Submitted: 27 July 2020 | Approved: 19 October 2020 | Published: 20 October 2020
How to cite this article: Waldman D. StatesCare–The Cure for “Patient” Healthcare. Clin J Nurs Care Pract. 2020; 4: 039-044.
Copyright: © 2020 Waldman D. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Fifty years of Washington’s fixes for healthcare have brought us to the brink: insurance is unaffordable and care is unavailable, certainly not in time. The way to make healthcare work for We the Patients (all Americans) is to take healthcare authority away from third-parties – government and insurance – and restore the direct doctor-patient connection with no bureaucrat in between. The cure for patient Healthcare is StatesCare combined with market-based medicine. Financial models confirm this approach will make care both affordable and accessible in a timely manner.
After fifty years of federal fixes-that-failed-or-backfired, U.S. healthcare has reached a tipping point. Both Americans and America are spending money they can’t afford. Despite spending twice what others are expending on healthcare, Americans can’t get the care they need and die while waiting [1,2].
Within five years the U.S. will be spending $5.5 trillion on healthcare . 20% of our GDP, which nearly equals the entire 2018 GDP of Japan, $5.2 trillion. The Medicare-for-All plan touted to solve all our healthcare problems is estimated to cost $30-40 trillion [4,5]. For perspective, the combined GDP of all nations on planet earth is $87 trillion.
Keep in mind that at least 34 percent of healthcare spending goes to federal BARRC: bureaucracy, administration, rules, regulation, and compliance [6,7], not to patient care. As the U.S. spent $3.6 trillion on healthcare in 2018, that means Washington diverted no less than 1,220,000,000,000 patient care dollars to pay itself.
According to actuaries for the Medicare Trust Fund, Medicare will be insolvent by 2026, at which time seniors will be unable to obtain hospital care because there will be no money .
In 2018, the average American family spent $28,166 , 39% of their total income, on healthcare, mostly for insurance premiums. Despite its title, the Affordable Care Act (ACA) more than doubled the cost of insurance premiums .
According to a Merritt Hawkins survey , the average maximum wait time in 2007 to see a primary doctor was 100 days: ten years later due to the Affordable Care Act, it was 176 days. Before Obamacare, the national acceptance rate by physicians of new Medicaid patients was 74%. Now, it is 55%.
Both our veterans  and Medicaid enrollees [2,12,13] are experiencing death-by-queueing: literally dying while waiting in line for care.
Americans are asking why they can’t find a doctor and can’t get care in time so they don’t die when they could be saved [14,15]. The answer is U.S. healthcare has cancer. Location of the primary malignancy is Washington, which has metastasized diffusely.
There is extensive evidence that proves the cancer is the federal take-over of healthcare. Following are three examples.
Example #1. Drug prices are soaring and Washington is talking about further regulation, i.e., price controls. Yet Washington regulations are the primary reason for high prices. The FDA protects monopolies,  restricts innovation , and its approval process adds $2.4 billion to the cost that patients must pay . Federal insurance regulations protect the pharmacy rebate structure that greatly increases the cost of drugs . If Washington truly wanted to lower the cost of pharmaceuticals, it must look to itself and deregulate.
Example #2. Spending on Medicaid is either the largest or second largest budget item in every state budget. According to Section 1801 of the original 1965 Medicaid law, programs are supposed to be “administered by the state” . Every management expert knows that lower level decisions, i.e., closer to the value adders, tend to be more efficient and effective than blanket mandates from headquarters (Washington). Yet federal mandates administer (control) all state programs. Washington decides where state money goes, not the state residents through their legislators.
Example #3. With federal healthcare comes federal bureaucracy and its insane complexity, such as the International Code of Diseases–10 code book. There are approximately 1400 ailments and injuries that befall humans. The code book to bill for care contains more than 68,000 codes, such as W55.21 (bitten by a cow), W61.33 (pecked by a chicken), V00.01 (pedestrian on foot injured in collision with a roller blader), and Y92.146 (injured at a swimming pool within a prison).
