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Let's lay out the parameters for a bill, a fairly-modest update to my two previous missives on this point here and here (note the dates) and which can be easily turned into formal legislative language:

  • All providers must post, in their offices and on a public web site without any requirement to sign in or otherwise identify oneself to access it, a full and complete price list which shall apply to every person.  This instantly allows customers to compare pricing between providers for services and products in the medical realm.

  • All customers must be billed for actual charges at the same price on a direct basis at the time the service or product is rendered to them.  This immediately and permanently decouples "insurance" from the provision of care.  The current system of an "explanation of benefits" that often features a "negotiated discount" of some 90% is nothing other than an extortion racket and is arguably felonious -- threatening to bankrupt someone if they don't buy your "insurance" through a threat to charge them ten times as much certainly appears to be a criminal enterprise and, given that more than one entity is involved, looks like it meets the definition of Racketeering.  Insurance coverage may well cover some, part or none of a given bill, and nothing prevents an insurer from telling you in advance of your visit how much they will pay (if anything) for a given procedure or drug.  Indeed you should demand that information from them and use it as part of choosing where to obtain treatment but the bill still has to be rendered to you, you have to be the one to file the claim and everyone must pay the same price to the same provider for the same kind and quantity of product or service.
  • For a bill to be valid and collectible it must be affirmatively consented to in writing, with a disclosure of the actual price to be charged from the above schedule for each item to be provided whether good or service, prior to the service being performed or the good furnished, subject only to the emergency exception below.  A bill that is increased, has items added to it after consent is obtained, which contains any open-ended promise to pay without an actual price listed for each service or good prior to customer consent or is issued with no consent at all (including having a customer sign a consent form while under the influence of drugs the facility gave them as occurs in virtually every instance today while you're being wheeled into the OR) is deemed fraudulent and void. This instantly stops "drive-by" doctor charges in hospitals as just one example.  It also prevents charging $20 for an aspirin; nobody would tolerate being billed by the square for toilet paper in a hotel!  Hospitals will of course squawk that they cannot operate like this as they "can't" figure out what is required until after-the-fact but that's false; nothing prevents them from advertising "Appendectomy: $2,000" and that being the soup-to-nuts price.  In fact that's exactly what the Surgery Center of Oklahoma does today so quite-clearly it both can and does work.  In addition this change will permanently and immediately put a stop to the ridiculous practice of defensive medicine (read below for the explanation.)  You would never accept a gas station that only displays the cost of your gasoline after you pumped it and varied that price based on who your car insurance was bought from or a grocery store that had no prices posted at all and only gave you a total after your groceries were taken out of the store and the transaction could not be refused.

  • No event caused by or a consequence of treatment can be billed to the customer.  This instantly aligns the interest of the customer in not having such an adverse complication (e.g. MRSA, etc) with the medical provider.  As it stands right now hospitals actually have an incentive for you to have a complication since they make more money if you do.  If you call me to fix your roof and I drop my ladder causing it to crash through your picture window I get to pay for the glass I broke through my ineptness.  The same must apply to medical providers.  For those who claim hospitals and similar can't adopt such a model I point to the OKC surgery center, which does exactly this -- and has a lower complication rate (gee, I wonder why when they have to eat it if they cause it....)

  • All true emergency patients, defined as those who are unable by medical circumstance to choose where their treatment is to take place and require immediate medical intervention to either stabilize their condition, prevent severe permanent impairment or death (e.g. transported by an ambulance, unconscious with no person with medical power of attorney at-hand, having a heart attack in the ER, etc) must receive the same price for the same service as a person who consents to said service.  For a bill to be valid for a true emergency documentation must be maintained and presented showing that the customer was unable, due to exigent circumstances at the time they presented to the provider, to provide consent prior to services being rendered.  Any medical provider who attempts to bill any service or product above that price to a person in exigent circumstances forfeits 100% of their invoice and is guilty of consumer fraud.  Note that this does not prohibit a hospital from having a published price list that charges more for services rendered through their Emergency department, those that are provided at 3:00 AM, etc. so long as those who walk in, are conscious and able to consent get the exact same price as someone who is unconscious and flat on a gurney.  If you demand that an A/C repairman or plumber come out now at 3:00 AM he most-certainly can charge you more than if you call and ask him to show up during normal business hours!

  • All medical records are the property of, and shall be delivered to, the customer at the time of service in human readable form (a PDF provided on common consumer computer media such as a "flash stick" shall comply with this requirement.)  Any coding or other symbols on said chart must include a key to same in English delivered at the same time.  No separate charge may be made for the provision of a contemporary record of a medical visit or treatment other than a reasonable charge for physical media if the customer does not have same with him or her.  The obvious way to do this is for the customer to bring a flash drive to which the human-readable chart is written.  If the customer doesn't have one the office can certainly maintain a small supply of $10 flash drives and charge the $10 to their bill.

  • All surgical providers of any sort must publish de-identified procedure counts and account for all complications and outcomes, updated no less often than monthly. Consumers must be able to shop not only on price, but also on outcomes.  Because outcome odds do vary with the seriousness of the presented case providers may classify severity as well provided it can be done in an objective way.  Complications must be broken down as to type (specifically identifying any that are not due to presentation but rather the facility via infection or error), severity of injury (including death) and additional time and/or drugs and procedures to resolve on a ratable scale commensurate with the original prognosis.

  • Auxiliary services (e.g. medical or dental Xrays, lab testing, etc) may not be required to be purchased at the point of use.  If you wish to buy your tests from the lab down the street (which also must post a price) that's up to you.  If you wish to have your bitewings taken at the imaging center across town, that's up to you.  The dentist or doctor cannot require that you buy those services from them; they must compete for them like everyone else.

  • All anti-trust and consumer protection laws shall be enforced against all medically-related firms and any claimed exemptions for health-related firms in relationship to same are hereby deemed void; for private actions all such violations proved up in court are entitled to treble damages plus a $50,000 statutory civil penalty per impacted person.  If the government won't bring these charges (and we know they won't since despite not one but two US Supreme Court cases here and here making clear anti-trust laws apply to medical providers of all stripes not one charge has been leveled against any of the medical firms) let's make it damn attractive for individual private suits by making the price of losing such a suit for a medical provider ruinously expensive (and lucrative for the attorneys bringing them!)

  • Any test or diagnostic that carries no exposure to drugs or radiation, nor is invasive beyond a blood draw, may be purchased without doctor order or prescription.  If you want an A1c or CBC you thus need nobody's permission to have one.  Same for an MRI.  For those tests and procedures in which exposure to drugs or radiation are involved, or are invasive (e.g. internal biopsies, etc) requiring some sort of chain of evidence of need due to that risk is reasonable.  But for most diagnostics this is demonstrably not true.  There is a clean argument to be made that for young, outwardly healthy adults a metabolic panel and CBC might actually be more useful in catching incipient serious disease than an annual physical which typically is nothing more than 5 minutes of observation and no checking of metabolic parameters beyond blood pressure and pulse rate!  The former can be had for $10 while the latter is often a $100+ charge.  Let the people and evidence show which is superior on a cost:benefit basis; after all it's my ass on the line from my decision not yours.

  • Wholesale drug pricing in the United States must be on a "most-favored nation" basis.  The impact of this would be to force a level price across all nations for drugs produced by any pharmaceutical company marketing both in the US and anywhere else in the world.  Violations, including attempts to "offshore" via subsidiaries to evade this requirement are deemed criminal and civil acts.  The civil penalty shall be 300% of the difference paid to the customer who got screwed, and another 300% for each instance of a prescription filled at an inflated price paid as a fine to the government.  This would drive drug prices down by at least half in the United States and for many drugs by 90% or more.  It would instantly and permanently end, for example, the practice of charging someone $100,000 for scorpion antivenom in Arizona when the same drug from the same company is $200 for the same quantity 40 miles to the south and across the Mexican border.  Since all prices must be posted at the retail consumer level for both goods and services controlling the drug pricing problem at a wholesale level is both simpler and sufficient since competition will already exist at the retail pharmacy level.

  • No government funded program or government billed invoice will be paid for medical treatment where a lifestyle change will provide a substantially equivalent or superior benefit that the customer refuses to implement.  The poster child for this is Type II diabetes, where cessation of eating carbohydrates and PUFA oils, with the exception of moderate amounts of whole green vegetables (such as broccoli) will immediately, in nearly all sufferers, return their blood sugar to near normal or normal levels.  The government currently spends about 25% of Medicare and Medicaid dollars on this one condition alone and virtually all of it is spent on people who can make this lifestyle change with that outcome but refuse.  If you're one of the few exceptions and it doesn't work in your case you have the burden of proof.  Nobody has the right to light their own house on fire on purpose and then claim FEMA benefits for same.  This one change alone will cut somewhere between $350 and $400 billion a year out of Federal Spending and, if implemented by private health plans as well, likely at least as much in the private sector.  That's more than three quarters of a trillion dollars a year that is literally flushed down the toilet due to people being pigheaded and refusing to do things that would not only save the money but also save their limbs, eyesight and ultimately their life.

  • Health insurance companies must sell true insurance to sell any health-related policy at all.  A true insurance policy is defined as one that (1) does not cover any condition you have received treatment for over the last 24 months (in other words, p != 1.0), (2) if an adverse event does occur your obligation to pay any further premium ends with regard to coverage for that event and all consequences thereof while the company is required to pay reasonable costs of treatment until and unless the condition has been resolved without limitation on the necessary amount or duration of said payments and (3) does cover, with a selection of deductibles available to the buyer, all accidental injuries and truly life-threatening emergency medical events.  Medical underwriting is permitted for such catastrophic policies but once undertaken is transferable to a new company without a new round of underwriting provided no interruption in coverage of more than 60 days occurs.  Such a policy may exclude intentional acts (e.g. acute drug overdose by other than non-consensual consumption), perhaps with an exclusionary period (such as that for suicide on life insurance.)  A common policy of this sort with the above reforms would cover things such as heart attack, cancer, liver failure by other than alcoholism, rare diseases and similar and would be very inexpensive.  For a young person of normal weight the cost of such a policy might be $100 a year.  For a 50 year old, maybe $300 a year.  If you're overweight or obese (or worse, have a high A1c) then it's going to be considerably more-expensive because your risk of heart attack, for example, would be much higher.  Ditto if you're a smoker.  To protect against fraudulent misconduct by insurance companies with regard to rescission of policies after an event, which used to be quite common, the only grounds for rescission is evidence that you actually underwent medical treatment for the condition that is medically proved as the underlying cause of the claim or fraud in the application (e.g. claiming to be a non-smoker when in fact you are.)  The two-year "no treatment" period balances sufficient protection against anything that (1) is degenerative and emergent and (2) would otherwise lead to a claimable event against the abuse of rescission against the possibility of a customer attempting to rip off the insurance company (and thus all the other policy holders) by buying a catastrophic policy after a serious event has become evident to them.

