"The best interest of the patient is the only
interest to be considered." — William J. Mayo
A Story to Begin
In July of 2025, a humanitarian physician aboard a floating
seastead clinic was called to treat a young engineer suffering from acute
appendicitis. The medical side was straightforward: surgery, antibiotics,
recovery monitoring. The billing side was chaos.
There was no national insurance system. No government
payer. No recognized billing codes for procedures performed in a
man-made ocean platform outside any national jurisdiction.
Payment came in the form of pooled crypto-tokens from fellow
seasteaders. The surgery was a success. The patient survived. But the bigger
question remained: how do you run a sustainable healthcare system where
billing, documentation, and legitimacy simply don’t exist?
This is not a one-off. It’s the frontier of medicine.
In refugee camps, in unrecognized states, in space stations, in floating cities
— clinicians are facing the same issue: medicine is universal, but billing
is not.
Why This Topic Demands Attention
- 63%
of physicians believe there aren’t enough qualified doctors to fill
workforce needs, and underserved zones bear the brunt (Medscape, Aug
2025).
- Policy
fragmentation is worsening access, as seen in U.S. vaccine policy
disputes, which ripple across global humanitarian health systems (Vox, Aug
2025).
- Refugee
populations have reached over 45 million people worldwide (UNHCR,
2025), many living in billing “black holes” where care is undocumented,
unreimbursed, and invisible.
- Private
ventures are actively designing seasteads and orbital habitats, but
healthcare financing is barely an afterthought.
When we talk about healthcare equity, we rarely ask: who
pays when there is no payer?
Expert Round-Up: Three Perspectives
1. Dr. Alicia Romero, Global Health Consultant
"Billing isn’t just reimbursement. It’s legitimacy.
Without documentation, the work you do in a camp or a seastead doesn’t count in
the eyes of international systems. Invisible work leads to invisible workers —
and eventually burnout."
Romero argues for a portable, borderless billing
framework that NGOs, insurers, and international bodies can recognize.
Without this, thousands of procedures vanish into undocumented space.
2. Dr. Kenji Sato, Space Medicine Researcher
"In space habitats, billing will define survival.
There is no CMS orbiting Earth. We need hybrid models: part insurance, part
mutual aid, part digital ledger. Otherwise, the first hospital in orbit will
also be the first bankruptcy in orbit."
Sato’s research focuses on blockchain-anchored billing
— ledgers that travel across space, Earth, and stateless regions without
relying on a single government.
3. Dr. Miriam Klein, Humanitarian Physician
"In refugee zones, it’s not just about getting paid.
It’s about continuity of care. If a child with asthma moves from a Syrian camp
to a Jordanian hospital, their history is gone. Billing frameworks double as
continuity frameworks."
For Klein, billing equals record-keeping. Without it,
displaced populations lose not just their finances, but their medical
narratives.
The Numbers Behind Stateless Billing
When discussing billing without borders, the
conversation often feels abstract. But the statistics show just how urgent this
problem really is:
- 45
million+ refugees worldwide (2025) are living in camps or transit
zones where no standardized billing exists (UNHCR).
- 63%
of physicians report a shortage of qualified peers, with underserved
and stateless regions hit hardest (Medscape Survey, Aug 2025).
- 80%
of refugee camps rely on donor funding or voucher systems,
but less than 20% of those systems use standardized billing codes
(WHO).
- Over
$5 billion USD annually is spent on healthcare in humanitarian zones,
yet much of it is untracked by formal billing frameworks, leading
to waste and duplication (World Bank 2024).
- In
seastead pilot projects, 90% of medical encounters were self-pay
or crypto-funded, with zero recognition in international health
systems (Ocean Frontier Report 2024).
- Healthcare
worker turnover in stateless zones exceeds 40% annually, driven in
part by lack of recognition for undocumented work (Doctors Without Borders
internal data).
- In
simulated space medicine trials, billing for treatments was tested
using blockchain tokens, and 100% of participants agreed
that digital ledgers could solve continuity issues if scaled
(NASA-affiliated Mars Habitat Study 2023).
Tactical Advice for Practitioners
- Document
anyway. Even if there’s no reimbursement now, create coded records
that could be recognized later.
- Think
portability. Use blockchain, portable encrypted USBs, or NGO
record systems that survive relocation.
- Standardize
costs. Post transparent fees, even in camps, so NGOs and donors
can anticipate needs.
