CHAPTER 2
A FEW WAYS OF REDUCING COSTS SIGNIFICANTLY
“Economy is a savings - bank, into which men drop pennies, and get dollars in return.” – J. Billings
“The art of medicine consists in amusing the patient while nature cures the disease.” - Voltaire
§ 2.1.0 PLACEBO EFFECTS AND FAITH
§ 2.1.1 The Placebo effect is found throughout medicine. Essentially, a percentage, between 10 - 40%, of people will recover from ailments if provided an inert treatment, such as a pill made entirely of sugar.
§ 2.1.2 The old medicine men and witch doctors knew that faith alone could heal some ailments suffered by some people, some of the time.
§ 2.1.3 While not ethical nor proposed, imagine the savings by providing “sugar pills” for non-life-threatening ailments for which the available medication is very expensive. If it were to be efficacious in the most conservative 10%, medical costs could be reduced $30 B a year.
§ 2.1.4 This fact is one of the reasons why I so strongly recommend the integration of behavioral health with primary care medicine. Faith in healing seems to be enough in a percentage of cases and a contributing factor in many cases. In almost all cases in which the patient presents with previous faith, that faith improves the QOL while ill.
§ 2.2.0 REDUCE FELT NEED BY PROVIDERS TO PRACTICE DEFENSIVE MEDICINE
§ 2.2.1 GOLDEN FLEECE AWARD: Most (93%) physicians admit to practicing defensive medicine (a doctor places orders not medically necessary, so, if sued, a defense attorney can argue all efforts were made). While 100,000 people die each year from medical errors, only 5% of doctors are willing to say that “medical errors” is a problem. Either doctors prevaricate to avoid lawsuits, they are unaware of any problem with medical errors, or they believe that medical errors do not affect outcomes.
§ 2.2.2 When Medicare provider liability was curtailed, 9% of health care spending was eliminated, of course, the old thinking hadn’t changed nor was total tort law reform, so only partial confidence in the experiment was achieved. Still 9% of $2,500 B is $225 B.
§ 2.2.3 The Public Health Service (PHS), the CDC-P, and Federal Health Clinics (FHCs) must provide mandatory education, confidential discussion facilitation, and surveys to identify how to reduce defensive medicine and medical errors. Costs of defensive medicine are more than malpractice.
STUDY DEFENSIVE MED CO$T %
#1 $10 B / YEAR 00.40%
#2 $225 B / YEAR 09.00%
#3 $250 B / YEAR 10.00%
#4 $300 B / YEAR 12.00%
§ 2.2.4 I estimate practicing defensive medicine costs about 14% or $350 B a year. I have a goal of reducing defensive medicine by $225 B (9%) a year (we can’t reduce it entirely – when a litigious patient insists on a procedure that’s not totally unreasonable, it is often performed). Defensive medicine can only be reduced by combining each one of 6 things:
* Tort Law Reform *
* Confidential Learning from Errors *
* Vigorous but Fair Enforcement *
* Efforts to Acknowledge & Reduce Medical Errors *
* Mens Rea Risk Aversive Practice Shift *
* Jury Dynamics *
§ 2.3.0 TORT LAW REFORM
“Lawsuit: A machine which you go into as a pig and come out of as a sausage.” - Ambrose Bierce
§ 2.3.1 1% of attorneys collect 20% of legal fees.
§ 2.3.2 Tort law allows one who sustained an injury from another to sue in court and be awarded compensation for damages, pain and suffering, and punitive damages. Special health care courts ought to be designed that specifically address such cases. These special courts would allow greater efficiency in addressing health care concerns. The added cost of these courts might approach $1 B a year.
§ 2.3.2 Lawyers, depending upon custom and state regulation, charge 25% of a settlement when awarded out of court or 40% of an award when the case goes to trial. Plus costs!
§ 2.3.3 Previous attempts at tort law reform still resulted in provider’s liability in other states and federal courts, they were not combined with efforts to mold a new mens rea, reduce medical errors, reduce the practice of defensive medicine; nor did they address jury dynamics. I suggest that under the 14th Amendment, the US Congress can mandate reform to states’ tort laws.
§ 2.3.4 The ABA must improve monitoring professional behaviors in malpractice cases. Most Americans perceive lawyers pursue medical malpractice suits for money rather than justice.
§ 2.3.5 Fierce competition between too many struggling attorneys results in more suits. The US has more attorneys per capita and is expected to grow 11% by 2016. The average revenue for private practice attorneys is $300,000; the average salary of lawyers working for someone is less than $100,000.
§ 2.3.6 THE CRUX OF THE PROBLEM - Tort law reform could be seen as threatening attorneys’ livelihood and, frankly, justice. Physicians and conservatives align in seeing tort law reform as necessary for protection from costly lawsuits. This clash of special interests has stalled effective health care reform for 50 years.
“Good lawyers know the law; great lawyers know the judge.” - Author Unknown
§ 2.3.6.1 - Judges ought to provide actual costs, histories jurisdictionally and nationally as guidance in making awards to juries that have found in favor of the plaintiff. § 2.3.6.2 - Judges should authorize cost changes from insurance the defendant buys at the time of the award. This ought to include early death benefits.
§ 2.3.6.3 - The actuarial approach (NH = $100 K /yr, so, 5% of $2 M provides $100 K in perpetuity) versus the “irrational” approach ($100 K x 78 years equals $7.8 M) must be used in awarding damages. This would reduce provider malpractice. OB-GYN services would be more available, especially in underserved regions.
§ 2.3.6.4 - Medical malpractice plaintiffs often have pain and suffering. P&S ought to be continued. Providing information on normative patterns of awards ought to be sufficient for curtailing unusual awards.
§ 2.3.6.6 - When a patient dies, actuarially-based damages placed in escrow ought to be returned to insurance companies, saving it and providers money. Payments ought to be paid immediately; if appealed, it should be placed in escrow, accumulating interest.
§ 2.3.6.7 - Punitive damages should be placed in a COMMUNITY CHEST providing funds, in perpetuity, to improve the community. The logic of concluding that the defendant merits a punitive damages award escapes me. The entire community suffers from a single injustice and community chests would benefit the entire population.
§ 2.3.6.8 - Lawyers’ fees ought to be awarded and approved by juries and judges, based on quality of litigation, within a legislated range. They ought not necessarily be based upon the awards to the defendant.
§ 2.3.6.9 - Attorney’s fees must not attach to punitive damage awards above a modest amount (say, $25,000).
§ 2.3.6.10 - Legal, court, and interest costs of the opposite side ought to be paid by losing side.
§ 2.3.6.11 - Companies that stall hoping to bankrupt accusers ought to pay greater court costs.
§ 2.3.6.12 -Class action suits challenge potential injustices upon classes of people by another (e.g., a drug company might produce a medicine that prevents one disease but results in headaches in 2%. A crafty attorney advertises to capture claimants and files suit. The jury makes an award for each “victim” and the attorney skims 40%, plus costs). Reform of class action suits is needed so that attorney fees are within reason.
§ 2.3.6.13 - The short-term cost of implementing tort law reform might approach $10 B over the next 10 years (about $1 B per year. The savings, mostly in the form of reduced litigation and malpractice awards, would be about $2.5 B a year.
§ 2.3.7 These modifications in tort law would result in -
§ 2.3.7.1 - Fewer Lawsuits would reduce court demands. The use of Electronic Medical Records (EMR) would increase provider accountability, confidence in records presented to court, and might increase lawsuits in the short term.