  • All health insurance providers selling true insurance, in whole or part, must provide within their "true insurance" the ability to "replace like with like."  This is the premise of insurance, subject to policy limits.  If you wreck your car you're not entitled to a new car, but rather either (1) repair of the one you wrecked to "as before the wreck" condition or (2) its current value in money.  To the extent reasonably possible health insurance for "true insurance" events (as above) must therefore cover the provision of services and goods to return "like for like" within the area where you are at the time the event occurs, or to where you are involuntarily transported in the event you are incapacitated.

  • Medicare becomes just another insurance provider.  There is no "special" Medicare-accepting doctor list; it is simply an insurance plan and one that does not pay for routine physician visits and similar but rather covers unexpected insurable expenses.  In other words Medicare Part "A" will continue as-is along with Part "D", but Medicare Part "B" will be deleted.  Since Medicare was sold to the public as an "80/20" plan (the customer bears 20% of the cost of care) this change represents no violation of that promise.  In addition Seniors can still buy "Medicare Advantage" plans should they wish that covers all medical costs (with possible deductibles and co-pays) as is currently the case.

  • Medicaid is repealed entirely. No, we're not leaving the poor out in the cold.  See the next point; the poor will in fact obtain better care than they have now as they will have full access to the entire body of physicians, hospitals and facilities.
  • For those who have no means to pay and find themselves with a need for medical attention the following provisions shall apply:
    1. EMTALA is hereby repealed.
    2. The provisions of this section, bearing on those who cannot pay for medical services, shall apply only to US Citizens and lawful permanent residents. This instantly puts a stop to the "uncompensated care" problem for illegals and the "come here pregnant and poop out a kid" expense issue as well.  No medical provider shall have any liability, whether civil or criminal, for their refusal to provide care for which they are unable to secure payment when furnished to other than lawful permanent residents or Citizens.  Other nations that wish to negotiate a billback provision for their citizens in order to insure that payment is secured may, of course, do so but under no circumstance shall a person who is not a citizen or permanent resident obligate any provider to provide services without payment, nor may they avail themselves of the backup payment provisions of this section, nor does any cause of action in favor of any person arise in equity or law for a provider's refusal to provide care to a person who is not a citizen or permanent resident without sufficient guarantee of payment for medical goods and services.
    3. For those with true emergencies (as defined above) and who are lawful permanent residents or citizens and thus can identify themselves as such but are unable to pay the treating hospital/ER shall bill the US Treasury for the lawful charges incurred under the above framework and shall be paid within 30 days.  All provisions of the above shall apply for what constitutes a lawful and payable bill and shall be provided to the customer at the time of service along with the fact that same has been forwarded to the US Treasury for payment.
    4. For those with non-emergency conditions who are (1) US Citizens or (2) lawful permanent residents and who assert they are unable to pay the medical provider shall bill the US Treasury for the lawful charges incurred under the above framework and shall be paid within 30 days with the provision that government billing shall not be available for any condition, drug, device or treatment for which a lifestyle modification that the consumer refuses to make will alleviate any or all of said expense and need for medical goods or services.  Again, all provisions of the above shall apply for what constitutes a lawful and payable bill and shall be provided to the customer at the time of the service being provided.  Treasury shall provide a means of rapid verification of citizenship or permanent resident status for the use of medical providers, with access to same restricted for this exclusive purpose so as to allow validation of such claims at the time of service (if we can have a background check call-in number for gun sales we can certainly verify citizenship status for those who claim to be indigent and in need of medical care!)
    5. Said charges under (3) and (4) will, when submitted to Treasury, result in an invoice being sent to the taxpayer in question and may be settled within 90 days of submission at no penalty.  This allows a person who temporarily cannot pay or who is misidentified as not having a means of payment (whether insurance-based or otherwise) to make payment directly to the US Treasury without risk of an adverse tax action.  If said bill(s) are not paid in full within 90 days then they become a tax lien subject to collection exclusively from any or all of (a) refundable tax credits, which may be garnished at up to 100%, (b) tax refunds, which may be garnished at up to 100%, (c) other entitlement checks excluding Social Security retirement which may be garnished at a rate of no more than 25% (e.g. social security disability, general assistance, etc) and (d) windfall amounts in cash or property that cumulatively exceed $10,000 in a rolling 12 month period from any source (e.g. inheritances, lottery winnings, gifts, etc.) that may be garnished for payment up to their full amount.  Statutory interest at 110% of the current 1-year Treasury bill rate, with the rate adjusted on the last business day of each calendar quarter, shall be applied on any remaining balance until paid in full. This will be vastly cheaper than Medicaid -- about 10% of what is spent today, in fact, and a good part of it will be recoverable over time.
    6. At death if a tax lien exists for unpaid medical bills it shall be treated as any other tax lien for the purpose of claim against the decedent's estate except that in the case of a married couple with a surviving spouse who's marriage pre-dates the medical expenses in question any such claim shall not be recoverable during the surviving spouse's remaining life but rather shall become a claim against said surviving spouse's estate at the time of their death.  Remarriage, creation of a trust or other estate-planning vehicle after the event(s) giving rise to the medical tax lien shall not modify or defray this liability and may not be used to shield the assets of the surviving spouse from an existing claim.
    7. Any provider of service that falsifies billing under this section, bills at inflated prices or otherwise violates the provisions of this law in regard to any bill submitted to the US Treasury for payment shall be deemed guilty of a criminal felony for which the punishment shall be the forfeiture of three times the billed amount and each individual who has caused such an invoice to be issued, transmitted or otherwise participated in same shall be subject to a fine of not less than $1,000 nor more than $10,000 and imprisonment of not less than 2 and not more than 5 years.  Each fraudulent invoice shall constitute a separate and distinct offense, all penalties shall be consecutive and additive, and liability for same shall be joint and several.
    8. Misrepresentation of citizenship or permanent resident status for the purpose of obtaining health care to be billed to the Treasury shall be deemed a criminal felony punishable by not less than one and no more than ten years imprisonment and a civil penalty of three times the amount of the charges incurred.  Upon conviction said individual shall also be immediately deported and suffer permanent exclusion from the United States; said penalties may not be decreased or waived irrespective of other circumstances.

  • ALL provisions of the PPACA and other public health related laws contrary to the above, whether in law, CFR, Internal Revenue Code or otherwise are declared contrary to public policy, void and unenforceable, and all State Laws and Regulations contrary to same are preempted, void and unenforceable since medical care inherently involves commodities that travel in interstate commerce and thus the sale of such goods and services fall under the Commerce Clause to the US Constitution.  Rather than go through and strike them all (which of course Congress could do) that one sentence will take care of it until the necessary clean-up can be performed on a chapter-by-chapter basis.  Yes, this means the taxes, mandates and similar -- all gone.

Now let's look at what you could expect under such a system.

Let me first note that such changes would drop Medicare expenses in the budget by at least 75%.  Again, 25% comes off from changing how we handle Type II diabetes alone; these are not "pie in the sky" numbers.  This results in a complete deletion of the federal budget deficit on an instant and permanent forward basis and as a result everyone in the country becomes richer every year because their purchasing power of money stops going down and starts going up.  

The CBO is out with their latest estimate on the detonation of our federal budget, and it's not pretty. They point out what I've said repeatedly on the budget and "entitlements": Social Security is not the problem and in fact will start declining in share of the budget in 2028; politicians speaking of "entitlements" lumping Social Security in with Medicare and Medicaid are lying.  The entire problem is in medical spending and if current trends are not reversed -- not just "adjusted" over time -- will destroy the federal budget and economy.  We will not get to 2037 before it happens either; in fact, if we do not act we'll be lucky to get through the next four years as the markets will figure out that neither political party will take this issue on and resolve it.  Simply put we must solve this problem and we must do it now.

If we don't this is what the federal government will try to do with debt

That will fail because it must; infinite exponential expansion of debt is impossible to sustain and will result in a fiscal crisis.  Since this is being entirely driven by health care spending the only means to avoid collapse of the government will be forced rationing or even collapse of both Medicare and Medicaid -- an immediate disaster for everyone dependent on them.

We must act now to stop this, and the above plan (or something substantially identical to it) is the only workable means to do so.

Let's take some pessimistic estimates of the result from enacting this set of changes -- that Medicare spending will go down by half and Medicaid by 60%.  These are in fact very pessimistic, since a 25% reduction is simply from policy change rather than cost control.  What does that do to the budget even if that's all we get?

Total spending goes from $3.85 trillion to $2.92 trillion in an afternoon.

In other words we go from a $587 billion dollar budget deficit last year (on "official" terms) to a $342 billion surplus; that is, from a 15.24% deficit (as a percentage of the budget) to an 11.70% surplus!  This change in spending and the surplus is maintained forevermore into the future -- in short this change ends, permanently, the federal budget deficit.

At least as importantly for you, as a consumer, we take the destruction of purchasing power of your money caused by deficit spending and permanently reverse that.  Over time this will eliminate the federal debt -- without cutting any discretionary (or military) spending.

Let me add to this: I have, since The Market Ticker began publication, said that Social Security is not going to blow up; the entire problem is in health care.  Lawmakers and candidates love to either scare Grandma by saying their opponent will "cut" Social Security or threaten that we must address "entitlements" in which they include Social Security. Here's proof from the CBO that I'm right and they're lying: Social Security does not materially increase in budget load over the next 30 years, and more to the point it starts declining in impact ten years from now as the Boomers begin to pass on!

 by tickerguy

Fixing Health Care prevents the destruction of the Federal Budget and prevents you from losing access to medical care -- especially if you're a Senior Citizen or poor.  If we do not pass this bill or something substantially identical to it and you are either a Senior Citizen or poor within the next five to ten years you will face forced rationing of your health care or the government will collapse.

This bill will materially increase access to doctors, clinics and similar by Medicare customers since there is no longer any discrimination between who does and doesn't take the program -- Medicare is simply an insurance payer just as any private program is, and will list its payable amounts for care just as will any private party insurance does.  This also leaves the Medicare Advantage programs, for those who decide they like that program better, fully intact.  For those Seniors who have medical expenses that exceed what Medicare will pay they will wind up with a tax lien just as will any other citizen.