- Build
legitimacy. Work with professional societies to push for global
billing standards in extraterritorial care.
- Collaborate.
Partner with engineers, policymakers, and economists — billing
without borders is not a physician-only project.
- Train
local staff. Empower nurses, aides, and community health workers
to use basic billing tools so the burden doesn’t fall only on physicians.
- Adopt
mobile-first tools. Use smartphone-based billing apps that work
offline and sync when connectivity is restored.
- Prioritize
continuity. Always ensure billing systems also track medical
history, not just costs, to maintain patient care across borders.
- Leverage
donor interest. Link billing records to impact reports that
show funders exactly how their money was used, improving trust and
sustainability.
- Pilot
small systems first. Test billing frameworks in micro-clinics or
temporary camps before scaling them to larger humanitarian or seastead
populations.
- Plan
for data security. Stateless populations are vulnerable; prioritize encryption
and patient privacy in billing documentation.
- Advocate
for recognition. Share your experiences with policy bodies,
journals, and medical associations to push billing in stateless zones
onto the global agenda.
Questioning Best Practices
Best practice says: code in ICD-10, submit to CMS or
private payer, reconcile with EMR.
But what happens when:
- ICD-10
has no code for orbital decompression sickness treated in a space
station?
- CMS
has no jurisdiction over a seastead procedure?
- Private
payers deny claims for “extra-territorial procedures”?
The industry insists on universality, but the truth is
clear: billing best practices collapse at the edges of civilization.
Real-World Failures
- A
physician in a South Sudan refugee camp delivered 300 babies in two
years. When the camp relocated, all records vanished. She had no
evidence for credentialing boards, and the mothers had no documentation of
care.
- A team
on a seastead performed 20 surgeries funded by Bitcoin donations.
Months later, none of those cases were recognized in international health
reporting.
- In one
Middle Eastern refugee corridor, tuberculosis treatments went
undocumented, meaning WHO could not count the impact in its global
burden data.
Each failure highlights a single point: billing is not
just financial. It is recognition.
Myth Buster
- Myth:
Humanitarian medicine doesn’t need billing.
Truth: Billing matters because it validates care, supports continuity, and allows for resource allocation. - Myth:
Stateless healthcare is too rare to matter.
Truth: With 45+ million refugees, multiple seastead projects, and active space missions, it is not rare. It is expanding. - Myth:
Billing is only about payment.
Truth: Billing is also about legitimacy, recognition, and continuity. - Myth:
NGOs can handle all the financial tracking without billing codes.
Truth: Without standardized billing systems, NGO records remain fragmented, making cross-border accountability almost impossible. - Myth:
Patients in refugee camps don’t care about documentation.
Truth: Patients value proof of care for immigration, resettlement, and continuity; without records, their health history is erased. - Myth:
Insurance companies will never recognize extra-territorial claims.
Truth: Some global insurers are experimenting with limited coverage models for stateless or space-related health events. - Myth:
Technology will automatically solve billing gaps.
Truth: Blockchain and digital ledgers are tools, but they need governance, adoption, and ethical frameworks to be effective. - Myth:
Doctors should only focus on saving lives, not billing.
Truth: Billing ensures sustainability. Without it, physicians face burnout and healthcare systems collapse under invisible labor. - Myth:
Billing systems are too complex for low-resource or stateless zones.
Truth: Simplified billing frameworks can be designed, focusing on essential codes and portable documentation. - Myth:
Stateless healthcare challenges won’t affect established nations.
Truth: Pandemics, migration, and off-world ventures mean stateless billing failures spill over into national systems.
FAQs
Q: Who pays for medical services in stateless zones?
A: Typically NGOs, philanthropies, or patients directly. No standardized
payer system exists.
Q: Can insurance cover care in these regions?
A: Rarely. Some global emergency policies cover limited care abroad, but
space or seastead care is excluded.
Q: What’s the risk for physicians?
A: Uncompensated, undocumented labor — leading to financial loss,
burnout, and career stagnation if work is not recognized.
Q: What’s the first step toward a solution?
A: Develop universal, portable billing codes that any NGO or payer can
recognize across borders.
Q: How do refugee camps currently handle billing?
A: Most use donor-funded subsidies or voucher systems, but
billing data is often fragmented and inconsistent.
Q: Could blockchain solve the problem?