§ 2.3.7.2 - Saved Money from Malpractice Awards will total $2.5 B a year but will cost $1 B a year for the next 10 years.
§ 2.3.7.3 - Reduced Practice of Defensive Medicine will save an estimated $225 B per year.
§ 2.3.7.4 - Increased “Community Chest” Funds – I estimate that about $20 B a year will be awarded to “community chests” in punitive damages. I suggest the principal remain untouched but interest earnings become available for civic projects.
§ 2.3.7.5 - Congress would have to act against the wishes of the ABA and Trial Lawyers’ Association, very powerful lobbies in a Democratically led Congress.
§ 2.4.0 REDUCING MEDICAL ERRORS
§ 2.4.1 GOLDEN FLEECE AWARD: Medical errors kill 10 times more people than guns. I’ve read reports that between 12,000 and 250,000 Americans die each year from medical errors (depending on the definition of medical errors and biases of the authors). Conservatively, 100,000 people die and another 2.1 M are injured due to medical errors. 95% of doctors don’t think medical errors are a problem. Costs of $220 B a year are incurred from medical errors. It may be the fifth leading cause of death in the US! I have a goal of reducing the costs of medical errors by $165 B a year over the next 10 years.
“The person I like most is the one who points out my defects.” - Umar (radi Allahu anhu)
§ 2.4.2 CRUX OF THE PROBLEM - If my dad’s doctor flippantly doesn’t give him the right diagnosis / treatment, and dad dies, I don’t want that doctor to walk away with impunity. However, by my “forcing” justice, that doctor will be more likely to hide / ignore / deny the error and will be less likely to learn from that error, nor will the doctors next to him learn from that error. By hiding, rather than broadcasting mistakes, errors are likely to continue.
§ 2.4.2.1 - Critical Incident Investigations (CIIs) ought to be carried out for all medical errors new or demanding attention. These must be confidential and privileged, if not criminal cases. They ought to be conducted by medical investigators whose mission is to reveal truth and recommend changes for reducing the probability of re-occurrence of that error in the future.
§ 2.4.2.2 - Confidential and privileged facilitated discussions at FHCs ought to be conducted.
§ 2.4.2.3 - Some situations call for punishment. I defer to ethicists, attorneys, courts, and providers, in determining when punishment is merited and what evidence ought to then be made available for investigations by professional organizations, licensing boards, civil attorneys, or prosecutors. Since I elsewhere advocate confidentiality of discussions of medical errors at FHCs, perhaps documents of those discussions and subpoenas of attendees might not be available.
§ 2.4.3 If my dad died from a medical error, I’d be angry. If I found out that the hospital conducted a CII, I’d see that the hospital took my dad’s life seriously and it was truly trying to learn from that error. I would be much less likely to consider filing suit.
§ 2.4.4 I believe that all medical errors ought to be anonymously posted on the internet. Perhaps the PHS could operate a web site into which every health care provider in the US could access. They could review CII findings, errors, join discussions, and post observations or errors. Discussions would remain confidential and privileged.
§ 2.4.5 While these discussions and data are confidential and privileged, anonymous compiled data ought to compare hospitals / providers’ efficacy and these data ought to be available on the internet. Trust me, if a doctor has rankings averaging 2 stars out of 10 by 1,500 patients, I’ll drive to the next town. These rankings ought to follow a provider, accumulating across states and years.
§ 2.4.6 Improved regulation by licensing boards and professional organizations may reduce errors.
§ 2.4.7 An adequate number of providers will decrease “need” to overlook repeated errors of less competent providers. Further, more providers means less stress and less likelihood of the commission of errors.
§ 2.4.8 A thorough review of the equality of foreign and US health sciences education ought to be made, across fields such as radiology, orthopedics, nursing, pharmacy, and psychology.
§ 2.4.9 Cost sharing of malpractice insurance incentivizes quicker learning from medical errors. Say, a provider shares 5% of the cost of awards and settlements. A system through which providers found to deviate from best practices on multiple occasions would be assessed progressively increasing proportions.
§ 2.4.10 Electronic Medical Records reduces errors.
§ 2.4.10.1 - Pharmacy IT has reduced medication errors in hospitals using this system by 86%.
§ 2.4.10.2 - All patient records, “recommended” tests, medications and dosages (especially for pediatric, elderly, those with liver damage, metabolic changes, etc.), and procedures developed from statistical decision-making programs must be automatically presented, in essence, discussing options with the physician.
§ 2.4.10.3 - Each doctor’s order must be screened by a program that analyzes for contra-indications, interactions, allergies, or inappropriateness based on patient historical factors or recent testing or observations, providing stop alerts that can be consciously over-written.
§ 2.4.10.4 - Verbal orders must be immediately followed-up by the prescriber with electronic record.
§ 2.4.10.5 - Reminder systems would be automatically presented so that nursing personnel are warned in advance of upcoming procedures. A picture of medication capsules with a copy of the prescription and dose would be
presented.
§ 2.4.10.6 - I project front-end development of a comprehensive, interactive system to cost $30 B. Beyond that, providers would likely incur costs of $10 B for updated computing systems.
§ 2.4.11 Real time monitoring by government agencies of EMRs might more accurately and efficiently identify errors, patterns, save lives, and reduce costs.
§ 2.4.12 A credible internet-based Journal of Null Results would increase access to information that could merit further investigation or which calls into question the findings from published studies that are erroneous.
§ 2.4.13 Federal limits ought to exist on provider hours. Medical interns can spend days at the hospital whereas truck drivers are required to sleep and rest so many hours a day. Nurses are more likely to commit errors on 12 hour shifts.
§ 2.4.14 Temporary providers make lots more errors, not knowing the system, staff, or patients.
§ 2.4.15 One study reported that 1 patient in 5 in the ICU was misdiagnosed! More studies ought to be conducted to reduce this error rate. Allowing providers immediate access to all EMR ought to reduce misdiagnosis rate significantly and ought to reduce the length of time which patients spend in the ICU being diagnosed.
§ 2.4.16 The costs of programs to reduce medical errors could approach $80 B over the next 20 years ($4 B a year). I estimate savings to be $165 B a year or $3.3 T over the next 20 years.
§ 2.5.0 USE EVIDENCE BASED PRACTICES
§ 2.5.1 All health care providers ought to be using evidence-based practices. Evidence-based practices are generally safer and provide greater efficacy. The degree to which they are adhered ought to be reviewed by state licensing boards. Neglect of evidence-based practices might be grounds for training or license suspension.
§ 2.5.2 The converse of evidene based practice is practice based on belief, superstition, kick-backs, pressures to generate income. The nice thing about living in the information age is that providers can have immediate access to best practice information AND regulators who assure our safety can immediately evaluate lists of procedures to assure safety and recommendations for compliance to best practices.
§ 2.5.3 I have not found research that soundly estimates savings. I would hypothesize that a 5% savings might be reasonable, approaching $125 B a year, by simply using evidence based practices.
§ 2.6.0 FEDERAL TAX LAW COMPLIANCE TOO COSTLY AND WASTEFUL!
§ 2.6.1 If we want one easy way of saving lots of money, simplify the tax code. Sure, an accountant could fill it out for me, for $900, but, at $30 K a year, that is a big compliance fee. The cost of compliance with tax law is about 20% of revenues generated. That’s inefficient!