The cancer in healthcare is a bipartisan affair. Both Republicans and Democrats are guilty of poisoning patient Healthcare. To be fair, the Democrats’ Affordable Care Act spread the cancer. Medicare-for-All plan, H.R. 1384, would put healthcare and Americans in a coffin .
Expecting Washington to fix healthcare is waiting for cancer to cure cancer .
How Americans lost control
Prior to 1929, medical care was financed two ways. Patients paid doctors or hospitals directly usually with money, often with an extended payment plan, and occasionally on barter. Care was also funded by numerous charity organizations  such as Catholic Charities and Hebrew Home for the Aged. Medical insurance was strictly to pay for lost wages or a fixed sum after the patient had paid the bill.
As a result of the Great Depression, Americans could not afford survival necessities such as food, shelter, and medical care. Charities could not take up the slack and Washington stepped in. The Social Security Acts and Amendments of 1929 through 1935 began the federal funding and thus takeover (federalization) of healthcare. Over the years, Washington expanded its financial support of health care to “aged, blind, and disabled” (Medicaid, 1965), retirees (Medicare, 1965), children (Children’s Health Insurance Program, 1997), breast and cervical cancer victims (P.L. 106-354, 2000), and most recently to healthy individuals under the age of 26 years (Affordable Care Act, 2010).
Between Medicaid, Medicare, and Tricare, Washington pays for health insurance for more than 130 million. For the 180 million individuals with private insurance, the federal government makes medical and financial decisions indirectly through its regulatory apparatus. Prior to the CoViD pandemic, there were less than 20 million uninsured Americans who received care through the Emergency Medical Transport and Labor Act of 1986, thus also under federal regulation. Thus, Washington controls health care decision making for all Americans, excepting only those with direct-pay care arrangements.
Health insurance began a radical change in 1929 at Baylor University Hospital in Dallas, Texas, where they started offering pre-payment insurance rather than a fixed sum after medicals bills were paid . In exchange for 50 cents per month per enrollee, the hospital would provide, i.e., pay for, all necessary care including laboratory and operating room charges, anesthesia, and medical/surgical bills.
In this way, a cancer of federally controlled third-party payment took hold of the U.S. healthcare system and spread everywhere. Americans lost their right to choose, both for their spending as well as medical decision making. Healthcare is now an unstable economic system with a fixed amount of input and an unlimited demand for output of money, goods, and services. Both medical and financial decisions are made by government and insurance bureaucrats, not by Americans themselves.
The way to cure all forms of cancers is the same: cut it out. The scalpel might be stainless steel, chemicals, radiation, or biologics. When the malignancy is Washington, the scalpel is votes. The surgeons are we the People. The procedure for patient U.S. healthcare is StatesCare.
There are no less than eight reasons why StatesCare–withdrawing federal control from healthcare–is the right, curative approach.
Constitutionality of StatesCare
Excision of Washington from healthcare is consistent with the Constitution, which precludes federal authority in healthcare. The Tenth Amendment to the Constitution reads as follows. “The powers not delegated to the United States [federal government] by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people.” Healthcare was never “delegated” to the federal government. With five doctors as signatories to the Declaration of Independence and many more physicians as members of the Constitutional Convention, the founding fathers did not simply forget about healthcare. StatesCare is constitutional. Federal control is not .
Who practices medicine on you?
By law, only licensed care-givers such as doctors and nurses are legally allowed to provide medical, surgical and mental healthcare treatments to patients. Yet at present federal bureaucrats and insurance executives are dictating to care-givers what they can and cannot do for their patients. Pharmacy benefit managers are a prime example, as they restrict what medications are available for doctors to prescribe .
Legally, only physicians can practice medicine on patients, yet physicians do not have requisite authority. They often must practice in accordance with requirements of an insurance company, a pharmacy benefit manager, or federal guidelines. This produces inferior and sometimes avoidably erroneous patient care. The authority-responsibility imbalance is a source of extreme frustration among clinicians .
Practicing good medicine on patient healthcare
Optimal treatment of any patient, human or system, requires the removal of the root cause of illness. Patient Healthcare has a cancer. The primary is situated in Washington and it has metastasized diffusely. StatesCare excises the malignancy wherever it exists and is therefore optimal therapy for patient Healthcare. As written by management guru Russell Ackoff, “dissolving” or excising the root cause assures that the problem, whatever it is, can not recur .
