Although I had stated that I would limit postings on this list to health policy issues, because of the volume of responses received, I am unable to respond individually to your comments on my “weak apology” for the anti-war poetry. Thus this message.

Simply stated, my faith has been restored.

Although somewhat narrowly focused, I believe that the comment on a sign at peace demonstrations in Los Angeles, graciously forwarded to us by Anne Marie Staas Niedorf, expresses the sentiment and priorities of most of us:

SADDAM DIDN’T CLOSE MY HEALTH CLINIC

Economic and Social Research Institute February 2003 Issues in Coverage Expansion Design

Coping with Risk Segmentation: Challenges and Policy Options by Elliot K. Wicks, Ph. D.

A factor that complicates almost all proposals to extend health insurance coverage is how to cope with risk segmentation in the small-group and individual insurance markets. Experience in these markets shows that if market forces are left to operate unfettered, people seeking private health insurance will be segregated into small risk pools that reflect their expected risk of incurring medical expenses and charged premiums accordingly. Premiums will vary widely across the spectrum of expected risk, and risk will not be widely shared. These are problems that generally do not plague large employers, because they are large enough to form their own risk pools and self-insure; that is, costs are sufficiently spread among higher-risk and lower-risk employees within the group. So the discussion that follows applies to health insurance for small employers and individuals buying coverage on their own.

Risk segmentation and the consequent wide variation in premiums create at least two kinds of problems. First, some high-risk people are not able to afford coverage. Second, the wide premium spread requires some people to pay much more than others for identical coverage, which many would consider inequitable.

Alternative Ways to Deal with Risk Selection

Prevent Risk Selection

Approach 1: Require insurers, in setting premiums, to community rate everyone.

Approach 2: Require everyone in some subset of the population who purchases coverage to buy from a common source and have each insurer base premiums on the experience of all its enrollees in the pool – for example, require all small employers to buy from a purchasing cooperative or insurance exchange.

Approach 3: Instead of charging people premiums, use public financing, as with the Medicaid and Medicare systems.

Approach 4: Single payer without health plans that accept any risk.

A single-payer system that did not put health plans at risk – as with fee-for-service Medicare – would solve both sides of the risk segmentation problem. Enrollees would not pay premiums, and thus there would be no difference in cost associated with risk differences. And insurers would not bear risk – they would just administer the system – and thus there would be no reason to compensate them for differences in the risk of the people they enroll. There would be no risk segmentation because there would be only one insurer – government.

Allow but Offset Risk Selection

Approach 1: Allow wide (though perhaps not unlimited) variation of premium based on price, but provide subsidies to help high-risk enrollees pay the high price they will face.

Approach 2: Make risk selection unprofitable by having a very good risk-adjustment process.

http://www.esresearch.org/newsletter/february03/risk_segmentation.pdf

Comment: This report describes the policy implications of various approaches to segmenting risk. It is worthwhile reading this nine page report because you will understand the problems that arise with each approach. Understanding risk segmentation makes it clear why it is so difficult, or, actually impossible, to ensure that everyone has equitable, affordable health care coverage. But the exception is the single payer approach which is unique because there would be no risk segmentation since there would be only one insurer – the government.

Why do we waste so much effort and expense on playing the risk segmentation game, perpetuating inevitable inequities, when we can save time and money and establish equity by dumping the health plans and establishing a single payer system? Do we have an aversion to logical solutions?

The Access Project, with other organizations February, 2003

The Consequences of Medical Debt

Summary of key findings:

* Having health insurance does not always protect individuals from out-of-pocket medical bills they cannot afford to pay. In our survey of low-income individuals in three communities, respondents with and without insurance were struggling with comparable levels of medical debt.

* Confusing and multiple bills, and the challenge of understanding what is owed and to whom, add to the problem.

* Provider practices – requiring cash payment upfront, flatly refusing care or suggesting people use other sources of care – made it harder for many respondents with medical debt to access care with any regularity. Patients often responded to these practices by not seeking care or filling prescriptions, or otherwise not complying with treatment regimens.

* Health care providers seem to be adopting more aggressive collection procedures, including turning over their accounts to collection agencies 30 to 60 days after a missed payment (instead of a more customary 150 to 210 days) and encouraging patients to pay off their medical bills with credit cards, a practice that burdens patients with not only large debts, but high interest payments as well.

* Many of the individuals we interviewed wanted to pay off their debt and had tried to negotiate payment plans, but found the terms of the plan very difficult to maintain given limited incomes and apparently inflexible hospital collection practices.

* Few respondents, in spite of very low incomes, were able to secure public assistance to defray the cost of their medical care. Many turned to family and friends for help, suggesting that communities may help relieve the burden of medical debt, but also share in it.

* Like other forms of debt, medical debt can have substantial financial consequences, including serious credit problems and, in extreme cases, personal bankruptcy. However, unlike other forms of debt, medical debt is often involuntary, the result of an event over which one has little or no control.

* Bankruptcy may offer a means to relief from medical debt and from the harassment of collection agencies and its attendant stress. This is particularly the case for the uninsured – people who are likely to have relatively fewer resources and be less able to make regular payments on their debt.

* Medical debt made it harder for respondents to achieve self-sufficiency; they were hindered in their ability to get a bank loan and other lines of credit, to save money, or to pay for basic goods and services.

* The effects of medical debt can be compounded if a health problem leaves a person unable to return to work. Because of the debt, people may be deterred from seeking the care needed to allow them to work. Job seeking may also be hindered by the fear of wage garnishments.