§ 2.6.2 If tax laws were simplified, for all, it could save our national economy billions of dollars and move us toward prosperity instead of keeping us bogged down in the mire.
§ 2.6.3 At 20% of $2 T a year, Americans spend $400 B ($1,333 per person) on tax compliance. This is especially burdensome on the middle class.
§ 2.6.4 Imagine, we only spend $40 B a year on tax compliance and we invest the other $360 B a year on educating our children, developing new businesses, and finding a cure for Alzheimer’s Disease.
§ 2.6.5 GOLDEN FLEECE AWARD: The current federal tax code has evolved into a boondoogle that assures employment of millions who don’t produce anything but spinning wheels designed to save as much in tax dollars as their fee is for saving that tax bill.
§ 2.6.6 These brilliant people, instead of plugging in numbers and devising schemes to reduce others’ payments of taxes, could produce, generate a product, and help lead this nation to greater prosperity.
§ 2.6.7 I suggest that the tax code be simplified over the next 3 years, so that $300 B in tax compliance costswill be reduced. I propose that $75 B per year of this savings be utilized for health care. I propose that $75 B a year be utilized to pay for re-tooling these professionals into fields that are likely to lead to US economic prosperity for the next 5 years. $150 B can be distributed to taxpayers.
§ 2.7.0 FRAUD, WASTE & ABUSE
§ 2.7.1 When I read the Senate Finance Committee’s report that 3.6% or $10 B consisted of inappropriate payments, I first thought to myself, as a former provider, Medicare paid me only about 85% of my costs, so, inappropriate payments ought to have been 15%. Then I had one of those “ah-hah” moments. Ah-hah, they mean that providers are over-charging Medicare. As a taxpayer, when I see that a Miami chiropractor reaps millions off of Medicare beneficiaries with little to no service, I am appalled and I want prosecution. However, I also see the provider perspective. Allowing a psychotherapy session to flow an extra 5 minutes in order to earn the additional $15 dollars so that overhead can be met this month is not uncommon. When providers are insufficiently paid, I submit, they are more likely to be placed in a position in which inappropriate billing is needed to make ends meet. Of course, those providers don’t have the money to hire the most expensive lobbying firms.
§ 2.7.2 The Senate Finance Committee report requires reporting of gifts to physicians with several reasonable exceptions, such as drugs for use by patients and items worth less than $10. It seemed odd that “profits from publicly traded companies” was included there. Any receipt of profits by companies ought to be reported, certainly whenever the appreciation or dividend is greater than $10. Physicians and health care providers might place their health related investments in a blind trust and thus avoid the need for reporting. A provider with a vested interest in a small, publicly traded company in which she owns 20% may be at increased risk of ethical conflicts and referring patients for profit.
§ 2.8.0 MORE WANTS EVEN MORE
§ 2.8.1 The US has 3 times the per capita MRIs of other OECD nations. Linear thinking might lead you to speculate that our MRIs are used 1/3rd of that of OECD MRIs. You would be wrong. More MRIs leads to more use and reliance on MRIs. In Economics 101, we talked about supply and demand. Well, if the number of MRI machines available is too high, then the reimbursed price ought to be coming down. Instead, it goes up to pay for more MRI machines and procedures than are truly necessary. Use of purchasing co-operatives can save over $5 B per year.
CHAPTER 3
PREVENTION PROGRAMS
“Dig your well before you’re thursty.” – Hindu Proverb
§ 3.1.0 PREVENTION’S ROI
§ 3.1.1 Programs targeting enhanced wellness and reduced health care costs have been found to net returns of $1.75 to $6.00 per $1.00 invested. Thus, for most prevention programs, investments are well worthwhile.
§ 3.2.0 PREVENTION INFORMATION i
“It is a wise mans part, rather to avoid sickness, than to wishe for medicines.” - (Sir / Saint) Thomas Moore
§ 3.2.1 Federal Health Centers (FHC), totaling 2,500, ought to provide coordinated prevention, outreach programs, and basic treatment, especially in rural communities and inner-cities. These FHCs will cost about $15 B a year to operate and will conservatively save $15 B a year.
§ 3.2.2 Providers must invest a moment with each patient near the end of the visit, assuring compliance ability, assessing comprehension of diagnosis, treatment, and expected behaviors. If the patient does not demonstrate comprehension, that’s great, we might’ve saved a life! S/he requires retraining, family intervention, or home health care referral.
§ 3.2.3 Prevention video streams by CDC / NIH / PHS / FDA ought to be presented on relevant risk factors at the end of each PCP visit. These programs may cost $100 M a year and will conservatively save $300 M a year.
§ 3.2.4 Readable, informative, and attractive pamphlets ought to be available at all health providers. The availability of these pamphlets may cost $300 M a year and will conservatively save $300 M a year.
§ 3.3.0 INFORMATION WHEN TRAVELING
“Every human being is the author of his own health or disease.” - Sivananda
§ 3.3.1 When a passport is issued, an electronic referral ought to be made for the citizen to visit an FHC or review internet prevention and risk reduction information at a CDC / PHS / State Department web site. It ought to be completed and the person “checked-off” prior to leaving on their travel. Custom’s officials and TSA employees ought to have sets of questions, updated, by region, to screen for diseases among people visiting the US. This is estimated to cost about $100 M per year and will likely reduce health care expenses and societal costs at least $100 M per year.
§ 3.4.0 SAFETY, CPR, FIRST AID, LIFE SAVING, & EQUIPMENT
“Prevention is better than cure.” – Anonymous
§ 3.4.1 All children (as well as programs being open to parents) ought to complete a mini-course on safety each year (trauma is one of the 5 most costly conditions and one of the most common causes of injury and death among children). We must prevent, wherever possible, and train for primary intervention. Fire and police safety programs must be provided periodically. A fire prevention and evacuation plan ought to be encouraged by teachers, providers, and first responders.
§ 3.4.2 All school students; staff and perhaps some residents of medical, government, military, educational, and corrections institutions; ought to complete CPR and First Aid, including use of external heart defibrillators (EHDs); without cost. Free Advanced First Aid and Life Saving ought to be offered.
§ 3.4.3 I estimate that the cost of life saving classes would be $2.4 B per year. If only 1% of traumatic events or heart attacks are met with knowledgeable hands, the 12,000 lives saved each year ought to exceed $24 B per year in value.
§ 3.4.4 Prevention Equipment is critical. First Aid kits, smoke detectors, carbon monoxide detectors, fire extinguishers, EHDs, batteries, car safety kits, a loud whistle for people walking at night time or in dangerous communities, even cell phones and Global Positioning Systems ought to be accessible to first responders, available in public places, and available in every American home. People at elevated risk of heart attack ought to have an EHD in their home / car. Home monitoring equipment might also be provided preferential treatment, especially for seniors, those with chronic medical conditions, or in neighborhoods in which there is a heightened per capita risk of crime. Children might have GPSs or cell phones with GPS ability to which parents and LEOs can access for the purpose of preventing crime. The purchase of this equipment might result in “advanced” tax rebates of $3.0 B a year and tax deductions of $12 B a year. Reductions in crime, trauma related treatments, loss of property, and costs of death would exceed $15 B a year.
§ 3.5.0 DENTAL DISEASE PREVENTION
§ 3.5.1 For each dollar invested in fluoridation, $38 is saved in subsequent dental services. Teaching how to floss and brush is worthwhile.
