entitlement means, “having a right to something.” You do not need to qualify for an entitlement or pay for one either. People tend to lump together the major entitlements – Social Security, Medicare, and Medicaid – believing all entitlements are essentially the same.

Entitlements in the U.S. are quite different from each other.

The Social Security Act (SSA) of 1935 “established a system of old-age benefits for workers; benefits for victims of industrial accidents; unemployment insurance; aid for dependent mothers and children; the blind; and the physically handicapped.” Subsequently, in its constant, apparently inexorable expansion, the federal bureaucracy created separate agencies for each separate part of the SSA. You know them as Workmen’s Compensation; Unemployment Insurance Agency; Aid to Families and Dependent Children; Medicaid; and CHIP along with other spinoff agencies.

Today’s Social Security Agency deals almost exclusively with old age benefits. The federal government empowered itself to take out a certain amount from the paycheck of every working American (legally here or not). At retirement, those who are legal citizens then receive a monthly stipend that corresponded to how much they put in over the years plus growth.

However, there was no waiting period before payouts started. So, the Fund started paying out money to people who had never put any money in. Those funds had to come from somewhere. They came from the people who were still working. So, Congress started a Ponzi scheme before the word became a household phrase.

Additionally, your retirement funds were supposed to be kept separate from everyone else’s, in a fund with your name on it. This was called the lockbox concept.

However, Congress passed a law allowing it (Congress) to take all the hard cash that people paid in, open the lockbox, and dump its contents into the General Fund. They then substituted IOUs accounting them as though they were the same as cash.

Any accountant not employed by the federal government would shudder at such behavior. Everyone knows that cash is a hard asset, and an IOU is…an act of faith.

Washington lawmakers are magical thinkers. Because they think of something, it must be so. Because they think an IOU is a hard asset, it must BE a hard asset.

Medicare was signed into law in 1965. It was advertised to be the same as Social Security but was also a Ponzi scheme, but even less sustainable than Social Security. The federal government took out a certain fixed amount from the paycheck of all working Americans like Social security. But Medicare payouts – for old age health care services – are unlimited, in stark contrast to the fixed payouts to Social Security.

Estimates vary but best guesstimates suggest that the average person who works for 40 years pays $115,000 in to Medicare, and after retirement will take out at least $375,000 in medical expenses.

Anyone who has ever balanced a checkbook knows you cannot spend more than you have…unless of course you are the federal government.

Further, within the first three months of Medicare’s passage, 12 million Americans signed up for benefits. So like Social Security, Medicare started paying out to people who had never put anything in.

The federal government did not even bother with the lockbox concept for Medicare. They took the hard cash and comingled it with the other monies in the General Fund replacing it with IOUs. Medicare is scheduled to be bankrupt by 2017.

Medicaid is a true entitlement in every sense of the word. As long as you meet one of the criteria such as low income, certain illnesses, are under age, etc – you qualify. You pay nothing and receive insurance coverage for health care.

Now comes the newest entitlement – the Patient Protection and Affordable Health Care Act of 2010 (PPAHCA). Per its name, PPAHCA promises three entitlements: 1) protection and high quality; 2) access to health care; and 3) care that is affordable.

PPAHCA gives new meaning to the phrase “disingenuous bureaucratic title-in-reverse,” a phrase I just made up. You know what disingenuous means: lying. Title-in-reverse is like George Orwell’s newspeak in his book 1984, which was apocryphal when written in 1948. In the book, “newspeak” phrases meant the opposite of what they usually mean. Newspeak firemen started fires rather than putting them out.

PPAHCA does not protect patients: it increases medical errors and constrains learning. PPAHCA spends a trillion or more dollars we don’t have. No sane person would call that “affordable.” PPAHCA provides no care at all. Indeed, it reduces care.

As an entitlement for health care, PPAHCA is a cruel joke. It cuts money that should go to care providers and gives it to the bureaucracy: it raises cost-shifting to a whole new level. PPAHCA creates six whole new federal agencies, hundreds of new organizational charts with thousands of new regulators and overseers, but not one new nurse, doctor or therapist. Meanwhile, the new Medicare reimbursement schedule of payments makes it financial suicide for a doctor to care for Medicare patients.

The four big U.S. entitlements are all different. But in one way, they are identical. They promise that which they cannot deliver.