A: Possibly. Blockchain billing systems could provide secure, portable,
and verifiable records, but adoption is slow and requires international buy-in.
Q: Are electronic health records used in these zones?
A: Rarely. In many camps and seasteads, records are still paper-based,
which increases the risk of loss during relocations.
Q: What role should governments play?
A: Governments could recognize extraterritorial billing frameworks, even
if services occur outside their jurisdiction, to ensure legitimacy.
Q: How do patients respond to direct pay in stateless
settings?
A: Many cannot afford direct pay. Barter systems, pooled funds, or
crypto-based tokens have been used, but these are inconsistent and
unstable.
Q: Is there an ethical dimension to billing in stateless
zones?
A: Yes. Ethical concerns arise when lack of billing frameworks leads to
unequal access, undocumented care, or exploitation of vulnerable populations.
Q: What happens to unpaid medical debts in these
settings?
A: In most cases, debts are written off or absorbed by NGOs, since
there’s no enforcement mechanism across borders.
Q: Are medical professionals compensated fairly in
stateless zones?
A: Often no. Many rely on NGO stipends or volunteer contracts, which may
not reflect the volume or complexity of the work performed.
Q: How might space medicine handle billing in the future?
A: Experts suggest a hybrid system — part mutual aid, part insurance,
part digital ledger — to handle healthcare costs in orbital habitats or lunar
bases.
Building Solutions
- Portable
Coding: ICD-11 or blockchain-compatible ledgers that survive
relocations.
- Shared
Platforms: NGO consortiums maintaining unified billing/record systems.
- Training:
Teaching clinicians to code and bill even when no payer is present.
- Policy
Pressure: Advocacy to WHO, UNHCR, and insurers for recognition of
extraterritorial billing.
Pitfalls in Stateless Medical Billing
Even with good intentions, efforts to create billing systems
in refugee camps, seasteads, or space habitats often fall into common
traps:
- Over-complex
systems. Designing billing frameworks that mirror national-level
complexity (like full ICD-10 or CPT databases) overwhelms clinicians
in low-resource zones.
- Ignoring
local context. Billing models imported from high-income countries
often fail in camps or stateless regions where internet access,
electricity, or literacy is limited.
- Data
silos. Different NGOs or clinics often build separate billing
records, leaving patients with fragmented or duplicated medical
histories.
- Technology
overreach. Jumping straight to blockchain or AI billing solutions
without training or infrastructure creates confusion and distrust among
staff and patients.
- Lack
of transparency. When patients or NGOs don’t understand costs, trust
erodes and resource allocation becomes contested.
- Unrecognized
records. Even when billing data exists, if it is not accepted by
global bodies (WHO, insurers, governments), the work remains
invisible.
- Staff
burnout. Burdening clinicians with extra administrative tasks
without support systems accelerates turnover in already high-stress
environments.
- Ethical
blind spots. Billing systems that prioritize certain services over
others can unintentionally discriminate against vulnerable groups.
- Security
risks. Storing billing and patient data in unstable or stateless zones
without encryption exposes populations to exploitation or political
misuse.
- Short-term
fixes. Many pilots collapse when donor funding ends, leaving behind nonfunctional
systems and staff trained in tools they can no longer use.
Proof of Concept
- In
Haiti post-earthquake relief, physicians piloted mobile billing apps
that tracked services and linked them to donor funding.
- In a
simulated Mars habitat in Hawaii, billing was trialed using blockchain
tokens, proving feasibility in extreme isolation.
- Several
refugee health NGOs now use hybrid systems combining billing and
clinical data to satisfy both donors and medical continuity.
Key Insights from Stateless Medical Billing
- Documentation
is power. Even in stateless zones, detailed records validate
care, support continuity, and protect clinicians. What isn’t
documented often disappears from both history and recognition.
- Portability
is essential. Healthcare systems that move with patients —
whether through blockchain, mobile apps, or NGO networks — are the
future of extraterritorial care.
- Simplicity
outperforms complexity. Lean, portable billing frameworks are
more effective than trying to replicate national insurance systems
in low-resource or stateless environments.
- Collaboration
drives sustainability. Working with NGOs, engineers, policymakers,
and funders ensures billing systems are practical, recognized, and
durable.
- Ethics
and transparency matter. Billing is not just financial; it is ethical,
ensuring fair access, continuity of care, and trust with vulnerable
populations.