§ 3.5.2 With the costs of dental services about $100 B a year and revenues per dentist averaging $700,000, a well coordinated effort must be made at dental disease prevention. I proposed that FHCs and CDC coordinate dental disease prevention programs. I propose that these would cost $3 B a year. These prevention efforts ought to reduce the need for dental services by $3 B a year.
§ 3.6.0 HEALTH AND FITNESS CENTERS (HFCs)
“Those who think they have not time for bodily exercise will sooner or later have to find time for illness.”
- Edward Stanley
§ 3.6.1 Every day you swipe your medical card at an HFC, you get a credit (say $5) toward your Health Savings Account (HSA) from which a monthly fee is paid to the HFC. This would immediately reward HFC use. HFCs would have to meet a certain threshold in order to qualify for this program and a “reasonable range” would be determined (e.g., $2,500 a month in Beverly Hills would be excessive). In every community, health fitness centers ought to be available for children, adults, and the disabled / elderly.
§ 3.6.2 HFCsmprove mental and physical health, reduce health costs, and ought to reduce other societal costs (drugs, gangs, sick leave, lost productivity).
§ 3.6.3 Federal Health Clinics in underserved communities might provide HFCs, where other fitness options are not available for residents.
§ 3.6.4 If I take my family on Saturday morning, we would be credited $5 each, $20 total, to our accounts. The credit ought to be tied to length of visit (a one minute visit should not count – perhaps 45 minutes or more). Likewise, if I return Saturday afternoon and evening, I would only receive the credit once per day.
§ 3.6.5 I project that the cost of this program, essentially providing a credit of $5 per day per person who attends a HFC, would be approximately $150 B per year. That is a great cost. More than what President Obama suggests is the cost of providing health care for 47 M. It goes without saying that exercising at fitness centers will improve health, reduce disease, reduce health care costs. As the balance above HFC costs would go to individuals’ HSAs, the government would not need to contribute as much money to insurance for the poor to middle class, thus, saving some money to pay for this benefit.
§ 3.6.6 Many Americans already have access to fitness centers. Almost all children have access to physical education programs. Students, faculty, and staff have access to fitness centers. Many patients or residents of psychiatric facilities, training centers, SO facilities, military installations / bases, large or special government facilities have access to fitness centers.
§ 3.7.0 GUN SAFETY
§ 3.7.1 While childhood deaths from guns has declined (from 5,000 to 3,000 yearly), it’s still higher than other OECD nations. As a dad, this breaks my heart!!! I urge:
§ 3.7.2 Safety courses ought to be mandatory for all who purchase, own, or handle a firearm. These courses might be offered by the NRA or a similar rifle safety organization.
§ 3.7.3 Trigger locks ought to be mandatory when purchased. While the use of trigger locks on guns in storage saves lives, it also can interfere with a gun owners ability to protect him / herself if someone is breaking in.
§ 3.7.4 Standardized background checks, in all settings, using all federal, inter-pool, and intra-state criminal and mental health databases ought to be required. The government need not know what guns or ammunition a person purchases nor would it need to report to the gun shop specific feedback on an applicant beyond approved or declined. Those with a conviction for a felony, membership in a gang or organization that violates the Patriot Act or RICO Act, a violent offense, someone involuntarily committed for psychiatric treatment would not be permitted to purchase a firearm (say, for 10 years, once residing in the community, with no recidivistic events on file).
§ 3.7.5 Those with a recent diagnosis of a severe medical condition or a MI for which involuntary inpatient treatment was not ordered ought to undergo a safety interview to assure that the person will not be using the firearm for suicide or homicide.
§ 3.7.6 Restrictions:
§ 3.7.6.1 - Safe hunters must have access to guns.
§ 3.7.6.2 - Because of the constitution’s “well regulated militia” clause, I recognize that people ought to be allowed to own a firearm and, someday, we might need to rely on some people who have more lethal weapons.
§ 3.8.0 DRIVER’S SAFETY
§ 3.8.1 I am flabergast by the inaction of American society regarding automobile safety. Seat belts save lives and their not being used must be penalized. Each year, there are 6 M auto accidents that kill 45 K people (10 times the number killed in the Wars in Iraq and Afghanistan). These accidents injure 3 M people a year. These accidents cost $120 B a year.
§ 3.8.2.1 - Teens are easy to distract (radio, phones, i*pods, other passengers), often lack skills to drive in bad weather
or night time. Partial licenses might be extended 2 years.
§ 3.8.2.2 - Licensure requirements might include 200 hours of documented driving with adults.
§ 3.8.2.3 - Advanced safety / skill development courses consisting of 12 Saturday mornings and several evenings in which students and a teacher individually rehearse dangerous scenarios, building skills, will lessen accidents, save lives, and reduce costs. It must be required. I estimate that costs will be $1,000 per teen or about $5 B a year total. I estimate teens and parents will pay half of these costs, $500 per teen or about $2.5 B a year, with federal programs covering the balance. I estimate that savings will exceed $20 B a year and save tens of thousands of broken hearts.
§ 3.8.3.1 - Tractor trailer drivers often drive the same route for years, getting tired.
§ 3.8.3.2 - Some consume stimulants to mitigate fatigue.
§ 3.8.3.3 - Truck accidents are more deadly and costly.
§ 3.8.3.4 - The criminal justice system ought to impose severe penalties for drivers with past offenses.
§ 3.8.3.5 - DUI, possession, or DIP might preclude training, licensure, or forfeit license.
§ 3.8.3.6 - Companies that hire dangerous drivers must be subject to more severe penalties.
§ 3.8.3.7 - All potential employees or contractors must submit to a records investigation.
§ 3.8.3.8 - Full reimbursement of accident clean-up costs to states and locales is mandatory.
§ 3.8.3.9 – The costs of these programs may exceed $500 M per year and will save $20 B a year.
§ 3.8.3.10 - As the US population grows and we consume more products and many of these products are no longer local, they must be delivered to us. Americans used to use trains and, to some extent, still does when fiscally sound. An Elevated-Rail system would increase efficiency, reduce transportation costs, and reduce the risk of car – truck accidents on the interstates that very frequently lead to death.
“Health consists with Temperance alone.” - Alexander Pope
§ 3.8.4.1 - Nearly 1 M arrests each year are for DUI. DUI related offenses must be treated very harshly. I think that a first offense ought to include $10,000 in fines and 3 months in prison (in which they pay housing / board costs).
Vehicular homicide might result in charges of first degree murder, especially when the defendant had a previous DUI. The total costs approach $20 B, including $10 B for prisons, $1 B for courts, $2.5 B for NIH, and $6.5 B for law enforcement. The total revenues would equal $10 B in fines, $2.5 B NIH assessment, and $4.5 B housing fee, totaling $17 B a year. The net cost of a DUI program would be $3 B a year.
§ 3.8.5.1 - Involvement in an accident or multiple moving violations increases risk of further accidents. As such, people with a moving violation or accident ought to be monitored for further offenses. If another offense should occur, or if the first offense was serious, then the individual ought to obtain a “Probationary License”, complete a driver’s safety course, and pay increased licensing fees. The “defendant” would pay for all program costs averaging $1,500 each and totaling $4.5 B. This program would be likely to save $20 B a year.
§ 3.8.6.1 - Age, disease, and medicines may slow thinking and reactions, while increasing accidents, injuries, and death.