Over more than fifty years, Washington has promised to fix healthcare history. Note what they have accomplished. Medicare will go broke shortly . Americans with government-provided insurance, such as Tricare and Medicaid, die waiting in line for desperately needed care [1,2,15].
EMTALA’s unfunded mandate is forcing rural hospitals to close . The ACA doubled cost of insurance and reduced access to care.  Medicare-for-All would bankrupt the nation [4,21].
Healthcare is like a football team whose head coach, Washington, who has lost every game for 55 years. It is time for a new coach called StatesCare.
One size does NOT fit all
Rhode Island and Montana have the same populations, one million residents each. Rhode Island has 5146 physicians within its 1212 square miles. There are three world famous medical centers less than one hour’s drive of Providence, R.I. Montana has 1100 doctors scattered over 145,000 square miles. From the capitol in Helena, Montana, the nearest major medical and trauma center is more than eight hours away in Salt Lake City, assuming the roads are passable. Despite these differences, Washington mandates a one-size-fits-all approach in both states.
It makes no sense to expect that what works for healthcare in Rhode Island will also work in Montana. Central (federal) control produces uniform policy, a one-size-fits-all approach that does not works. Washington’s track record amply proves this.
Excising Washington from healthcare would also remove its massive and costly bureaucracy. Evidence-based estimates of the cost of the federal bureaucracy indicate no less than 34 percent of healthcare expenditures go to BARRC . Since the U.S. spent $3.5 trillion on healthcare in 2018,  our own government took away from the American people $1,400,000,000,000 worth of patient care to pay itself.
With StatesCare, Americans can recoup most of that money and either leave it in taxpayers’ pockets or spend it on doctors and nurses instead of wasting healthcare dollars on bureaucrats.
The American public has little respect for members of Congress. Approval ratings have been below 30 percent for more than ten years and hit an all-time low of 10 percent in 2012 . The public understands that federal legislators are not responsive to Americans’ needs. By contrast, state legislators are (highly responsive) . They live alongside the people who voted them into office, and legislators’ neighbors have no qualms about calling them at home to voice concerns.
State legislators are much more likely to enact healthcare that the people want if StatesCare were allowed .
The over-arching American principle is freedom. By the Constitution and its Amendments, Americans are protected from control by a central authority and from the constraints of a structured class system. With that freedom comes the right to choose, the potential for individual success or failure, and the responsibility to accept the consequences of personal choices.
In 1776, Americans freed themselves from a tyrannical aristocracy. Today, by accepting government entitlements, we are drifting back toward a new tyranny, this time by the professional political class.
Being free means Americans can choose their care providers, can decide their own medical care, and are willing to accept the consequences, both medical and financial. Americans should be free to control their own spending without a third party, government or insurance, dictating where patients’ money goes and how much of taxpayer dollars the third parties pay themselves.
If Americans are free, they are responsible. If they accept federal entitlements, Americans transfer responsibility to Washington and give away their freedom. One can be free or entitled, not both . By rejecting Washington and by “not yielding to federal blandishments” , StatesCare can reassert Americans’ independence and freedom.
Healthcare system(s) with StatesCare
After gaining freedom from federal healthcare domination, what type of system should the U.S. adopt? There is a two-part answer. First, it is not necessary or even optimal for the U.S. to have only one system for 327 million people with a wide variety of healthcare issues spread out over 3.8 million square miles. As the Rhode-Island/Montana example demonstrates, different needs and diversity of resources dictate different systems.
Second, We the People in our states, singly or in groups of states, are the best people to decide what healthcare will serve us best. By the Constitution and Bill of Rights, We the People are the only ones who should decide.
If 39 million Californians want single payer , if 28 million Texans want market-based medicine , and if 6 million residents of Washington state want their version of universal healthcare;  by what authority does the District of Columbia deny 73 million Americans the right of self-determination?
When a resident of one state is visiting another state and needs care, reciprocal arrangements should be in place. This is a matter of negotiation that Americans would expect their states to accomplish. Furthermore, if a resident in one state strongly objects to the system chosen there, he or she is free to move elsewhere. People are already relocating because of state tax rates .