- Technology
is a tool, not a solution. Innovations like digital ledgers or AI
are powerful, but adoption depends on training, infrastructure, and
governance.
- Global
standards are overdue. Stateless zones expose gaps in healthcare
systems: there is an urgent need for international recognition of
portable billing codes and documentation frameworks.
- Failures
are lessons. Failed pilots, lost records, and unrecognized care
highlight what not to do, providing invaluable guidance for
designing scalable solutions.
- Future-proofing
matters. As space habitats, seasteads, and refugee populations grow,
early investment in robust billing frameworks will prevent costly
disruptions and burnout.
- Impact
is measurable. Effective billing systems enable better reporting,
resource allocation, and funding transparency, which ultimately
improves patient outcomes.
Step-by-Step Guide to Stateless Medical Billing
Step 1: Assess the Environment
- Identify
the type of zone: refugee camp, seastead, space habitat.
- Evaluate
available infrastructure: internet, electricity, mobile coverage.
- Determine
local partners: NGOs, clinics, aid organizations, or tech
providers.
Step 2: Define Billing Goals
- Decide
whether the billing system will track costs, patient records, or both.
- Prioritize
legitimacy, continuity, and portability.
- Set realistic
scope based on available resources.
Step 3: Standardize Codes and Services
- Use ICD-10/11
codes where possible; create custom codes for extra-territorial
procedures.
- Clearly
define services, procedures, and medications for billing purposes.
- Establish
transparent pricing or donation-based equivalents.
Step 4: Choose a Documentation System
- Digital
ledger or blockchain for portable records.
- Encrypted
USBs or mobile apps for offline access.
- Paper
backups as contingency in low-tech environments.
Step 5: Train Staff
- Educate
clinicians, nurses, and administrators on the system.
- Emphasize
data security, accuracy, and portability.
- Include
cross-border protocols for when patients move locations.
Step 6: Pilot the System
- Start
small in a single clinic or temporary site.
- Track
workflow, usability, and error rates.
- Gather
feedback from staff and patients.
Step 7: Monitor and Adjust
- Continuously
evaluate accuracy, compliance, and acceptance.
- Fix technical
or operational gaps promptly.
- Update
codes, procedures, and fees as new needs arise.
Step 8: Integrate with Partners
- Share
records and billing data with NGOs, funders, or global health
bodies.
- Ensure
compatibility with donor or government reporting.
- Build
redundancy for future migrations or expansions.
Step 9: Scale Thoughtfully
- Expand
to multiple camps, seasteads, or space modules once tested.
- Ensure
staff training, infrastructure, and governance scale in parallel.
- Maintain
transparency and accountability throughout.
Step 10: Evaluate Impact
- Measure
patient continuity, funding utilization, and recognition of care.
- Document
lessons learned for future deployments.
- Publish
findings to influence global health standards.
Final Thoughts
- Healthcare
without borders is no longer theoretical. It is real, present, and
growing.
- Billing
is the missing infrastructure. Without it, care is invisible and
unsustainable.
- We
must act now before the gap widens.
Call to Action
Get involved. Join the movement. Step into the
conversation. Start your journey.
Be part of something bigger. Engage with the community. Raise your hand.
Lend your voice.
Take the first step. Start here. Share your ideas. Help shape the future.
References (This Week)
- Physician
shortage survey (Aug 2025): 63% of doctors say there aren’t enough
qualified peers to fill open positions, underscoring the pressure in
underserved and stateless zones. Read at Axios
- Vaccine
policy conflict (Aug 2025): Leading physician groups defy rollbacks on
vaccine policy, highlighting how governance gaps disrupt healthcare
delivery. Read at Vox
- WHO
humanitarian health frameworks: WHO guidance on refugee health
highlights the lack of billing infrastructure in humanitarian delivery. Read at WHO
About the Author
Dr. Daniel Cham is a physician and medical consultant
with expertise in medical tech consulting, healthcare management, and
medical billing. He focuses on delivering practical insights that help
professionals navigate complex challenges at the intersection of healthcare and
medical practice. Connect with Dr. Cham on LinkedIn to learn more:
linkedin.com/in/daniel-cham-md-669036285
Hashtags
#HealthcareWithoutBorders #MedicalBilling #StatelessZones
#SpaceMedicine #RefugeeHealth #MedicalInnovation #FutureOfCare
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