§ 3.8.6.2 - Driving after a stroke can be scary for the driver. Everyone who has experienced the freedom allowed by driving wants to hold onto it. Following a serious medical incident, people ought to attend safe driving classes, in order to assess their safety, help them to develop alternative, coping skills and acquire confidence. For those individuals who can not acquire new, safe skills, forfeiture of license will be mandatory.
§ 3.8.6.3 - Everyone after a higher risk age ought to take a driver’s license exam every three years to assure safety so that they are not at increased risk of an automobile accident. The individuals might be required to pay an assessment fee of $50. If they fail, they will either forfeit their license or complete a safe driving class. Such safe driving classes might be offered by not-for-profit groups such as AARP or AAA. I propose that the reduction in costs from accidents would exceed $12 B a year.
§ 3.9.0 TARGETED PREVENTION EFFORTS
“To cease smoking is the easiest thing I ever did. I ought to know because I've done it a thousand times.” - Mark Twain
Increase exercise Pay for weight loss program
Decrease over-eating Decrease unhealthy eating
Teach stress management Reduce smoking
Reduce depression Reduce anxiety
Reduce DUI Reduce drug use
Reduce gangs Get treatment early
Get pets Approve preventive measures
Annual Physical Exam Ask Questions of your Physician
Be Safe Comply with your Physician’s Orders
A quarterly stress management session or physical message might reduce re-occurrence of heart attacks.
Full payment for medical procedures such as Gastric Bypass Surgery (GBS), stress management, smoking cessation, substance / alcohol abuse counseling, weight loss programs, nutritional counseling, compliance enhancement techniques all ought to be expeditiously reviewed and, where proven efficacious, instituted immediately. Insurance companies make money by spending lots of money on health care. Spending money on prevention reduces insurance company’s future spending and future profit margins. So, why in the world ought they be expected to provide prevention programs? As I think about this, I also wonder, why would the federal government want to pay for prevention programs? For the most part, prevention programs result in earlier deaths that, in the long run, are less costly than “natural causes” and do not also incur Social Security payments.
§ 3.10.0 NATIONAL SCIENCE FOUNDATION (NSF)
§ 3.10.1 The maker of tomorrow’s scientists and engineers is the NSF. Great basic research is funded by the NSF. If America is to really firmly root its feet and establish itself as the global leader in the 21st century, we must re-commit ourselves to scientific pursuits.
§ 3.10.2 We must be examining basic physiological processes, pharmacological fundamentals, applications of genetic mapping to the development of vaccines. As tens of thousands of Americans return from Iraq and Afghanistan with severe wounds and amputations, collaborative research with the VAMC and military on the development of prosthetic devices driven by bio-computer technology is critical for their re-integration into society. While automobile accidents and toxin exposure secondary to cancer are leading causes of death in the US, I suggest that basic research in transportation safety, E-train systems, development of alternative energy sources, and development of clean coal technologies (with the EPA and the coal industry) ought to be priorities.
§ 3.10.3 Research programs must be coordinated between NSF, other federal, state, and international agencies.
§ 3.10.4 The US faces a significant shortage in the number of individuals with training in the sciences, mathematics, health care, engineering, and computer sciences. NSF must establish, coordinate, and fund programs to enhance interest in these fields and stimulate growth in relevant education programs.
§ 3.10.5.1 - The present system of NSF grants is inefficient for grant recipients. While 16.00% of the government’s budget covers the costs of ADMIN, 20% of grant recipients’ budgets are ALSO spent on ADMIN. I recommend that enhanced technologies and policy changes be implemented to reduce this figure to 7.50% by 7 years for each grant recipient. This 12.50% reduction in recipients’ ADMIN costs will increase the number of grants able to be funded by 14% without budgetary increase. Remember, our goal is to generate more scientific advancements, not make sure investigators dot their i’s and cross their t’s.
§ 3.10.5.2 - I suggest that the current spending of $1.1 B (16%) per year on ADMIN makes the NSF a less efficient organization. I recommend that spending on ADMIN increase over the next 7 years from $1.1 B to $3.4 B (while reducing the proportion from 16.00% to 7.50%). I suggest that the budget for the NSF be increased from $6.8 B to $45 B per year in the next 7 years. Some funds ought to be identified to aid US minority institutions, foreign health systems, insurance and health care providers, businesses, and universities.
§ 3.10.5.3 - GOLDEN FLEECE AWARD: Between the costly ADMIN operations and the costs of grant ADMIN, the NSF overspends on ADMIN.
§ 3.11.0 CENTERS FOR DISEASE CONTROL & PREVENTION (CDC)
§ 3.11.1 The leadership role of the CDC is critical today and will grow in future years.
§ 3.11.2 With faster transportation, global warming, new bio-threats, and greater biochemical terrorism, CDC must have a physical presence on all continents. The recent outbreak of the pneumonic plague in northwest China is an example of the need for coordinated and focused resources greater than the WHO alone can provide.
§ 3.11.3 Bioterrorism prevention, monitoring, and intervention programs must be expanded. Where the Anthrax scare of October 2001 was “surgical” in nature, it cost hundreds of Ms of dollars to clean up.
§ 3.11.4 Prevention programs might be operated through FHCs with CDC and NIH.
§ 3.11.5 New ITs ought to permit global prevention monitoring and education and intervention by CDC.
§ 3.11.6 The CDC ought to assume an increasing role in QA and centralized wellness programs.
§ 3.11.7 Health sciences prevention must use the business model of return on investment (ROI). For example, if a plague will likely result in 5 M US deaths, 25 M chronic illnesses, and $12 T in costs next year, an escalation in resources would be merited in proportion to the threat. The US ramped up to meet demands during WWII and I am confident that we could do so again, in the event of a bio-chemical threat. However, the structure must be present to allow us to face these challenges.
§ 3.11.8 Many special drugs and vaccines will be developed through these programs that, I would envision, would be beneficial to the pharmaceutical industry. It ought to go without saying, but, if the CDC increases the average life expectancy by 3 years, the additional 9 M people will be purchasing private health insurance, medicines, etc.
§ 3.11.9 I would envision that many drugs and vaccines will be purchased from pharmaceutical manufacturers and distributed to citizens from other nations.
§ 3.11.10 - The CDC must have a mission beyond simply controlling disease and preventing disease in the US. It’s mission, while focusing ultimately upon the health of Americans, must include international programs.
§ 3.11.11 - I envision that the CDC budget must increase from $9 to $45 B a year over the next 7 years. I also envision that with global expansion in its mission, that the CDC will obtain part of its funding from other nations and corporations and, perhaps, foreign citizens. As the first Iraq War resulted in foreign countries paying the US military much of the costs of its operations, I would envision that the US government would only be responsible for about $30 B of these costs.
§ 3.12.0 NATIONAL INSTITUTES OF HEALTH (NIH)
“Knowledge will forever govern ignorance; and a people who mean to be their own governors must arm themselves with the power which knowledge gives.” - James Madison
§ 3.12.1 NIH is the premier health research organization worldwide. It’s suffered insufficient funding in recent years. From 2000 to 2003, its share of research funding decreased from 36% to 28%.
§ 3.12.2 GOLDEN FLEECE AWARD: I suggest that NIH is inefficient and needs new management approaches. It must be revitalized to include new perspectives. Many “proven” old lines of basic research have been ineffectual, although titillating and scholarly-sounding. Economically desperate times require that most NIH research funds be “applied” or practical or clinical much more so than basic. NIH spends too great of a portion of its budget on ADMIN.
§ 3.12.3 Basic research ought to be funded by the National Science Foundation.