Providing health care is not inherently complex. In fact, it is simplicity itself, or should be. A patient selects a doctor and makes an implicit service contract. Doctor provides service. Patient pays for service. Period. It is the incursion of the third-party as payer and decision maker that disconnects patient (buyer) from doctor (seller). Such disconnection turns a simple contract into an insurance nightmare with an incomprehensible, ever-changing structure of rules and regulations for coding, billing, review, and compliance that allows bureaucrats to practice medicine. Instead of being protection against financial disaster, insurance has become the arbiter of healthcare decisions, both financial and medical.
To solve this problem, simply reconnect patient and doctor: cut out the third-party payer as decision maker and return insurance to its original purpose.
Whether the name is single payer, Obamacare, universal health care, Medicare-for-All, or National Health Service in Great Britain, these are all systems where government controls healthcare. Government first determines how much to pay itself and what remains is available for patient care. Government strictly rations the care with resultant avoidable deaths (byqueueing) [1,40,41]. To quote Winston Churchill, government healthcare results is the “equal sharing of its [socialism’s] miseries.”
If Americans want healthcare that works for them, if they want the freedom to make their own medical as well as financial decisions, they must reject Washington’s false promises in favor of personal choice and personal responsibility. If Americans want doctors who know them by first name, who have studied their medical history, who will see them tomorrow not in six months, and who will spend time talking with them, then we the Patients must control their own spending. That is called market-based medicine or direct-pay health care .
High deductible, catastrophic insurance? By all means. Insurance that makes medical and financial decisions for patients? Absolutely not! Patients should have large HSAs that they control with no time limit for use. Patients shop for providers and care, and pay from the HSA. Providers would compete for buyers’ (patients”) dollars. Just like buying a car, patients would require not only prices but also various outcome metrics in forms they can understand. That is sellers’ job. If they want to stay in business, i.e., to have customers, they will compete for patients’ dollars, not for contracts with insurance companies as they do now.
Responses to nay-sayers
Here are some opposing arguments and rebuttals.
To those who say StatesCare is unrealistic, impossible, can’t be done, the best response is: Do you want to create a self-fulfilling prophecy? History is replete with fulfilling impossible dreams. In 1960, President Kennedy told his advisers he wanted Americans to go to the moon. The experts all said, “Impossible! We don’t have the knowledge or technology!” On July 20, 1969, Neil Armstrong took, “One small step for man, one giant leap for mankind.”
StatesCare can only come into being if Americans believe they can do it and use their power.
Some might chant, Washington is too strong. StatesCare is impossible, a political non-starter. Proper response is a reading of the Constitution. We the People elect them to office. We have the power and delegate it to them. If we wish to take back our power and freedom, Americans need to commit to voting into office only those who will pass a StatesCare approach to healthcare.
Since at least 70 percent of Americans disapprove of congress , it is easy to imagine a groundswell to elect new people in congress who promise to pass StatesCare.
Medically fragile Americans
Opponents might point to the disabled, aged and blind and say, they will die for lack of care when StatesCare eliminates all federal mandates, including Medicaid.
States can choose to create medical safety nets for their medically vulnerable residents. The safety net could be a high-risk pool  or a state-supported HSA , or whatever structure will work best for their population. They know best their local needs and resources and can protect those who need medical support.
“If not me...?”
Another response to the StatesCare doubters is a paraphrase of Rabbi Hillel’s words from the book, “Ethics of the Fathers,” written shortly before the common era. President Kennedy also recited this aphorism. “If not me, who? If not now, when?”
Finally, care-givers have an important role in fixing our critically ill healthcare system. In addition to accepting responsibility for the individual patient before us, clinicians should recognize their responsibility to patients at large, to We the Patients. For their welfare as well as our own, care-givers at all levels need to begin educating, enlisting, and energizing patients to demand StatesCare.
Washington is the problem in healthcare and can never be the solution. Per the Constitution, Washington should not control healthcare, which is “reserved to the states respectively, or to the people.” Two actions by American voters will fix healthcare so that people can get the care they need when they need it at an affordable price.