This bill will make customer choice not just a function of price but also of outcomes.  Today there is no accurate way for a person seeking a procedure to compare the success rate between various providers of a given procedure.  This must be fixed immediately if we are to have true competition as some doctors are outstanding, some are excellent, many are average and some are poor.  There is literally no way for a customer today to know, other than by anecdote, which category a physician falls into.

The bill will also destroy PBMs and the outrageous extraction of funds they commit by forcing price transparency and decoupling price from "insurance."  You will be able to call or go online to look up drug prices from any pharmacy and they will in turn have to honor the same price for all retail buyers.  Competition will return at the retail level and the practice of "gagging" pharmacists, which is arguably illegal as it is done for anti-competitive purposes, will end immediately.

If you're unable to pay or accrue medical expenses in your Senior years (or otherwise) that wind up being paid by Treasury then when you die they go "poof" (Treasury eats them) to the extent that your estate is unable to pay them off as ordinary debt prior to distribution through probate (will) or trust.  If you're married then your spouse cannot be punished for said debt during their life should they survive you despite some (or all) of your assets being titled in common, but your joint assets cannot be shielded when the surviving spouse dies against your medical claims nor can you marry after incurring such expenses as a means to prevent recovery from your assets.  This prevents "serial marriage" or late trust-creation gaming of the system yet also protects a surviving spouse, which will be particularly important for poor couples and will prevent some of the nastiest situations that occasionally arise today (where long-married couples are essentially compelled to divorce for economic reasons due to medical expenses and collection efforts.)

Medicaid goes away entirely on a formal basis however poor people actually acquire superior access to health care. The amount spent by Treasury would drop by at least 80% instantly.  A fair amount of the remainder would be, in future years, recoverable as some people leave the ranks of the poor and if and when they do their accumulated medical debt would be recovered over time.

This bill stops the detonation of all of the state public pension fund budgets -- a catastrophe that has been driving property tax increases and threatens to destroy all of the state budgetary systems.  That all ends in one day.

It deletes all state Medicaid spending immediately (the states may choose to use said funds,or some part of them, to pay for low-income clinics and similar for residents in their states, much as County Health Departments do today in the States.)

It makes bilking the government by submitting false or inflated bills to the Treasury severe criminal offense.  The poor and disabled are the least able to press their own claims and fraud is rife in both Medicare and Medicaid today.  This puts real teeth in the anti-fraud provisions for those individuals who, most of the time, cannot reasonably bring their own suits.  It also protects the poor and disabled from improper tax liens while at the same time recovers from them the cost of their care should their financial situation improve in the future.

An often-repeated claim is that medicine is "highly variable"; the person who presents to the hospital or ER has an unknown expectation for complications and follow-up requirements.  But this is true for car repair as well. I remind you that it was not that long ago (if you're old enough you remember) that the practice in car repair was to put your car on the rack, get a blanket authorization, rip it apart and tell you what the bill was when they were done.  This often led to vehicles being literally held hostage and outrageous bills that nobody would have agreed to in advance.  That was made illegal and during the debate over these laws all the car dealers and repair shops said they "couldn't" accurately estimate and would go out business if forced to do so.  They lied; the dealers are still there but the racketeering they used to engage in and the rabid screwing the consumer used to take is gone. Car dealers dealt with this by introducing a "flat rate" book.  The "flat rate" for repairing your front brakes is $400.  This includes a set of pads and rotors and the labor to install them along with a margin for expected and possible complications; the dealer has no idea what sort of condition the vehicle is in other than that it needs brakes when he takes it into the shop.  The flat rate book gives him the expected time to perform the procedure including a margin for possible complications.  In some cases the dealer will take less time to fix the car and in some cases more. That doesn't matter; what does matter is that on average that's what it will take with a reasonable profit for the dealer, and in addition the dealer typically adds a "shop charge" that is a flat 10% of his repair price for small and hard-to-itemize things like shop towels, grease and similar.  If he gets it done faster and cheaper, he wins.  If he runs into complications, he loses.  The book gets released with each new model and can be updated as actual service history is fed back to the manufacturer.

The "must post a price" model, incidentally, does not mean that providers cannot differentiate between customers who have objectively-measurable differences in presentation.  For example a provider could charge 25% more for someone who is morbidly obese but must do so for everyone who is, and must post that up front on their price list.  There may well be a higher complication rate for such a person in that practice's history.  If a provider is willing to come in at 3:00 AM to take care of something urgent but wants to charge double to do so rather than waiting until the morning they can, provided they disclose it up front in their price list.  Likewise, perhaps some practice has a lot of available appointments in the afternoon and wishes to offer a 10% discount for appointments between 1-4 PM.  No problem.  Competition once again comes into play; if some provider figures out how to get rid of the additional complication rate caused by said obesity they can then undercut the other guys on price and gain that business.  If one provider is more skilled than another and thus has a lower complication rate they can undercut their competitors which is good for everyone except the lesser-skilled provider.  Who do you want practicing their medicine on you -- the better guy or the lesser one?  This is how progress is made folks.  It's also why the shop charge to change an alternator in one make and model of car is different than the same job done on a different make and model; one may have easy access from the top, the other does not.

Likewise insurance companies employ a whole bunch of actuaries for the purpose of figuring out the odds of a given thing happening and what it will cost if it does.  To do this they analyze previous events.  After this change in law hospitals will be no different; the hospital has access to fine-grained data on all of its previous procedures done, for example, to perform a coronary artery bypass.  It knows on average how many sutures must be laid, how many scalpels are used, how many units of blood get consumed, what drugs and in what amounts are consumed, how many hours in the operating theater and so on.  It knows that X% of the operations go without a hitch, Y% have some minor complication and Z% are a disaster requiring other major interventions because of unforeseen complications -- some of which are avoidable (e.g. infections acquired in the hospital) and some of which are not.  From all of this data the hospital can compute an average and that's the price they set.   Just like the car dealer does not know if your car has frozen bolts that will have to be chiseled off in order to change your brakes or a caliper that will have to be swapped out because when it is reset it starts leaking fluid the hospital does not know all of the possible complications that may arise from a procedure when you are admitted.  By mandating a quoted pricing model competition comes into the game and the hospital now has an incentive to find ways to reduce the complication rate and waste.  The complication rate is very important to you as a customer since avoidable complications (e.g. MRSA infections) are severe consequences that you suffer and a good part of the time it happens because they screwed up.  It is utterly essential if we are to improve the quality of care that the incentives align for the provider and customer in this regard and if the hospital across town (or across the state!) can reduce the infection rate, for example, that also reduces its average cost for a given procedure and thus said provider can offer a cheaper price.  That's called innovation or, if you prefer, productivity enhancement and it is the driver for progress in your quality of life both personally and economically.

One of the often-repeated claims is that much testing today is undertaken for the purpose of "defensive medicine" in the form of preventing malpractice lawsuits (or at least making them harder to win.)  Forcing the doctor ordering said tests to present a price to the customer and obtaining their consent before the test is done ends this instantly.  If the customer refuses to consent to spending the money on some diagnostic then the result of doing so is on him or her.

"Poof" goes the defensive medicine problem in a puff of smoke because the customer made the choice rather than the doctor!  Physicians often claim we need "tort reform" and that they order tests by the bucket-full as a means to defray lawsuit risk. Various advocates, for their part, want to outlaw bringing such suits.  The problem with so-called "tort reform" is that sometimes lawsuits are appropriate -- the classic example is when the doctor amputates the healthy foot or hand leaving the diseased one attached!  The best, easiest and most-equitable reform when it comes to the "tort lottery" game played today is to replace the current "order 10 tests" paradigm with informed consent and shift consent along with the cost and potential benefit analysis to the customer.  If the doc says "I want you to take a CT scan because I suspect X and it costs $200" and I say "No" because I don't want to spend the $200 then if it turns out that the bad thing would have been discovered by the CT I cannot sue because I was offered but refused the test!  Customers need to become the decision point, not doctors; they must be presented both the cost of such procedures along with the expected benefits -- including the odds of either proving up or refuting a possible diagnosis.  My ass, my choice, my expenditure, my risk.  That permanently resolves the entire tort lottery problem yet leaves the legal system intact for the outrageous cases where consumers should have redress in the courts.

Now on to some personal examples of expected financial outcomes.

First, let's compare against an Obamacare policy that contains a high deductible for a reasonably-healthy, 40 year old person.  That person is today charged approximately $400 a month and the policy has a $5,000 deductible.

This means they pay $4,800 a year for exactly nothing and if they use any health services at all there is no coverage until $5,000 in additional funds are expended, at which point the insurance covers 80% up to the "cap" (typically $7,000 or $8,000.)

Under this system that customer would (voluntarily) pay $300 for a catastrophic policy.  Since they are nominally healthy they might decide to have an annual physical (at a cost of $150)  If they remained healthy they would spend nothing more through the year on medical care.

Their cost of health care would go from $4,800 a year today to $450 for a reduction in cost of 93.7%.

Now let's take the person who is nominally ill.  Their current expense, assuming they consume $5,000 of medical care under the current insurance system is $9,800 a year -- $4,800 for the "insurance" and $5,000 for the deductible.

What do they pay under this system?  $300 for their catastrophic policy which does not cover their existing conditions but does cover an accident or new catastrophe not caused by their existing circumstance and all of their current treatment at a discount of 80-90% of today's pricing.

How much medical care can you buy for $9,500?  Well, you can buy one of many operations at the Surgery Center of Oklahoma, should you require one (and not many people need more than one in a year!)  You can buy a hell of a lot of pharmaceuticals when they're sold at outside-US prices, which they would be immediately -- in other words divide current drug prices by anywhere from 5 to 20 or more.  Monthly "specialty" visits to the doctor to monitor your condition would run you $700 over the entire year.

Do you really think you'd spend more than $9,500?  Probably not, and you might spend a hell of a lot less.

In fact, in many cases you might spend 80% less depending on exactly what's wrong with you.  Further, if you go from "ill" to "well" during that year your expense immediately stops since the $400 a month otherwise extracted from you is gone.

A poor person would enjoy dramatically improved access to care over what we have today since there would be no "Medicaid provider lists."  They could access any physician or other treatment option that was medically indicated and there would be no discriminatory pricing for or against, nor any discrimination in access.  Both access and outcomes would improve dramatically for poor people while cost to the government would be dramatically slashed.

How about the person "covered" through their employment, which is most of the population?  Your employer would see thousands of dollars a year in cost reduction, and even more in his liability insurance premiums would disappear.  For the average family of four the premiums covered by your employer are likely close to $10,000 a year.  That is salary that you will receive.  

To put this in perspective the average family makes some $50,000 a year. That "average" family would see an immediate 20% increase in spendable income; roughly $10,000 each and every year forevermore into the future.  That's huge; there is no other way to have such a large impact on consumer income and wealth in this country on an aggregate basis than this.