§ 3.12.4 Most basic researchers cannot effectively administer “applied” divisions.
§ 3.12.5 Grant recipients spend 20% of research budgets on ADMIN. If this were automatized and policies updated, ADMIN costs could be reduced to 7.5%, saving a projected $19 B a year (> $4 B under the current funding level).
§ 3.12.6 Health science research must be funded from the business ROI model. Given risk, our desired ROI ought to be 8% (more if a stock trader but less if a mom who doesn’t want her daughter to die). AD, set to increase 33%, could cost $250 B a year. At 8% ROI, an investment of $3 T over 20 years could be justified ($150 B a year). Wellness research is critical.
§ 3.12.7 A private – public – international collaborative ought to be formed, coordinating research on prevention and treatment in a cogent, planful manner, rather than the haphazard manner by which science currently progresses. A program will be established providing loans and grants for businesses to conduct research with total funding of $10 B annually in 7 years.
§ 3.12.8 NIH budgets must increase to $150 B a year over the next 7 years. Some funds ought to be identified to aid US minority institutions, foreign health systems, insurance and health care providers, businesses, and universities.
CHAPTER 4
THINGS THAT WON’T WORK
“It is by acts and not by ideas that people live.” - Anatole France
§ 4.1.0 PRIVATE INSURANCE STIPENDS
§ 4.1.1 Stipends could be given to companies to help them provide insurance to the uninsured.
§ 4.1.2 The problem is that many employers would stop providing health insurance, making employees obtain insurance through this plan.
§ 4.1.3 The shift in insurance coverage could cost the government more than $200 billion unless we could assure private companies provide fair coverage and dumping is prevented.
§ 4.2.0 PAYMENT FOR OUTCOME OVER SERVICE
§ 4.2.1 At first, I liked this. Payments for how good you are! If a heart surgeon only gets paid if he saves 95% of patients, he’ll do two things. He’ll perform “safer” and less invasive procedures that are less risky in the short term but he’ll increase the “denominator” by performing excessive surgeries upon people who might marginally benefit from such services.
§ 4.2.2 I like golf. The outcome is directly related to my skill. Except, during a hurricane, when my son stuck gum on the golf club head, when the ball is defective, when the t breaks, or when my colleague sneezes.
§ 4.2.3 If a cardiologist has made great effort and used best practices but the heart attack patient dies, ought he receive no payment? That would be wrong! The woman at McDonalds gets paid whether my French fries are hot or cold.
§ 4.2.4 Local surgeons perform routine surgeries with great results but the brilliant “cutting edge” surgeons at the distant University Hospital perform surgeries on the most difficult cases but have less than stellar results as the high risk patients they accept are more likely to die. Ought these brilliant specialists be punished for welcoming the most difficult cases?
§ 4.2.5 Outcome is often very idiosyncratic to the individual – “I feel better”, “I go to work four days instead of just one day a week”, “I didn’t commit suicide last week”, or “I still hear voices telling me to kill you but I’m ignoring them more often now.” How do you define success?
§ 4.3.0 COST BUNDLING
“It is no measure of health to be well adjusted to a profoundly sick society.” - Jiddu Krishnamurti
§ 4.3.1 Health care cost bundling is sort of like the bundling of mortgages that caused the current international financial mortgages fiasco that drove the world economy to the crevice’s edge.
§ 4.3.2 When will we learn that bundling groups to sell or pay does not motivate, lower cost, or increase honest profits. Bundling is non-sense and must stop!!!
§ 4.3.3 You’re fortunate if you get the inexpensive groups of patients. If you get high risk bundles, you file bankruptcy.
§ 4.3.4 Some medical conditions are related to environment. Higher altitude or descent from more equatorial regions might result in the expression of some immune disorders. People west of a chemical plant might have increased risk of cancer. People who hold certain sets of values might have increased risk of alcoholism, infidelity, divorce, etc. Individuals in rural communities are more likely to have certain disorders. Individuals in inner-cities are more likely to have certain disorders. Ought providers be punished or rewarded for these epidemiological variations? If an inner-city trauma surgeon has a success rate of 90% in performing surgery on gun shot victims on a daily basis, whereas the rural practitioner who performs surgery on this year’s gun shot victim because he had experience performing the same surgery 3 years ago, ought the rural practitioner be not paid if his second patient (50%) dies?
§ 4.3.5 Cost bundling makes doctors raise severity levels so patients with greater need can obtain needed treatment. Doctors personally benefit from the raise in severity level. And, insurance companies pay more, charge more, and can profit more.
§ 4.3.6 Cost bundling is not a viable cost-containment strategy but, in theory and on paper, it looks very appealing. It will increase costs, not lower them!
§ 4.3.7 I am gracious in my criticisms of physicians elsewhere, but, what moral imperative urges reformers to conclude that providers ought to share risks, given that the majority of patient outcomes is out of the hands of providers and in the hands of the individual patient?
§ 4.3.8 If we reduce defensive medicine, modify tort law, directly address the issue of medical errors, use evidence-based practices, and institute effective prevention programs, then cost sharing by providers will be unnecessary, .
§ 4.4.0 TAXING HEALTH CARE BENEFITS
§ 4.4.1 Taxing high-end health care plans is an option, but, our ultimate goal is to improve the health of all Americans. A tax on health care benefits would jeopardize this goal.
§ 4.4.2 If greater taxes on the wealthy are desired, then let’s do it upfront. Simplify the tax code and raise the tax rates on the very wealthiest Americans.
§ 4.5.0 HEALTH & CHILD CARE THRIFTS
§ 4.5.1 Thrift or savings programs are extremely costly, burdensome, less beneficial, and unjust.
§ 4.5.2 I buy my child cough syrup from the drug store at night, submit the bill for $3.29 to the benefits management company, and, one month later, it sends me a check from my own savings account for $3.29. Even at a 36% tax bracket, I’ve saved $1.20 in taxes and it “only” cost $20 in total operations to do it!
§ 4.5.3 Why should Congress discriminate, allowing some employees to use “pre-tax” monies but establish a system that denies the desire of other Americans to have equal access to these tax benefits? Is this contradictory to the due rights clause? Many companies can’t afford to offer these services to employees.
§ 4.5.4 These programs are inaccessible to the wealthy, the unemployed can’t access them, the middle classes find them inefficient.
§ 4.5.5 These costly programs ought to be replaced with direct federal support of child care and elder care, and health care programs.
§ 4.5.6 Child and elder care as well as health care must have a tax rebate / deduction, phased out at highest incomes which is available in advance on a monthly basis.
§ 4.5.7 GOLDEN FLEECE AWARD: Thrift programs cost more to operate than they save taxpayers. This inefficiency costs tens of Bs in wasteful ADMIN!
§ 4.6.0 GIVING PRIVATE INSURANCE COMPANIES ANOTHER CHANCE TO REDUCE COSTS AND IMPROVE QUALITY
§ 4.6.1 When I first heard Senator Baucus’ suggestion that we give private insurance companies another chance to reduce expenses, I liked the suggestion. But, as a slept on it a few nights, I thought – we live in a capitalistic society. The market should have brought profits and costs under control by now. Capitalistic incentives for companies to compete with one another and provide the best product at the lowest cost have not worked in the past 50 years. Why would they work now, suddenly?