The first step is called StatesCare, repealing all federal healthcare laws, regulations, and mandates. This returns authority where it belongs: in the hands of We the People (We the Patients) in their states. StatesCare also allows the public to recoup more than a trillion “healthcare” dollars a year wasted on bureaucracy.
The second step is choice of healthcare structure(s) by Americans, not by federal or state politicians. There need not be only one structure for the whole country. Residents in single states or groups of states can decide what approach will work best for them and inform their local politicians by referenda. Past experience shows that government-controlled healthcare fails to produce timely care and is overly expensive. The optimal structure for healthcare–offering timely, affordable care and restoring personal autonomy–is a market-based system with a safety net for medically vulnerable individuals.
- VA Office of Inspector General. 2015. Review of Alleged Mismanagement at the Health Eligibility Center. Report: September 2, 2015; 14-01792-510.
- Nicholas H. Hundreds on Medicaid Waiting List in Illinois Die While Waiting for Care. Illinois Policy. 2016.
- Thomas B. National Healthcare Expenditures Expected to Reach $5.5T by 2026. 2018. Healthpayerintelligence.com
- Charles B. The Costs of a National Single-Payer Healthcare System. Mercatus Center. 2020. https://www.mercatus.org/system/files/blahous-costs-medicare-mercatus-workingpaper-v1_1.pdf
- Peter S. Bernie Sanders Thinks Medicare for All Could Cost $40 Trillion. Reason.com. 2020. https://reason.com/2019/07/17/bernie-sanders-medicare-for-all-cost-40-trillionobamacare-single-payer/
- David H, Campbell T, Woolhandler S. Health Care Administrative Costs in the United States and Canada, 2017. Ann Int Med. 2020; 172: 134-142. PubMed: https://pubmed.ncbi.nlm.nih.gov/31905376/
- Waldman, Deane. 2015. The Cancer in the Healthcare System: How Washington Controls and Destroys Our Health Care. Corpus Christi, TX: Strategic Book Publishing and Rights Agency.
- Steven MR. Acosta A, Azar A II, Berryhill NA, Verma S. 2018 Annual Report of The Boards of Trustees of The Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. The Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
- Alia P. “$28k: The average price a family of 4 will spend on healthcare in 2018. Beckers Hospital Review. 2018.
- HHS REPORT: Average Health Insurance Premiums Doubled Since 2013. May 23, 2017. 2020. https://www.hhs.gov/about/news/2017/05/23/hhsreport-average-health-insurance-premiums-doubled-2013.html
- Merritt Hawkins Team. 2017. Physician Appointment Wait Times & Medicaid and Medicare Acceptance Rates. MerrittHawkins.com
- Waldman, Deane and Jennifer Minjarez. 2019. Extend gains from welfare reform to Texas Medicaid. Texas Public Policy Foundation.
- David MJ, Chavez A. A Preventable Tragedy.” “Skimping on Care.” “Texas pays billions for ‘sham’ networks.” “Gloss-over of the Horror.” “Parents vs. the Austin machine (Part 5 of 5).” June 3, 4, 5, 6, 7. 2018. Dallas Morning News.
- Laura O. Toothache Leads to Boy's Death. ABC News. 2017. https://abcnews.go.com/Health/Dental/story?id=2925584&page=1
- Mehgan G. Death from a Toothache: The Story of Deamonte Driver and Where We Stand Today in Ensuring Access to Dental Health Care for Children in the District. O’Neill Institute for National and Global Health Law. 2018.
- Deane W, Ginn V. Government Hypocrisy Over EpiPen: The Pot Calling the Kettle Black. Forbes.com. 2016. http://www.forbes.com/sites/realspin/2016/09/14/government-hypocrisy-over-epipenthe-pot-calling-the-kettle-black/#59138247468e
- Mary R. Death by Regulation. Kalamazoo, MI and San Francisco, CA: SunStar Press and Liberty International. 2018.
- Thomas S. A Tough Road: Cost to Develop One New Drug Is $2.6 Billion; Approval Rate for Drugs Entering Clinical Development is Less Than 12%. Policy & Medicine. 2019.