Let's assume that "average family" has a kid during the year -- a routine, uncomplicated pregnancy.  Today that's about $10,000 worth of expense, but if you have "good insurance" you don't see any of it directly.  The cost of having that child as a matter of routine vaginal childbirth would drop to about $1,000.  You'd get $10,000 more in salary and spend $1,000 of it; the other $9,000 would be yours.  If something goes wrong then your $200 catastrophic policy would cover it, perhaps with a $3,000 deductible.  You'd spend $1,000 for the routine part of the birth, $3,000 on deductible, the cat policy would cover the rest of the emergency and you'd be $6,000 net positive -- with a complex childbirth in the mix.

Now let's assume under this system you're nominally well and have a heart attack.  What do you pay?  The $300 you paid for the catastrophic policy, and perhaps a $2,000 deductible.  The bypass you need to resolve the problem is $10,700 instead of over $100,000 because the local hospital has to compete with places like the Surgery Center, and that's what they charge.  If they don't then they sell exactly zero bypass surgeries to anyone who isn't having a heart attack right now, and they're not going to give up the income. They'll compete because the alternative is that they have almost no business at all, never mind that you will probably choose to have the $10,000 procedure before you have the heart attack (saving you from the risk of dying during the heart attack outright!)

Ok, who gets hurt?

1. The lobbyists.  They lose big.  In fact virtually all of them wind up out of business entirely.

2. The administrators who aren't needed and are very expensive.  Many, maybe most, get fired.  The hospital becomes a place full of doctors and nurses but damn few administrators since now their cost can't be shoved off on others -- it's overhead, and is subject to competition from the hospital across town or in the next town over.  Not only does this reduce employee cost at said hospital dramatically it also reduces the space the hospital uses for overhead which makes their per-person cost for actual procedures go down further since a larger percentage of their space goes to actually treating customers.  Yes, those former administrators will lose their jobs.  The good news is that the economy will expand due to greatly improved cost structures, so there will be new jobs in other fields available to them.

3. The drug reps.  Gee, what happens when you can't be a pusher any more and have to price on a level basis?  The rest of the world's prices go up some (there's many billions of "them") while ours fall like a stone (because there are only 330 million of "us")!  That's math; take the amount of revenue necessary to make the drug and a profit and divide by the number of users; there's the price.  Guess what -- forcing the US consumer to pay for the development cost of drugs used worldwide ends in a day.  This costs us hundreds of billions of dollars a year today.

4. The PBMs.  All gone.  These organizations are all quite-arguably committing unlawful acts on a daily basis in any event under 15 USC Chapter 1; using market power to restrain trade and fix prices is per-se illegal.  These firms appear to be nothing more than a racket -- and one that was tested in 1979 at the US Supreme Court with the drug firms losing their appeal.

5. Anyone who refuses to change their lifestyle and instead demands everyone else cover their willful acts.  That's a tough nut to swallow, but it must be swallowed.  If you can control a condition for zero cost you have no right to demand someone else pay tens of thousands of dollars a year to you every single year because you refuse.  There are millions of Americans who do exactly that costing upwards of $350 billion every year just between Medicare and Medicaid and every penny of that expense must end right now.

That's a good start.

The problem isn't that health care is "expensive."  The problem is that it's a rip-off and is laced through with fraud, theft and arguably even racketeering from top to bottom.  You can find myriad examples of what competitive prices look like for health services and products if you bother to look around, even in the United States, and since we know what those prices look like what I laid out up above isn't a fantasy-land dream -- it's a reality we can have right now and forevermore into the future.

To do it we must demand that the politicians put a stop to the scam and back that demand up with whatever political and economic action is necessary until and unless they do so.

Perhaps we should all start showing up at town hall and campaign events with a simple plastic spork and wave 'em in the air from start to finish.  They're obviously not weapons but the message ought to be pretty clear when it comes to what the people might, at the point the economic and political system collapses due to all the fraud and theft the political class is enabling through medical scams, choose to eat first.

What will implementation look like?  Read here.

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Where is the discussion of facts when it comes to health care?

Why do we keep talking about the cost of "health insurance" when that's a symptom and not the problem?

Why do we keep talking about "subsidies" (tax credits, etc)?

If you're coughing incessantly because you have lung cancer do you simply take a cough suppressant and call that a "fix" when you stop coughing for a while?

That entire line of discussion, which is the only discussion being held politically and in the news, is a fraud.

Why?

Two reasons: First, "health insurance" is not insurance to the extent it covers an event that is either certain to happen or has already happened. Insurance is a thing you buy to cover a possible future event you cannot pay for yourself.  It is less expensive than the event will be only because the probability is less than 1.0 -- that is, the event is unlikely.  If the event is either certain or worse, has already happened then the probability is 1.0 and the cost of "insurance" against such an event is always more than simply paying for it in cash because the insurance company has costs it must cover or it will go out of business.

Let me repeat that just in case you missed it: The cost of insuring against a bad event is directly and mathematically determinable by the cost and probability of said event.

Second, due to the above mathematical fact if you wish to decrease the amount "insurance" costs there is only one way to do it: You must decrease the cost of the event, the probability of the event or both.

This is arithmetic, not politics and anyone arguing otherwise needs to be indicted, tried, convicted and imprisoned for their intentional act of fraud upon the public because that's exactly what they're doing -- defrauding you.

I don't care if they're pundits, media personalities, Congresspeople or the President -- and I remind you that The President is well aware of how insurance actually works since he's been a Real Estate developer and operator for decades.

Now let's address the only two means by which we can lower health insurance costs.  And lower them we can -- by 90% or so, and quickly too -- in fact, within months.

First, insurance must be actual insurance.  In other words it must only cover events for which p < 1.0.  By definition those are events that are neither certain to happen (e.g. routine, every-day visits to a doctor) or have already happened (e.g. pre-existing conditions.)

While you might be able to buy fire insurance on your house if it's on fire (or you are in the process of setting it on fire!) the cost of that insurance will always be more than the fire damage to said house because the probability is 1.0 and the company has to cover its cost and make a profit or it goes out of business.  It is therefore always cheaper to simply pay cash for the fire damage than to buy said "insurance" and this is true irrespective of what you're "insuring" -- including health.

Again, this is math, not politics.

Second, we must address both "p" (probability) and "c" (COST.)

We must address "p" (probability) because it will directly and grossly reduce the cost of insurance since it is a multiplier to cost.  Reducing "p" by 10% directly reduces cost of insurance by 10% all other things being equal.

We must address "c" (cost) because that not only reduces the cost of insurance (but on a smaller basis than "p" since it's multiplied by the fraction of risk) for the person who has already had the bad thing happen to them medically it enables them to pay directly for the treatment required. I remind you that paying directly is always going to be cheaper than running that same payment through an "insurance" company (typically by about 10-20%) because said company has costs that have to be covered.

Let's take "p" on first.  An utterly enormous amount of health expense occurs because people choose to be overweight or obese.  As noted in a previous Ticker the American Diabetes Association claims $250 billion a year is spent by Medicare alone due to both the disease and its effects.  Best guess is that another $150 billion is spent by Medicaid (which they don't specify.)  This is for one disease and essentially all of that money doesn't have to be spent.  It is spent because people choose to consume foods that promote and exacerbate the condition rather than reduce or even eliminate its effects.  The cost of changing what you put in the pie hole, medically, is of course zero.  Therefore for each person who is diabetic (Type II) and makes said lifestyle change resulting in either the control or elimination of the harm to their body from same we eliminate all of the health spending by said person on said disorder!

There are myriad other diseases and disorders associated with being obese and overweight.  Hip and knee damage, eventually leading to (expensive) replacement surgeries, for one.  Heart attacks and strokes (many caused by high blood pressure that, again, is often a result of being overweight) for another.  These are all avoidable costs and if we wish to address the cost of health care reducing "p", the probability of bad events, is a key item.

It is absolutely true that personal choice is a huge factor here and the government does not have the right to tell you how or what to eat.  However, you do not have the right to demand that someone other than yourself pay for the consequences of your personal decisions.

It is therefore perfectly reasonable to put in place a protocol that says if you are overweight or obese and diabetic then the lifestyle change in terms of what you put in the pie hole that has a near-100% record of reducing or eliminating your need for drugs and medical procedures and has a cost of zero will be the only option offered under said publicly-funded programs until and unless you prove, by individually-shown test, that it doesn't work in the case of your particular metabolic makeup.

Doing this for one disease alone would cut roughly $400 billion off the federal budget this year and every year thereafter and would cost the patient exactly zero on top of it.

Can we extend this demand to private health care policies by force?  No, but we can certainly allow companies to multiply their pricing by the change in "p" that not following such a lifestyle, if you're overweight or obese, comes with.  Since this one disease is such a huge component of said spending my best guess is that the surcharge for refusal would likely be 25% or more and if you're already diabetic then it can (and should) be an immediate disqualifier for any coverage of any consequential event whatsoever unless you prove, by individual test, that the lifestyle change outlined above doesn't result in control of your condition.

Second, we must break all the monopolies in the medical system.  There are in fact simple ways to do this, requiring no new laws, which I've outlined before going way back in time.

If you force price transparency by treating any health provider who refuses to do so, or who tries to bill on a discriminatory basis as committing a criminal act under existing consumer protection and anti-trust laws (at both the State and Federal levels) you will instantly and permanently remove all so-called "network" games, break the monopoly pricing games played by the health industry and as a result competition will cause prices to fall like a stone.

It's worthless to even attempt to argue that this "can't" or "won't" work because we know it does.  The Surgery Center of Oklahoma does exactly this right here, right now, today and their pricing with the monopolist-laced chain of supplies for drugs and surgical devices still undercuts "traditional" hospital prices by 80%.  For example a cardiac bypass is $10,700 -- cash, all-in, one-price and if there's a complication taking care of that is included.

Can you come up with $10 large to save your life if you need it?  Almost-certainly, even if you're poor.  Yes, it would be a lot of money for someone without material means, but remember -- we're talking about a price that's anywhere from 1/10th to 1/5th of what that same procedure costs in a "traditional" hospital setting and you're choosing between that and death.

Don't tell me it can't be done and wouldn't result in these sorts of cost reductions because it is being done right now, right here, today and has resulted in these cost reductions -- even with a huge part of the medical scamjob monopolist games still embedded in their pricing because they can't get away from the drug monster in their ORs at present.  In other words their pricing is high (probably by 20% or so) compared to what it would be if we stopped all of the monopolist games.