“If an ass goes a-traveling, he'll not come home a horse.” - Akan Proverb
§ 4.6.2 No, I think that insurance companies have had plenty of opportunities to improve quality and reduce costs. They have chosen to build up the profits of their oligopolies and offer generous remuneration packages to their executives at the cost of shareholders, taxpayers, businesses, and employees of those other businesses.
§ 4.6.3 The phoenix program that I propose blends the private, not-for-profit, and public spheres. It covers all Americans. It provides opportunities for private insurance companies to compete with one another and the public sector by providing high quality low priced products for a market 300% larger. It includes mandatory coverage for all Americans in all 8 categories of health care.
CHAPTER 5
PROGRAMS FOR CHILDREN AND YOUTH
“Adults are always asking little kids what they want to be when the grow up because they're looking for ideas”
- Paula Poundstone
§ 5.1.0 BAD NEWS
§ 5.1.1.1 THE MOST COMMON CAUSES OF INFANT DEATHS IN THE US
Congenital Malformations Short Gestation / Low Birth Weight
Sudden Infant Death Syndrome Maternal Complications
Accidents Cord & Placenta Complications
Respiratory Distress Bacterial Sepsis
Neonatal Hemorrhage Circulatory System Diseases
§ 5.1.1.2 - The US ranks very poorly for infant mortality, low birth weight, and death in the first year of life. US infant mortality rates are worse than in Cuba!
§ 5.1.2 Most variance in childhood death rates is related to two factors – underfunding of maternity and children’s health and wellness as well as parental lifestyle (e.g., illicit drugs and alcohol misuse). One confound is that the US, Netherlands, and Japan, all register children of “unsustainably low” birth weights as live births whereas the rest of OECD nations don’t. This is relatively minor.
§ 5.1.3 The US is faces an epidemic of childhood obesity, mental health issues, and medication errors. I recommend several programs to improve health services.
§ 5.2.0 YOUTH MEDICAL EQUIPMENT AND SPECIALIZED TRAINING
§ 5.2.1 Non-profit hospitals, free clinics, physicians practicing in underserved regions who primarily serve the publicly insured, school health providers, laboratories, and health science education and training programs require specialized medical equipment (smaller or more sensitive) for use with infants, children, and youth. I estimate that the provision of this equipment will cost about $1.5 B a year for each of the next 5 years. I estimate that savings will result through improved health care and reduced child mortality save about $0.5 B a year for each of the next 5 years, thus creating a net cost of $1.0 B a year.
§ 5.2.2 More generalist medical personnel require better training in OB-GYN and pediatric issues, especially providers in rural communities and inner-cities. I estimate that this will cost about $100 M a year for each of the next 5 years. I estimate that savings will result through improved health care and reduced child mortality and save about $100 M a year for each of the next 10 years.
§ 5.2.3 More OB-GYNs, pediatricians, pediatric NPs, pediatric PAs, and specially trained nurses must locate in underserved regions [this will be discussed elsewhere]. I estimate that this will cost about $400 M a year for each of the next 5 to 10 years. I estimate that savings will result through improved health care and child mortality and save about $600 M a year for each of the next 10 to 15 years.
§ 5.3.0 PUBLIC SCHOOL PROGRAMS
“In general, my children refused to eat anything that hadn't danced on TV.” - Erma Bombeck
§ 5.3.1 US childhood obesity is higher than other OECD nations; one in six children is overweight, triple the 1980 rate; obese children have a 70% chance of becoming obese adults, posing health problems similar to people 20 years older and posing greater health costs than heart disease.
§ 5.3.2 We must: (1) We ought to encourage children to be healthier in selection of foods and beverages and exercise. The DOE / PHS / FHC might provide learning tools, videos, games, prizes, handouts, posters and teacher “manuals” to encourage children to be healthier in their selection of foods and beverages. As this is a value and not a simple fact to recite, information ought to be presented a short 3 minute bursts each week while children and youth attend school. I would envision this program may cost $0.30 B a year. Savings would be realized over the long term through reduced obesity rates and related disease and would save about $0.30 B a year over each of the next 20 years, for a cost / savings of $0 per year.
(2) We ought to provide healthier foods in schools. This would require eliminating access to vending machines and unhealthy snacks and replacing “marginally” nutritious foods with foods that might be more costly but fully nutritious. Buy local produce programs might be instituted. Each public school district ought to have (a) pediatric RD nutritionist to plan meals. Special meals ought to be available for children with special dietary needs. I would envision this program to cost $3.6 B a year and would save about $900 M a year, for a net cost of $2.7 B a year.
§ 5.3.3 I suggest that school districts operate their own health department that can employ licensed professionals and submit bills to third party payers. I recommend increasing staff in the fields of pediatric nursing; health information services, education, and prevention; pediatric dentists, pediatric dental hygienists, pediatric optometrists, pediatric behavioral health counselors, and school psychologists. I estimate that this will cost $33 B a year. I estimate that school districts and outside sources provide consultations and services currently that cost $16.5 B a year. Thus, schools would be spending an additional $16.5 B a year but reducing need elsewhere in the system, often unmet. The full costs would be billed to third party providers. The assessment of children for the purpose of determining need for special services due to medical conditions has previously been excluded from coverage by third party payers but it is essential that these services be covered routinely for all children, nation-wide. This unfunded mandate has cost school districts $3 B a year, has been especially difficult for poor school districts, and must be met. I propose that public school health infrastructure investments would cost about $1.5 B a year and would save $500 B a year.
§ 5.3.4 Provide sex, STD, AIDS, pregnancy prevention, and safety education (for each $1.00 invested in the Safer Choice Program, $2.65 ROI is realized – a much better investment than was Enron). I appreciate that some parents would prefer to discuss matters of sexuality themselves or, perhaps, not allow their children to ever hear of these issues. Societal costs versus respect for their wishes must be weighed. I propose that health education programs would cost $3.0 B a year and would save $4.5 B a year.
§ 5.3.5 I propose federal investments in school district infrastructure for health services and instruction in health sciences such as additional office space, dental chairs, counseling rooms, and video-teleconferencing equipment so that a nurse in a small elementary school can consult with a district-wide pediatrician in his central office or the high school. The federal government ought to fully fund science education, faculty, equipment and supplies, and related materials during this period of national crisis in which we have a severe shortage of scientists and engineers. We ought to offer summer science programs, develop kid-friendly web-sites, encourage youth to explore careers in the sciences, and develop science magnet schools. I propose that health and science education programs would cost about $12 B a year and would ultimately save, over the next 20 years, about $3 B a year. I propose that health and science programs would require infrastructure investments of $900 M a year and would save $300 M a year.
§ 5.3.6 We must expand health-related library purchases, subscriptions, and computers. I propose that this program will cost $3.0 B a year. This program will result in savings of $1.0 B a year.
§ 5.3.7 Only one in four high school students attends Physical Education (PE) each week! I propose a revitalized national program of physical fitness. Federal contributions to PE programs must increase and PE ought to be required of every student, K through 12, for at least 2 hrs weekly. I propose that hiring of additional staff and increased equipment purchases would cost $10.5 B a year. This program will result in savings of $5.3 B a year. I propose that PE programs would require infrastructure investments of $4.0 B a year for each of the next 15 years and would save $1.3 B a year.
§ 5.4.0 CHILDREN’S PROGRAMS
“When I see the Ten Most Wanted Lists ... I always have this thought: If we'd made them feel wanted earlier, they wouldn't be wanted now.” - Edie Cantor
“Diet cures more than the lancet.” - Hindustani Proverb
§ 5.4.1 Most habits (nutrition, exercise, social skills) practiced by adults were learned as children and, without a second thought, carried forward.
