Please consider Senator Rand Paul’s “Obamacare Replacement Act“.

Paul’s bill allows cross-state insurance. That’s a step in the right direction.

However, Paul misses many obvious improvements. I provide a list below. Any doctors or insurers care to chime in?

Mish Health Care Proposals

Published fees: Fees for routine services, medicine, and operations need to be published, not set by government mandate. Whether or not someone is insured, the fees should be the same.

Shopping Around: People should be encouraged to shop around for the lowest-cost provider. Insurance providers could allow specified amounts for specified services. The insured can then shop around for the best provider. Why should the insurance company care where the service is performed. Auto insurance companies typically don’t.

Foreign Services: Low-cost plans should be allowed to require foreign operations for hugely expensive operations for those Low-cost travel.

For example, Bloomberg reported Heart Surgery in India for $1,583 Costs $106,385 in U.S.  Demand treatment in the US? Fine. You should have to pay for it. Obviously, this provision does not apply to emergency services like an accident, or to a heart attack.

Insurers should cover travel expenses for the insured and spouse for stays longer than 10 days.

Drug Pricing: There should be a price schedule for drugs. Pharmaceutical companies should not be allowed to charge less to overseas buyers than US buyers. There can be volume discounts but they have to be across the board. Medicare and Medicaid should get the same volume discounts as everyone else.

Medicare/Medicaid: Medicare should be no different on foreign care or shopping around. Right now, those over 65 simply do not care much what things cost. Incentives are necessary to make sure they do. This includes forcing overseas treatment for those able to travel.


Right to Die: No one should be kept alive if they want to die. Nor should someone be artificially kept alive if they do not have insurance, or their spouse or designated appointee wants to pull the plug on someone’s behalf.

Right to Refuse Service: If someone is not insured, hospitals should have the right to refuse service.

Patent Restrictions: Patent laws need to be revised to prohibit making minor changes and renewing patents for extended periods again and again.

Eliminate State Restrictions: Allow any insurance company in any state sell insurance in whatever states they want.

Pooling: More pooling seems welcome. But I fail to understand one phrase in Paul’s proposal: “so long as the organization does not condition membership on any health status-related factor.”

Is age a health status-related factor? If not, we are going to see pools based on age.

Also consider a pool of those enrolled in college. How many people would take a class if it saves them a bundle on insurance? Pooling may require more careful thought than was covered by Paul.

Mish Synopsis

My proposals provide significant cost savings opportunities forced on drug providers, allowed by hospitals, allowed by insurers, and encouraged by insureds.

I invite doctors, insurers, and others to chime in on my proposals. Hopefully, we can quickly come to a solid consensus on a majority of these ideas and get them into the hands of President Trump and Senator Paul.


The original post was revised to remove the word “standardized” when my intent was simply to require published fees. The government should not set prices. Competition should. I also added a provision to eliminate state borders.

I also added a provision to eliminate state borders.

Do Something!

President Trump and Rand Paul are nibbling at the edges. We need serious reforms.If you like my suggestions, please contact your representatives and ask for them.

Click here to Find Your Representative. You may also wish to try Contacting Congress.

If you have ideas, please let them be known.

Mike “Mish” Shedlock