Here's the bottom line folks -- if you think "health insurance" costs too much you're being misled.  The problem isn't health insurance it's the cost of health care.  The solution to the problem is to first require firms to offer true insurance (that is, does not cover events where p = 1.0) then require all providers to post prices and charge everyone the same amount.

Next, using existing law you then indict and prosecute all violations of 15 USC Ch 1; the health insurance and related industries already tried to claim exemption in a case that went to the Supreme Court in 1979 and they lost.  It is therefore simply a matter of political willpower to get out the handcuffs and start issuing indictments.  That will further collapse prices since now providers will be forced to compete for business.

To put numbers on this we're talking about "health insurance" for catastrophic events being something that costs the average person well under $100 a month and for virtually everyone they would pay only a few hundred dollars more a year in direct, uninsured cost.

With the cost of care collapsed to 1/5th of what it is now for the truly indigent we can certainly afford to help -- but for nearly everyone we won't need to, because even those of modest means can afford to pay cash at a price 1/5th of what is charged in the United States today.

The obvious question is "Why won't Donald Trump or Congress take this position, since it's clear on the math that it will solve the problem permanently and at the same time nearly eliminate both the Federal budget deficit and all State and Private Pension budget problems at the same time?"

The answer is quite simple: Doing so will cause an immediate and deep recession as the health industry collapses from ~19% of domestic output back to its historical level of about 3-4%.

Said recession won't last very long because that money will get redeployed in other areas of the economy but until it does the impact on GDP will be severe, immediate and deep -- and both Congress and Trump know it.

Oh, and it will put a whole bunch of lobbyists out of business too.

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2017-03-02 07:00 by Karl Denninger
in Health Reform , 789 references
[Comments enabled]  

I can cut approximately 25% off Medicare right now without jailing one person, without breaking one monopoly, without doing one single thing to the actual health providers -- although all of those things should and in fact must happen.

In the private sector I can have a similar, but smaller (percentage-wise) impact.  Ditto for Medicaid.  The budget impact of this change would be roughly -$400 billion annually, which is wildly better than any projected "growth" addition (it would add to more than $4 trillion over 10 years.)

You simply have to allow me to make the following policy change with regards to one disease -- Diabetes:

  • For those with Type II diabetes we will provide unlimited metformin (cheap, off-patent generic medicine that costs pennies a day) to anyone with the disease.

  • We will provide no other care of any sort for Type II.  You want or "need" it, pay cash or die.  Period.

  • We will also make changes to how we deal with Type I diabetics' insulin requirements, as detailed below, that will cut said requirements dramatically.

Now before you scream in horror that I'm a monster, listen up.

Instead of medicine and, inexorably, amputations, dialysis, hospitalization and death we're going to prescribe a lifestyle of eating no more than 50g of carbs a day, all in green vegetables high in vitamin C (e.g. broccoli, brussels sprouts, etc.)

Caloric intake is to otherwise be 70% saturated (animal) fat and 20% protein.  Sugars, grains and starches, including but not limited to "white" foods (pasta, potatoes, breads, etc) are all prohibited.  Zero-calorie / zero-carb spices and condiments are unrestricted, of course.

In short you eat (and don't eat) what's described in this post, less the fruits (since they are all fairly high-glycemic and the vitamin C requirement is taken care of.)

For most Type II diabetics eating this way will reduce their need for other drugs, including insulin, to a literal zero and since their blood sugar will normalize their need for many-times-a-day testing will also disappear, getting rid of both the pain of sticking one's finger repeatedly and the cost.

For those who it doesn't the metformin is there to help.

We will also accommodate all actual, documented exceptions -- that is, those people for whom this lifestyle change legitimately doesn't work.

Those who claim "it doesn't work" will be locked in an isolation ward where they will be fed that diet for two weeks (with no access of any sort to any other source of sustenance) and be able to prove that for them, individually, it doesn't work.  If they're right then they will get whatever medication or other intervention is necessary provided they keep to the lifestyle change.  But if that empirical test shows that it does work (and it will for virtually everyone) then their ass will be discharged, the fact that they refuse to change what they eat will be noted in their chart and further complaints of "impossibility" will be ignored.

Type I diabetics will find their insulin requirement cut to a tiny fraction of what it is now and again those who claim "it doesn't work" will be subjected to the same empirical, isolation ward test -- with the allocated and paid for insulin amount (and/or other intervention measures) set by the results of said test.

If you are insulin-compromised but choose not to eat this way -- if you cheat, if you want those Doritos, potatoes, pasta, breads, cereals, sugars and similar, then have at it -- but you will get no medical care paid for by any insurance, by Medicare, Medicaid or otherwise.  You may buy whatever you want with your own money but there will be zero further support from the government or anyone else.

When diabetes causes gangrene in your feet you can use your own chainsaw to cut them off and your belt can be used as a tourniquet until you can sew the gaping flesh shut with your own hands.  When it causes blindness you cannot collect disability because you intentionally caused your own disabled state.  When it causes kidney failure you can pay for the dialysis yourself or die.  When the complications from all of the above kill you, tough crap.

If you're Type I your reimbursable amount of insulin under Medicaid, Medicare or private insurance will be limited to that which is required by a 50g/day carb load comprised of all low-glycemic green vegetables -- and not one unit more.  If you want to eat carbs or load up with excess protein (which gets turned into glucose in the body!) you pay for both the carbs and/or protein and the insulin.  Again, if you argue that the provision for what your coverage provides is too low or it's "unsafe" for your personal metabolic situation you get to do two weeks in said isolation ward and prove it. The results will go in your chart as irrefutable and individual evidence as to your actual requirements.

Not everyone is the same -- but the exceptions must be proved empirically, not just by what you claim.

It's simple, really: If you consume no carbohydrates of note and no fast carbs at all, along with little or no excess protein you need very little insulin.  If you have damaged your endocrine system so badly that you actually need injected insulin as a Type II diabetic then you will need a tiny fraction of what you use now and you can pay cash for it.

If you haven't, and most Type II diabetics haven't you will need no "advanced" medication at all and most Type II diabetics will need no medication of any sort as their blood glucose will immediately return to the normal range.

At the same time you will lose the extra weight if you have it, your blood pressure (if it's high) will probably come down and the odds of you needing any other sort of medical intervention -- all of which are a consequence of something bad going wrong with you such as a heart attack, stroke, blindness, kidney failure and similar -- will go through the floor.

If you're Type II over time your endocrine system might heal.  Or it might not.

But whether it does or doesn't isn't the point, nor is it the goal.

The point is that we're blowing over $200 billion a year in Medicare alone because people who are diabetic will not stop eating ****ing bread, pasta and potatoes while demanding that we pay for their pig-headed, self-destructive behavior!

That's not a disease it's a choice and by God we have to stop doing that crap right damn now.

Will Price and Trump mandate this?

You know good and ******n well neither will mandate any such change so **** them both.

Our current medical scam "system" is nothing more than feeding addicts -- sugar and carb addicts -- and then providing support for continuing addiction despite the fact that we know it is killing those who are addicted and have already had that addiction do severe harm to their bodies while stealing roughly four hundred billion dollars a year from everyone in the country.

We are, effectively, feeding crack addicts government-sponsored crack and forcing the public to pay for both the crack and the harm to the body that it does.

It's time to cut that crap out and indict, try and hang those who demand that it continue.

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2016-11-12 06:00 by Karl Denninger
in Editorial , 17576 references
[Comments enabled]  

Let me make a few observations.

First, eight years ago, and again four years ago, America elected a President.  Fully half, give or take a couple of percent, disagreed with the outcome.

There were exactly zero riots, fires, "mass protests" and similar following that outcome despite the fact that half the population vehemently disagreed with it.

This time around, not so much.

Now I want you think very carefully about the following.

Most of the land mass of this nation is owned and resided upon by people who are in "red" (that is, the winner this time) areas of the country.  With the exception of certain urban centers and right along the Mexican/Texas border there are very few "solid" blue areas.

Those urban centers consume roughly 90% of the energy and food in this country yet they comprise 5-10% of the land mass.  The "red" areas produce 95% of the food and energy this nation consumes and occupies 90-95% of the land mass.

Do you really think that doing something like eliminating the last pieces of the structure our founding fathers put in place to prevent tyranny of the majority from being able to take hold is a good idea?

A little history lesson: Prior to the 17th Amendment ratified in 1913 it was impossible for the Federal Government to shove any program down the throats of the 50 states.  That's because the state legislatures had effective control of the Senate and could recall their Senators.

The House was elected by the people, the Senate was elected by The State Legislatures (and could be recalled by same) and The President was elected by the Electors, which were voted for in the popular vote.

The latter provides a modest but real increase in the representation of "flyover" states; that is, those with lower population counts.  In other words it is a check and balance in the ultimate tyranny of democracy.

Yes, I said democracy is ultimately tyrannical -- because it is.

America is not a Democracy.  It is a Constitutional Republic.  This is very important; in a democracy 50%+1 can render the 50%-1 slaves by mere vote.  Those who are in the minority in a democracy have no rights at all.  Democracy is best represented by two wolves and a sheep voting on what's for dinner.

We are all minorities in some form or fashion.  If you're gay, black, yellow, male, female, whatever -- all it takes is some other set of groups to get together and decide to oppress you, and in a democracy you're ****ed.

America's founding fathers put in place two systems to prevent this.  The first was the bicameral legislature; a House elected by the people at large and a Senate elected by the State Legislators.  This structure guaranteed that a landmass that amassed 50%+1 of the population (not even in the same state or states!) could not band together and shove down the throat of the States any policy measure because you needed the concurrence of more than half the state legislatures, where each were delegated but two votes to their Senators who were accountable to said legislature, to pass anything at all.

This evaporated with the passage of the 17th Amendment.  Now you only needed 50%+1 of the people in a given state to pass anything you wanted and they could all live in a tiny percentage of the land mass -- such as is the case with Illinois where more than half the population lives in the immediate area of Chicago.

What came right after that?  Prohibition, shoved down the throat of the States, less than 7 years later!

What also came after it was an unbridled expansion of the Federal Government into state affairs.  Indeed, virtually everything became a "legitimate" federal matter.  Why?  Because it was impossible for the States to prevent it.

Do you think the founders were wrong to do what they did, and the 17th Amendment corrected that?

If you believe so then please consider this.

 

Ever drive through small town America?

Hell, how about "not-so-small-town" America?