§ 5.4.2 Pre-school, after-school, and summer program fees are often prohibitive. Fees of $5,200 a year are standard and $10,000 a student a year is common. For minimum wage employees, the cost of care for 2 children is often greater than their wage. The cost of child care for average income couples is itself prohibitive. Many couples now factor the cost of child care into equations of whether or not it is viable for one to work.
§ 5.4.3 Thrift programs are pointless to the poor and unavailable to the wealthy. Thrift programs are costly, operationally, and must be stopped, as they often cost more to operate than they, in fact, save.
§ 5.4.4 Having quality child care allows more people to work, adding to the GDP, increases health care provider availability, and provides care for children while parents receive medical services.
§ 5.4.5 Monthly stipends ought to be directly paid to authorized child care providers, based on community costs, parental eligibility (1 child or 21 children), and income. I suggest that employers ought to be required to provide at least $10 a week for employees who require child care or elder care. Employers with sufficient staff ought to be required to operate a day care at their facility, allowing flexibility for parental involvement in child care. Employees would pay the balance.
§ 5.4.6 In the US, there are 57 million children under 15. Only 8 M receive organized child care. Utilization will likely double if funded, but, increased utilization ought to result in greater competition and economies of scale. I anticipate that most of the increase will be in before and after school programs and “summer” programs. I propose that federal contributions for Child Care programs would cost $48 B a year and would save $72 B a year. In addition, I propose that summer camps, especially camps that encourage learning of mathematics, anatomy, botany, chemistry, physics, engineering, nutrition, safety, health sciences, and physical education would cost $2.4 B a year and would save $3.6 B a year.
§ 5.4.7 Salaries of child care workers are less than $25,000 a year, often near the minimum wage. I care much more about my son getting quality and safe care than about getting crispy French fries! Salaries ought to increase by at least 25%.
§ 5.4.8 Prevention programs will be regularly conducted by FHC employees on fire safety, exercise and nutrition, disease and prevention, and safety.
§ 5.4.9 Child care must be offered for ill children, through FHCs. Modest fees will be assessed to parents and perhaps school districts. Federal funding for programs for sick children would cost $600 M a year and would save $900 M a year. I propose that infrastructure investments might also cost $600 M a year, with $200 M a year in savings.
§ 5.5.0 LABELING
“So often time it happens, we all live our life in chains, and we never even know we have the key.” - The Eagles
§ 5.5.1 Once labeled “disabled”, it often sticks, contributing to lower grades, higher drop-out rates, under-employment, adult disability, drug use, and crime. Assimilation of the label “disabled”, lost wages and taxes, increased service utilization can cost several million dollars for each child. If only 1% had the effects of labeling prevented or reversed, those 200,000 people would add to productivity and reduce costs approaching $15 B a year. Such labeling programs would provide structure, incentive, stimulation, educational and vocational opportunities for the 25% of people likely to benefit. I propose that the cost of this program would be $500 M a year and would save, over 20 years, an average of $15 B a year.
§ 5.6.0 SCHOOL ORGANIZATION
§ 5.6.1 Thomas Alva Edison is one of my heroes. He was born in 1847. His mom realized that Thomas was “special”. His teachers found him bothersome. Mom removed him from school and home-taught him. If Edison were alive today, he would likely carry a diagnosis of Attention Deficit Disorder.
§ 5.6.2 Genius that he was, he did not conform to the imposed structure of school. It’s hard for children to sit in a classroom for 7 hours with minimal recesses and PE. They are not built that way. We must provide recess for all younger children and PE for all children. With additions built in for recess, physical education, and sciences, the school day might be extended 45” a day. This would result in increased salaries for teachers and would decrease the after school day care programs.
§ 5.6.3 I think that education ought to be revised to specifically address the needs and strengths of each individual student. That, I suppose, is fodder for another document.
§ 5.7.0 CHILDHOOD SPORTS & ATHLETICS
§ 5.7.1 Wellness is essential from the beginning.
§ 5.7.2 Childhood sports and athletics programs should be marketed and normalized. Funding ought to be provided by the federal government for 5 years until communities invest in the programs. I propose that sports and athletics programs be divided into school and civic. School related programs may cost $3.0 B a year and save $3.0 B a year. Civic programs may cost $1.5 B a year and save $1.5 B a year. Education of medical and psychology personnel in sports medicine will cost $150 M a year and save $50 M a year.
§ 5.7.3 These programs result in improved self-esteem, reduced MI, improved health, reduced obesity, and reduced educational and behavioral problems.
§ 5.8.0 SCHOOL NUTRITION
§ 5.8.1 I argue that school lunch programs ought to contain a healthful balance of nutritional foods and beverages. Unhealthy foods and beverages must not be available to children in schools. Cooking classes ought to examine nutrition and every child ought to appreciate and be able to calculate nutrititional daily recommended allowances.
§ 5.9.0 COLLEGE SCIENCE PROGRAMS
§ 5.9.1 America’s youth obtain lower scores on mathematics and sciences and they are less likely to pursue mathematics, sciences, or engineering education or careers. The avoidance of these topics is causing youth to choose careers in fields less financially remunerative and males are increasingly less likely to attend college than females. The US economy stagnates as we produce more crunchers and fewer generators of new ideas and producers.
§ 5.9.2 Government must fund more scholarships, facilities, equipment, and hiring of additional university faculty in sciences, mathematics, nutrition, health sciences, biology, chemistry, physics, PE, and behavioral sciences. I propose that funding toward scholarships, equipment, and staffing will cost $16 B a year and will save $4 B a year over each of the next 20 years. I propose that infrastructure investments will cost $3.0 B a year and will save $1.0 B a year.
§ 5.9.3 Higher education provides a model for the current health care crisis. Higher education costs have risen faster than inflation in the last 40 years, as demand outstrips supply. Colleges have become increasingly competitive. Colleges charge much higher tuition, but, most colleges are offering greater financial aid.
§ 5.9.4 Colleges and universities are, in part, keeping their costs slightly lower by higher adjunct faculty. An adjunct might cost $4,000 per course whereas a professor might cost $20,000 per course.
§ 5.9.5 This would result in improved self-esteem, reduced MI, improved health, reduced obesity rates, reduced societal costs, increased knowledge base on diseases, and increased likelihood that these students will aspire to become future health care providers.
§ 5.10.0 COORDINATED PROGRAMS WITH OTHER FEDERAL AGENCIES
§ 5.10.1 - Some of the diseases found in infancy, childhood, and youth are due to environmental conditions (e.g., pollution, dangerous emissions, etc.). Medical clinics ought to work with the EPA in identifying health threats and needed services across agencies.
§ 5.10.2 - Again, if, indeed, global warming proves valid, then the National Oceanic and Atmospheric Administration (NOAA) and the CDC will assume an increasingly active role in monitoring changes and investigating the effects upon the population.
§ 5.10.3 - The FDA has its hands full, being responsible for many more services than it can presently attend to
conscientiously. That said, it would seem that changes in the production, preservation, and distribution of foods and beverages over the last 50 years might have a relationship with increasing violence, alarmingly elevated increasing violence among females, changes in hormone levels, earlier onset of puberty, as well as onset of certain illnesses and death. Further study on the effects of pesticides, preservatives, genetic alteration, and growth hormone ought to be conducted longitudinally.
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