- Jake F. Industry Voices—Why it's time for PBM rebates to come to an end. Fierce Healthcare. 2019. https://www.fiercehealthcare.com/payer/industry-voices-why-it-s-time-for-pbmrebates-to-come-to-end
- Sec. 1801. [42 U.S.C. 13951] of Social Security Amendments, Medicaid Law. Prohibition against Any Federal Interference. 2019. https://www.ssa.gov/OP_Home/ssact/title18/1801.htm
- Deane W. Effect on Patient Care of H.R. 1384 “Medicare for All.” Texas Public Policy Foundation. 2019.
- Deane W. Curing the Cancer in U.S. Healthcare: StatesCare and MarketBased Medicine. Albuquerque, NM: ADM Books. 2019.
- Marvin O. The Tragedy of American Compassion. Washington, D.C.: Regenery Publishers. 1992.
- Dan M. Health insurance as we know it began in Texas 90 years ago. Now it must evolve. Houston Chronicle. 2020. https://www.houstonchronicle.com/opinion/outlook/article/Health-insurance-as-weknow-it-began-in-Texas-90-14927935.php
- Deane W. A doctor’s straight talk: America, your health care is not a federal responsibility. Fox News. 2017. http://www.foxnews.com/opinion/2017/01/04/doctor-s-straight-talk-america-yourhealth-care-is-not-federal-responsibility.html
- Deborah C. How PBM’s Control and Diminish Physician Prescribing Efforts. Board Vitals. 2020. 2018. https://www.boardvitals.com/blog/pbms-control-physician-prescribing/
- Deane W, Smith HL, Hood JN. Corporate Culture – The missing piece in the healthcare puzzle. Hospital Topics. 2003; 81: 5-14. PubMed: https://pubmed.ncbi.nlm.nih.gov/14513744/
- Russell A. Ackoff’s Best. New York, NY: Wiley & Sons. 1999.
- Allscripts. Why rural hospitals are closing. Becker’s Hospital Review. 2019. https://www.beckershospitalreview.com/populationhealth/why-rural-hospitals-are-closing.html
- Kimberly A. How Much Did Obamacare Cost? The Balance. 2017. https://www.thebalance.com/cost-of-obamacare-3306050
- Editorial Staff. How much did the US spend on health care last year? $3.5T, according to CMS.” Daily Briefing. 2018.
- Harry E. Congress’ approval rating hasn’t hit 30% in ten years. That is a record. CNN Politics. 2019. https://www.cnn.com/2019/06/01/politics/poll-of-the-week-congress-approvalrating/index.html
- National conference on State Legislatures. Representing constituencies in NCSL State Legislatures Magazine, July/August 1999: The Good Legislature.
- Deane W. Americans can be entitled or free — but not both. The Hill. 2019. http://thehill.com/opinion/healthcare/374435-americans-can-be-entitled-or-free-but-notboth
- National Federation of Independent Business et al. v. Sebelius, Secretary of Health and Human Services, et al., Supreme Court of the United States, 2012; 49: No. 11-393.
- Tullus, Paul. 2017. “Can California Go Single-Payer?” The American Prospect.
- Deane W. California wants single payer and Texas wants free market — say hello to ‘StatesCare. The Hill. 2017. http://thehill.com/blogs/punditsblog/healthcare/323424-california-wants-single-payer-and-texas-wants-free-market-say
- My Northwest Staff. “New bill looks to clear path for state universal health care.” Mynorthwest.com
- Editorial Staff. Americans Are Migrating in Droves to Low-Tax States. Investors’ Business Daily. 2018.
- Ezra K. In the UK’s health system, rationing isn’t a dirty word. Vox. 2020. https://www.vox.com/2020/1/28/21074386/health-care-rationingbritain-nhs-nice-medicare-for-all
- Deane W. Single Payer Won’t Save Us. Columbus, OH: Gatekeeper Press. 2016.
- Karen P. High -risk pools for uninsurable individuals. Kaiser Family Foundation. 2017.. https://www.kff.org/healthreform/issue-brief/high-risk-pools-for-uninsurable-individuals