Many of these towns look like something out of a WWI or WWII European war movie.  There was one factory or maybe two, but now it sits empty, weeds growing out of the parking lot as high as your head, all the windows are broken out and the roof has caved in.  Over on the outskirts there's a Walmart that pays $9/hour, but only offers 20 hours/week.  The factory paid $30/hour, full-time, plus benefits and food, power, medicine and beer cost half of what it does now. 90% of what formerly were little diners and shops in the "center" of the town, which might have one actual traffic light, are gone -- boarded up and often literally falling apart.  There might be one bank left, a branch of a big national chain, and maybe an antique store.  Maybe.  All the factory jobs left for China and Mexico and everything else died when the middle-class incomes to support them disappeared.  We did that as a nation with our "progressive" and "global" agenda driven by the 50%+1 that live in the closest big city 200 miles away.

The locals who used to work in the fields within 10 or 20 miles from that town are all unemployed too.  Why?  Because the illegal Mexicans came and we refused to throw them out.  They work for a few bucks a day in cash, no taxes, no unemployment, no nothing.  No American can live on that; the embedded cost of just trying to stay alive would leave you with zero.  But the Mexicans work hard and then sleep 10 to a single-room apartment, which incidentally is a total ****hole as you'd expect given that density of occupation.  They don't care; it's better than what they had in Mexico, you see, and they can Western Union home some of the money.  This is the face of "immigration", mostly illegal, that really exists in this country.  They brought their third-world ****hole here and while it's a little bit better than what they had in the process of doing it they dragged us into the gutter with them.

The people who lived in that town did and most who are still there do go to church every weekend, and some go again during the week, usually on Wednesday.  There's usually one, sometimes two churches.  Every one of them has the word "God" or "Christ" in the name on the front.  They mean it when it comes to their faith and in addition that's where all the local people shake hands, exchange chit-chat on the last week and, for younger people, it's where they meet one another.  You know, girls and boys.  Yeah.  Faith is real there, you see, and it's Christian. But from your point of view that's deplorable and that "those people" don't like the idea of making a wedding cake for a gay marriage is deserving of a federal lawsuit and loss of the bakery (which is, as a result, now closed -- putting yet more people out of work.)  The people who live in these towns don't see your point of view as a civil rights matter but rather as attacking God.

What was left after the factory was displaced isn't enough to run a "service economy", which is why it never showed up there and the old business buildings are all boarded up.  Nobody can afford $8 lattes on a $9/hour wage for 20 hours a week and nobody would want them if they could.  There's probably a McDonalds on the outskirts, and a couple of self-serve gas stations with a convenience store.  It sells cheap beer and lots of it to the locals who have nothing to do but drink and then go to church and pray for forgiveness for last night's 12 pack.  None of the jobs at any of these places, except maybe the store manager, makes more than $9/hour and Obamacare has forced all the regular workers down to 20 hours a week on top of it.  Try living on $180/week gross sometime -- before FICA and Medicare is taken out, never mind gas for the car and the rapidly-escalating car insurance bill -- and you might understand.  Yes, I know the car is 15 years old and runs like crap.  What do you expect on under $1,000/month of income?

This is what 40 years of sending jobs overseas with "trade deals" did.  It's what Amazon did.  It's what Walmart and its Chinese supply line did.  It's what "progressive America" did, and then to add insult to injury the teachers in the public schools tell all the kids that Mommy and Daddy are bad people and hate both the planet and their own kids because they don't drive a $30,000 Prius or a $60,000 Tesla.

This is everywhere in rural America.  Get in your car and out of your comfort zone some time and you'll see it. It's not far from wherever you are.  I've driven through dozens of these formerly-alive places in the last six months -- every one of them dead today, but full of real people.  I never met one such person that was a racist, xenophobic *******, but they're not very happy, and the people they're unhappy with are those very same folks you wanted to keep in office in Washington DC.

If you think the destruction of small town America is confined to farms you forget the other half -- energy.  Would you like your lights to work?  Many of those small towns are dead because of the insanity of our energy policy -- or lack thereof, tied to left-wing whackjob nonsense.

Now you want to add insult to injury when they show up to vote, exactly as civics tells them we have a right to do, and a large number of you in the cities did not show up.

They bought into the message of bringing American jobs back to America and ejecting those who have no right to be here.  You call them xenophobic, racist and small-minded -- they call it a shot at decent employment for the first time in 30 years.

They believe in the Henry Ford model of American business, and they're not wrong to do so.  Make the product here, pay the people well enough to be able to afford it, and you'll do just fine.

They win the election, in short, and you lose.

Then you decide to be a sore loser and loot, burn, beat people, issue threats, cry, whine on social media and try to obstruct everything by any means possible -- legal or not.  You bus people in to "protest" and riot, you "petition", you raise hell in short -- oh, and all this after you implored the other side to "respect the outcome of the election" and lambasted them for suggesting they might want to merely count the ballots twice!

Note again, as I pointed out above, that eight years ago, and four years ago, these very same people were on the losing end of your stick exactly as they had been for the previous three decades yet they did none of the above.  They understand duplicity and your double-standard quite well, seeing as they did the honorable thing and respected the outcome twice in a row despite getting screwed sequentially both times.  The only thing your brand of government offered them in the end was Medicaid or worthless "health insurance" through the exchange; the former has no doctors that accept it within 20 miles and the latter has a $5,000 deductible before it pays anything, which is utterly laughable when you consider these folks have a gross wage of under $1,000 a month.

Now the question:  Are you prepared for the possibility they might decide en-masse that they're done with this crap -- and with you?  That they're not going to take it any more?

What if the people who live in the "red" areas, that is, those who produce the food and energy that are consumed to the 90th percentile in the "blue" areas, decide they're not going to do that for the blue areas any more?  What if their middle finger goes up, in short?

Remember, we allegedly do not permit slavery in this country any more -- which means that which someone owns they have the right to sell - or not sell.  They have the right to produce - or, more to the point, not produce.

What if the people who peacefully conceded the result of two elections over the last eight years despite vehemently opposing the outcome decide that if the "blue" folks can riot, loot, beat people who vote the "wrong way" and similar they will not accept any further election result that doesn't go their way, and instead of rioting or burning things they will simply shut off the flow of food and energy to said "blue" areas?  After all, you don't value them at all -- you consider them subhuman, racist, xenophobic, deplorable and irredeemable -- all at once.

I'll tell you what happens if they take that decision: Every major city in the country would go feral within hours.

Within days those cities would not be blue, they'd be blackened and reduced to ash as those very same "protesters" you like so much loot, burn and shoot at each other trying to get the last scraps of food and fuel remaining.  They would then probably try to come out of the cities and take by force what had been denied them, only to run into a major problem - the "red guys" have more guns, they know the land because they live there, and more importantly they actually hit what they aim at, having had plenty of practice feeding their families with deer, wild boar and similar.  Mr. Gang Banger against Mr. Deer Hunter isn't a very fair fight, when you get down to it.

Oh by the way there's a phrase for what this would mean, if you haven't figured it out by now: Civil War.

Is that what you want?

It's where your actions are headed, if you keep doing what you're doing -- and nobody knows exactly where the tipping point is.

Better think long and hard, those of you in the "blue" places who are running this crap.  You do not have a snowball's chance in Hell of being able to grow enough in the way of crops on the landmass you control to feed a tenth of your population and every squirrel in your trees would be shot dead and eaten within an hour after this began.  Silent spring indeed.  Never mind the fact that most of you "wonderful snowflakes" couldn't shoot, skin, butcher and cook a deer -- or even a squirrel -- if you had to.  Never mind that a good 80% of you couldn't manage to run one mile if you were being chased by someone interested in eating you.

The day that cellophane-wrapped chicken stops showing up in the grocery store is literally the day 90% of Blue America starves.

Nobody in their right mind wants such an outcome.  But where do you think this all goes if you keep it up, eh?

Every bit of it has been enabled by the 17th Amendment and tyranny of the majority -- a tyranny you wish to increase by doing things such as abolishing the Electoral College.

There's a very good reason our founding fathers designed a Constitutional Republic instead of a Democracy.  They understand the problem with democracy: It doesn't work.  Democracy always ends up leading to riots and civil war, because exactly what the blue folks are doing now escalates until everyone starts shooting everyone.

A Constitutional Republic avoids this outcome because even a very large majority cannot infringe the rights of everyone else -- even when the majority lives in big, concentrated places like cities.

That was the magic sauce of the original design in our legislature and Presidency.  It's why we have an Electoral College -- to provide a bit of "overweighting" to those places that are utterly crucial to the cohesiveness and survival of the nation as a functional republic -- that is, a bit more balance against tyranny of the majority of 50%+1.

We got rid of the biggest check and balance with the 17th Amendment and I have, for decades, maintained that whenever America finally is declared dead and done, and the book is closed, that will be written in as the reason our nation's political system failed.  It's the only Amendment we cannot reasonably repeal, because to do so would require the sitting Senate to vote itself out of a job.  I'm sure you can figure out how likely that is.

But we can avoid doing more violence to our Constitution -- and we had better, or the outcome, given the annals of history available to anyone who cares to look, is quite certain.  If you want to see how this turns out should you keep pressing the issue go have a look at the map of how many states Trump won .vs. Clinton, or how the county-by-county map looks.  You'll see a lot more red of various shades than you will blue.

The bottom line?  Go ahead and be a sore loser.  Go ahead and whine.  Go ahead and try to change what our representative process led to.  Go ahead and decide to loot, burn and beat.  Refuse to accept the result of the election, if you insist.  Hell, go ahead and try to threaten or even bribe the electors!  Make sure you tear down the last little bit of foundation and structure inherent in the design of the legislature and executive of the United States.  Who needs it; it's all in the name of being "progressive", right -- even if when counted by landmass, counties or states the election was a landslide for Trump.

Just don't be surprised, if you keep it up, that at some point, given that you're utterly reliant on those you're abusing for the basics of life -- the loaf of bread, the gallon of gasoline, the electricity that powers your lights -- they decide they've had enough.  That day your supply of cellophane-wrapped meat and plastic bag full of bread disappears like a fart in the wind.  There comes a time when those who you've put the boot to for so long, and then try to deny the ability to change things peacefully through the representative process our founding fathers gave us, decide that despite their religious beliefs and good manners they're not going to service you on their knees any more.

Don't be dumb enough to think you can keep doing what you've been doing forever because you can't and if you go too far there will be no warning, no second chances and no saying you're sorry.  It'll just happen starting with one final stupid act -- and then we all lose.

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As promised here's an update after some time with my new BlackBerry DTEK60. You can read the original here.

Let's go down a bullet list and then we'll get into some specifics.  Buy this phone if:

  • You are on either AT&T or T-Mobile, or any of their MVNOs (e.g. Straight Talk, etc.)  It is not compatible with Verizon or Sprint as it doesn't have a CDMA radio in it.  (One note on AT&T below.)

  • You want a flagship-level device at a reasonable cost.  The phone benchmarks comparable to phones such as the Samsung S7 and is faster than anything in the previous class (pre-820-class CPUs.)  However, I caution people that "raw geeky stuff" rarely matters to actual overall performance -- although people do tout it frequently.  There are times that it really does matter (e.g. heavy-duty gaming), but they're rare for most users.

  • You find RF performance to be extremely important.  This ought to be one of the primary criteria when it comes to picking a phone, but usually isn't for most people.  This device is clearly superior in that regard.  Even in the first couple of days it was obvious that I had a single-grabbing monster in my hands, and it has not disappointed since.  This phone's ability to get and hold a signal reminds me of my old Nokia 3390 -- it's that good.  There's an airport over here that shares runways with Eglin AFB and the road that goes past it is always a "dead spot."  Not only does the DTEK60 not lose the signal it doesn't lose LTE!  It gets close, but never falls back.  At my home where everything else I've owned drops back to HSPA+  (I'm in somewhat of a black hole) again the DTEK60 holds a functional LTE signal.  I do not know if the QFE2250 antenna tuner (which the Qualcomm 820 supports) is in there, but whatever they've done in the RF area it is wildly successful.  My Blackberry Passport was pretty impressive in this regard -- the DTEK60 is better.

  • You want excellent cameras on both front and rear.  The Priv was known for an excellent rear camera and a crappy selfie cam, the latter forced by the slider and space considerations.  The DTEK60 has no such impediment; both are excellent.  Note that the main camera sensor itself is functionally identical to that in the Priv, and DXOMark rates both equally on a technical basis.  More on camera later; it's not the best available but it is excellent.

  • The form-factor works for you.  Let's face it, form-factor (size, etc) is important.  This is not a small phone, but it's not a huge one either.  It's the same size as other 5.5" devices, basically, and some people will consider that to be too large.  I don't, but if you do then this is a factor to be considered.

  • Security matters.  It ought to, and with the BlackBerry Android phones it is built-in.  DTEK tells you exactly what an app is doing and when, and gives you a quick and easy interface to shut off permissions if you find those actions objectionable and, if that winds up being insufficient, just uninstall the offenders.  As soon as you start looking at this you're going to find a lot of offenders and be either greatly restricting permissions or uninstalling things -- this comes from over a year's experience using the Priv.

I have no quarrels with build quality at all; it's just flat-out excellent, as is "in-hand" feel.  One point to be aware of if you run phones "uncased" is that the camera "bump" is there (as is the case with many devices) and that means running uncased is potentially hazardous not only to the glass back of the device itself (which is beautiful but since it's glass a sharp impact may shatter it) but also to the camera cover.  That cover, by the way, appears to be glass rather than plastic, which is great for optical clarity and scratch-resistance (important!) but makes it possible to damage it by impact.  I noted this is a phone you probably want in a case in my first look and I still feel that way, never mind the impact resistance a case gives you for the screen of the device.  Note that the Alcatel Idol 4s cases will fit this phone, should you want a wider selection than BlackBerry offers.  I am at present using an Incipio DualPro and like it a lot; it provides excellent protection (roughly "Otterbox" grade), keeps the "camera bump" slightly recessed and doesn't add too much bulk.  The case BlackBerry includes is functional as well, is a bit smaller in terms of its impact on device size and bulk but leaves the camera slightly protruding.

If you're wondering whether 4Gb of RAM matters here's your answer -- it does.

RAM matters more than raw CPU speed if RAM is constrained.  The difference between an app being cached (that is, already in RAM) .vs. having to re-activate it which involves reading it from storage, starting it and going through whatever initialization it requires is massive when it comes down to user-perceived performance.  3Gb devices are constrained by comparison to 4Gb ones -- it's that simple.  The counter-balance is that more RAM requires more power, and it requires it all the time since you must strobe RAM continually for it to retain its information.  We could wish that Android was more efficient with RAM use, but it is what it is as Android has always been a bloated mess from the outset and the reality is that with today's workloads and today's Android versions 4Gb is the sweet spot.  4Gb is also the limit for a 32-bit architecture and while today's processors tend to be 64-bit there is overhead involved in 64-bit operation that 32-bit doesn't have, so unless you need the capability the 32-bit system will actually be faster (even if only slightly), all other things being equal.

Now let's talk about the cameras since everyone and their brother seems to think this is arguably the most-important aspect of a phone these days.

There are multiple aspects to camera performance, and only some are captured by technical specifications.  DXOMark has tested the (main) camera and says its "equal" (in score) to the Priv, which had an excellent technical score.  I generally agree with this, but with that said let's talk about the differences, because there are some.

For background and to put some context on what follows I have been a photographer for pretty-much my entire life, starting as an early teenager.  I used to have my own darkroom back in the film days and have shot nearly everything, including cold-camera astrophotography for a few years when I had "at will" access to a very nice telescope setup in northern Michigan that cost far more than I've got available for such endeavors (and which at the time was so far beyond my personal means that it boggled my mind.)  Today I own a Canon 5d3 with a gaggle of lenses for various purposes and a very nice Sony 4k video rig, along with the usual plethora of tools to make use of those images (Adobe's suite, Vegas Video Pro, etc.)

The Priv's camera tended toward oversaturation of colors, which some people "like" but it is not what you actually saw when you looked at the scene.  It also had "ringing", probably related to that oversaturation, evident some of the time, and high-contrast edges often had minor artifacts that were visible in 100% crops.  Generally speaking performance was outstanding for a shooter on a phone, but I'm trying to pick some nits here.

The DTEK60 uses the same basic sensor as the Priv, however, it uses the entire 21mp frame instead of being limited to an 18mp one.  Why the limit on the Priv?  Simple: The Priv has OIS and a different lens system than the DTEK60, and both of those meant that illumination wasn't complete on the sensor, so only 18mp was used.  This means the DTEK60 has the same pixel size.  The lens on the Priv was f/2.2; on the DTEK60 it's claimed to be f2.0 but the embedded EXIM data claims f/2.2, so the DTEK60 either has a small (1/3rd of a stop) but real advantage in light gathering or is identical to the Priv, depending on which is correct.

The DTEK60 also does not exhibit the oversaturation that the Priv did.  I'm not sure why since the camera software (at the application level) is the same, but the firmware in the camera module is likely different.  Whatever the cause the oversaturation issue is gone.

Is the camera perfect?  No.

The large-mp-count sensor means that even with an f/2.2 lens under low light you're not going to get the same sort of performance you'll get from some of the cameras showing up in phones with 12mp.  There's a reason that Google, Apple and a few others went to smaller megapixel-count sensors -- it makes the pixels bigger, and thus the amount of light gathered per-pixel larger.  This in turn allows for a faster shutter speed for a given ISO, all other things being equal, which means less risk of motion blur and less sensor noise in low light conditions. Yes, you get less resolution but as with all things there are trade-offs, and some vendors have gone that direction.  BlackBerry did not. There is no free lunch, however, and in good lighting conditions resolution wins.  You choose; to get you must give.

The camera also does not have OIS, while the Priv did.  Does this matter?  Not as much as you might think, but under low light with a stationary object being photographed it can, quite materially, sharpen the image you obtain because it reduces (by a lot) camera shake.  Phones, of course, are hard to hold steady due to their shape.  This also matters during video shooting, but electronic stabilization can be used there, and the DTEK60 supports it.  The question to ask is how often do you shoot stationary objects in low light.  A person or group of people (or any scene containing people, animals and similar) is not stationary.  Neither is anything that can be impacted by wind or other movement sources. I can show you examples where the Priv outperformed the DTEK60 in this regard, allowing a slower shutter speed and a crisper image, but this actual scenario in real use is rare -- although darn easy to contrive for a test.  My personal view is that OIS is nice but not necessary and I consider it a minor, but real, ding to not have it.  It has not impacted my ability to take good shots at all.

The flash has less power than the Priv's by a small amount but it doesn't appear to impact the image quality.  Again, the issue is on the fringe of the range where you can use flash; the Priv will cover a modestly larger area than the DTEK60 in that regard.  I personally detest on-camera flash no matter the camera for the lighting field and effect it produces, but there are times you either use it or get no picture.  When the camera is pushed in low light but with a lot of dynamic range performance degrades in a reasonable fashion and while the defects are clearly visible with 100% crops you won't see them looking casually at the images.  Note that most uploads to social media or to blogs, including this one, are going to be cut down as the original files produced by the camera tend to be about 4Mb each so there's little point in trying to show you what the camera actually produces on a blog.  You simply need to either look yourself or find someone with the dedicated bandwidth resources for multiple huge files you can download and view at the 100% level.

BlackBerry's camera app has been updated a number of times since the Priv's first release and it is found on the DTEK60.  Beyond very simple exposure correction (which is nice) and touch-to-focus and take exposure lock (also nice) it allows for full manual exposure control should you wish.  Manual controls only work, obviously, when you have time to compose, set and shoot, but when you can use them the flexibility is appreciated.  Note that the one thing you cannot change in a cellphone camera is the f/stop and this means depth-of-field is not under user control; you must vary either shutter speed or ISO to change your exposure.  I like the BlackBerry camera app a lot and consider it a major plus compared against many others, especially the vanilla Android app that some phones have.  BlackBerry's camera app has face recognition and exposure compensation for detected faces (which can be turned off), and it works well.

Two things that are lacking on the DTEK60 camera, as with the other BlackBerry android handsets, are "Raw" capture and the Camera2 API.  RAW photos are huge and in addition worthless until post-processed, but they get all the data the sensor has and are how I prefer to shoot with my dSLR.  Having the option would be nice, and I'd like it a great deal if BlackBerry was to support it; since the DTEK60 has the ability to take a large SD card storage space is a non-factor.  Here's hoping BlackBerry adds this capability!  As for Camera2 the primary use for that is manual control and BlackBerry provides it, so that is IMHO far less important.

Here's an example of a 100% crop of a shot I took of the cat sitting on my lap in very low available light; there's very little artifacting, saturation is nearly bang-on as is white balance.  In short, that's exactly what the cat actually looks like when you see her with your eyes.  The problem with this shot at a 100% crop level is that the shutter speed and ISO combination made impossible completely stopping subject motion (if you think a cat is ever completely still forget about it!) and thus there's some evidence of motion blur when you dig into the image at the 100% crop level.

The shot, viewed as an image in Photoshop (or Microsoft's "photo viewer") in a "natural" size (e.g. fills my monitor) shows none of that defect; it appears to be very sharp and in-focus.  It's only when you dig in at a pixel-peeping level you see the cost of the larger pixel count in low light.  Of course as light level goes up that compromise disappears because shutter speed rises and ISO goes down; this shot has camera data in it saying exposure was 1/15th sec and ISO 757.

Noise (and moire!) is extremely bad at ISO 12000, but that's in the "ludicrous" range.  At ISO 3200 it's much better with the moire gone, and once you get down to and below 1600 noise is very good (and improves with further ISO reduction.)  That you can crank the ISO up far enough to make a photo possible in otherwise no-flash allowed conditions is interesting, but don't expect to like the results when you really push it.

There is a bug in the original firmware release; the positive exposure compensation adjustment is non-functional if the sensor gain is as far up as the software will allow, and the camera does not instead increase the ISO to allow the compensation to work.  All the other manual overrides work (including negative exposure comp.) This is something I'm sure BlackBerry will fix as they tend to be very "on the ball" with camera software updates.  In the meantime you can force the ISO higher manually and get your desired exposure compensation, so there is a workaround.

For video shooting the camera performs as expected.  It has electronic stabilization and can shoot in a number of modes and resolutions as shown here -- of note is that while it can capture at 4k slow-motion (60fps) only works up to 1080p.  You need a very fast SD card to be able to keep up with 4k recording -- UHS1/U3 (not U1!) is required and be prepared for utterly ridiculous file sizes!  If you run into trouble with 4k recording your card is too slow; there are a lot of cards that claim to meet spec but do not.  Stay with Sandisk or Samsung's Evo line and make sure they're U3 rated; you're going to pay more but they'll actually work.

Verdict: The camera acquits itself very well.  The "selfie cam" is excellent also, easily the best BlackBerry has ever put into a phone.  While "by the numbers" testing the main camera is equal to the Priv; in actual use it's a bit better.  Is it "best available", no -- not in low-light performance anyway.  It is suitable for a "flagship" level device?  You bet; color accuracy is excellent, the presence of artifacts (largely a function of the jpeg compression used) is very well-controlled and the stock camera app provides for full manual control if and when you desire it.

The screen is gorgeous.  As far as being accurate in its color rendition it's better than I expected.  AMOLED screens always have very deep blacks (since it actually turns off pixels entirely and has no backlight) but tend to lose in the color rendering accuracy department.  The common AMOLED sin of oversaturated colors and thus poor accuracy (although some people will claim that such inaccurate reproduction has more "pop" and thus they like it better) has been avoided on the DTEK60.  This screen is one of the best I've seen on a smartphone and it has the chops to be reasonably visible outdoors in direct sunlight which is where many AMOLED screens fall flat.

The fingerprint scanner is very fast and accurate.  But don't kid yourself -- fingerprint scanners are not very secure.  They beat nothing, and they probably beat a 4-digit pin, but they lose to anything more complex and maybe lose big.  If your fingerprint can be lifted from anything you've touched it can be trivially unlocked, so just keep that in mind.  With that said the boot password cannot be fingerprint (good) but I'd really like to be able to set the screen to not be able to be unlocked with a fingerprint but apps that can use fingerprints to remain available.  That would "stratify" the security model in the device since you have to unlock the screen first (the more-secure act) and then once that's done the fingerprint, while less-secure, is being used in the context of an already unlocked device.  Today there's no option to do that but BlackBerry could probably add it, and IMHO should.

The power amp (for headphones) is both nicely clean and plenty loud for nearly anyone.  The device sounds great through my Shure earbuds playing FLAC files.  Speaking of which, download the Onkyo HF player; I like it and it works exceptionally well.  If you're a real audio nut and want an external USB ADC there's a "pro" version of that player for a fee that supports them but that's not necessary for users that are happy with the built-in audio amplifier and headphone jack.

Notification sounds are a bit lower than I'm used to, even with the phone's volume set to maximum.  Phone ringtones start at a lower volume and ramp; I suspect there's an error here in that notification sounds are doing that too, but since they're short they end before the ramp happens.  If so that's something BlackBerry can easily fix in software, and I suspect they will.

On battery life it's simple: I'm impressed.  I've yet to run out of power in a day's use or need to recharge mid-day.  I've come home with 20% power remaining, but never a zero.  If you do need to "top off" this phone picks up power at an utterly ridiculous rate; about an hour from nearly empty to full with a QC3.0 charger.  The in-box QC2.0 charger will fill the battery from empty in about an hour and a half.  It appears BlackBerry and TCL got the balance of battery capacity .vs. power consumption right where it needs to be for a flagship in that most users and most workloads will get through a full day without having to recharge in the middle of it.

There are two things to keep in mind with regard to carriers.  First is the good -- T-Mobile appears to have no problem with the device including WiFi calling, Band 12 and VoLTE despite it not being listed as a "supported" device.  This is a big plus.  But AT&T appears to be blocking the phone's hotspot from working on purpose via their provisioning process when you insert an AT&T SIM (although the phone certainly can do it) and there are reports they have told customers that it's "corporate policy" not to allow it on devices they do not sell.  That's an apparent violation of the law, by the way, in that it implicates "tied sale" restrictions in anti-trust law, so if this matters to you then you should head over to the FCC web site and file a complaint.  We'll see how that turns out; I've done so, and the nice thing about the process is that the carrier has to respond.  I have in fact received a call from AT&T as a result of my complaint and read them the riot act; we'll see if that makes it way up the chain and leads to a resolution. Shaking the tree might just be enough, seeing as this "omission" could be an accident and with relatively-recent FCC action on unlocking codes and similar "that which is old but no longer defensible" sometimes is easily toppled over.  We'll see.  If Hotspot is not important then you don't care (and there is a workaround if you simply want to connect a laptop and it has bluetooth; since your account has Hotspot enabled it is not a TOS violation to use it either) but this sort of discriminatory conduct is something that should absolutely not be tolerated by anyone. Update: AT&T and/or BlackBerry have resolved this; the Hotspot now works on AT&T service.

What compromises are you making, other than the potential AT&T issue, by choosing this device?  A few.

  • There is no wireless charging.  Is it convenient?  Yes.  Is it fast?  No, and what's worse is that it contributes to a lot of heating.  I had a wireless pad I rigged in my car phone-holder, but it would shut down if the AC wasn't blowing on the phone at the same time and I tried to use it with Navigation running, which materially reduced its usefulness.  During the summer this was a non-factor, of course, but in the winter the last thing you want blowing out of your vents is cold air!  Wireless charging's best use is at your home at night; drop it on, next morning you're good, and it saves wear on the USB socket.  The latter is less of a factor with USB Type C connectors, but the convenience issue is real.

  • There are better low-light performing cameras out there.  However they're in phones that cost $200+ more; that's a 40% increase in price, and some of them don't have SD card slots either (e.g. the Google Pixel.)  I find the latter an utterly inexcusable and intentional omission designed to force you to buy a larger-storage phone (at much higher cost) or trust my data to the "cloud" (no thank you!) and thus refuse to buy a device without a card slot.  We're talking about differences at the margin however, not the difference between a "crap" camera and a "good" one.

  • If you want to root the device and install some other ROM, forget it.  This sort of ability used to matter to me, and still does if I don't get timely updates.  But BlackBerry has promised to provide timely updates and has a history with the Priv of doing exactly that which stretches back more than a year.  They've also already delivered the November security update for the DTEK60, right on time.  Never mind that unless you're moderately (or better) skilled you're taking a fairly serious privacy risk in loading "third party" firmware on your mobile device.  If you never have anything you care about (like your bank app) on the phone then perhaps that's not important to you, but most people these days do conduct at least some of their financial transactions over a mobile device, and thus you should care about security and data integrity.

  • If a multi-color LED is at the core of your "requirements" then this handset is excluded.  It has a red-only LED. I miss my multi-color notification LED. Is it enough to make the difference in what handset I choose?  No.

So we have four things that are "minuses" compared against some of the competition, but that's about it in terms of items I can identify.  There is certainly no difference in performance on a user-perceptible basis, you are giving up exactly nothing in terms of RF (in fact the radio performance is among the best I've ever experienced from any device), it's Android with all that's good (and bad) so you have the full Android app base and it has the BlackBerry "addons" that you can't get elsewhere, most-specifically DTEK.

Everything, in the end, has to be measured in terms of value received for price paid.  It is here that BlackBerry has really stepped out and upped their game.  Historically-speaking BlackBerry has tended to price their phones at the upper end of the range for a given set of specs, viewing their "special sauce" as having enough value to justify the ask.  This device is different; it comes to market at the top of the game but one notch in pricing above the mid-tier of devices.  This appears to be the result of BlackBerry exiting designing their own devices from the ground up, and instead selecting a reference design that already exists and asking for relatively-minor changes to be made to it.

The result of this change in strategy -- and pricing -- is that the only devices you can find with DTEK60 class specs at a cheaper price are the Chineesium devices with no promise of updates, an unknown provenance in terms of what might be in there you don't want (spyware, a root key that the Chinese government has, etc) and potential trouble with warranty replacement should the need arise.  Some of them (e.g. the OnePlus3) are disqualified for lack of an SD card slot as well.

Before you consider the "unknown provenance" comment to be speculative may I point out that it is definitely not.  There have already been devices caught in the last few months with "special" bootloader commands enabled from the factory but hidden that allow someone who is aware of them to break into the device.  This risk is real and if you buy something from a Chinese company with no accountability it's a risk that could bite you down the road.

The "mainstream" brands -- Samsung, HTC, LG, Google's Pixel, Apple and similar all have "flagship" class devices with comparable specs, and in some cases advantages (e.g. water resistance in the case of Samsung.)

The bad news is that all of them are much more expensive, starting at roughly 40% more than the DTEK60!

There's a hell of a difference in price between a phone that sells for $499 and one that sells for $699; you damn well ought to expect much better from the $699 phone, and quite-frankly there's no rational argument to be made on this point: You simply don't get it.

Instead what you get are improvements at the margin while having to fork up hideous additional cost.

For me, and I suspect for most others, the answer is and ought to be "no thanks."

If you hate money and will pay 40% more for a camera that can shoot better in very low light then buy a Pixel or S7.  If you tend to drop your phone in the toilet and hate money then buy the S7 since it's water-resistant (and 40% more expensive) while the other two competitors are not.

If neither of these descriptions fit you, signal-holding performance is very important, being able to easily monitor what apps are doing and control their behavior matters, a device that is inherently difficult to break into should you lose it or have it stolen is something you find to be of value, and you want a phone that runs with some of the best available today in terms of both specs and real-world performance, then buy the BlackBerry DTEK60.

The verdict is in and it is simple: Strongly recommended.

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