* Respondents told us that medical debt caused significant stress, anxiety and feelings of hopelessness. Medical debt can also be a source of embarrassment and shame, and many respondents were frustrated and angry that they were being financially punished for a medical event over which they had little control.

Health care is a business unlike most others. The customers are, by definition, in a vulnerable position by virtue of the medical problem for which they seek services. The providers of these services differ from sellers in most other markets because their product is essential and often life saving, and is governed by ethical responsibilities that exceed those that apply in typical commercial transactions. Purchases are often sudden and unplanned and, particularly for people without health insurance, may bring large financial burdens that are involuntary in the sense that they are not the result of a traditional consumer choice.

http://www.accessproject.org/downloads/med_consequences.pdf

Comment: Warning: this report is difficult to read. It is not a report of technical complexity. Rather it is a report that has a Dickensian quality, including the Tiny Tims whose suffering is compounded by medical debt, and the institutional and individual provider Scrooges with their passive automaticity when faced with the “need” to collect unpaid debts. The report is punctuated with quotations. If you cry easily, this may make you do so.

We are spending $1.66 trillion on health care this year. Our existing policies ensure that our administrative excesses will always be fully funded for the benefit of the insurers. But our policies are not designed to prevent medical debt for vulnerable patients. Yet only a very small portion of funds directed to the wasteful administrative excesses would be more than adequate to cover all medical debt. It is so tragic and so needless.

Let’s change our policies. Let’s reduce the waste by changing to an administratively efficient, public insurance program, and use the savings to provide everyone comprehensive coverage. Medical debt then could be relegated to the Dickensian novels where it belongs.

What is California HealthCare Foundation’s true mission?
By Don McCanne

Following is a description of the California HealthCare Foundation from their own website:

“The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care.

“CHCF’s work focuses on informing health policy decisions, advancing efficient business practices, improving the quality and efficiency of care delivery, and promoting informed health care and coverage decisions.

“CHCF commissions research and analysis, publishes and disseminates information, convenes stakeholders, and funds development of programs and models aimed at improving the health care delivery and financing systems.”

And California HealthCare Foundation’s stated mission:

“Mission statement: to expand access to affordable, quality health care for underserved individuals and communities and to promote fundamental improvements in the health status of the people of California.”

Understanding the origin of California HealthCare Foundation (CHCF) is important. During the decades that Blue Cross of California was a non-profit entity, it received favorable tax treatment not available to for-profit insurers. When Blue Cross of California converted to a for-profit entity, becoming a subsidiary of WellPoint, it was decided that the accrued value of the tax subsidy should not be granted gratis to the new shareholders of WellPoint, but should utilized for the benefit of Californians since this vested interest rightfully belonged to them. It was decided that this could be accomplished by establishing the California HealthCare Foundation and the California Endowment. The funds would then be used to improve the health care system in California, benefiting the underserved, and, in fact, benefiting all Californians by “improving the delivery and financing systems.”

Mark D. Smith, MD, MPH, President and Chief Executive Officer of California HealthCare Foundation, has infused foundation funds into research and reports on health plans, managed care, insurance markets, MediCal and other aspects of our current system. But he has often expressed his view that a single, universal health insurance program is not an option for reform. In spite of the California Health Care Options Project study that demonstrated that single payer reform could provide affordable, comprehensive coverage for all Californians (a goal of CHCF), he seems to continue to exclude that option from CHCF activities.

Yesterday we saw an interesting example of this apparent bias. The Kaiser Daily Health Policy Report sends out summaries of important policy issues, published by The Advisory Board Company. One item yesterday included reference to a New York Times article on employers’ concerns about health care costs, along with reference to the USA Today editorial debate on two views of controlling health care costs. It ended with my comment that we need to throw out the wasteful, ineffective health plans and spend the money on patients instead.

The items of national interest are often repeated in their entirety in California Healthline, a similar publication of the California HealthCare foundation, also published by The Advisory Board Company. The article above was no exception except for one remarkable difference. The New York Times segment was carried, but the USA Today segment on controlling costs by replacing health plans with a public program was deleted and another USA Today story on reducing costs by exercising and eating well was substituted. Is it not unreasonable to ask what happened? Why was a statement highly unfavorable for health insurers such as Blue Cross deleted?

The health care crisis in California, and, indeed, in the nation has reached proportions such that reform is mandated. This is the time to be examining all options for reform. An informed state and national discourse are essential. The California HealthCare Foundation should be front and center as a resource on policy issues. And since they are utilizing funds that originated from California taxpayers, they have an ethical obligation to be certain that their process is as open and unbiased as possible.

It is reasonable to ask a few questions.

* Does Blue Cross/WellPoint still exert any control over this process that has deliberately excluded options that would remove Blue Cross as a player in the health care system?

* Do members of the board of directors have any conflicts of interest that might cause them to fail in their ethical obligation to support the interests of Californians and their health care system?

* Does Mark Smith have either an ideological bias, or a vested interest in California health plans, especially Blue Cross, that might disqualify him from administering ethically the California HealthCare Foundation in the interests of all Californians?

* Why did The Advisory Board Company take the unusual step of changing a portion of this one article for publication in California Healthline?

* What is California HealthCare Foundation’s true mission?

These and other questions I believe are quite reasonable. I don’t have the answers. Perhaps those in the media receiving this message may want to try to discover the answers. If you have friends interested in investigative reporting, you may want to forward this message to them.

The rest of us must intensify our efforts to demand fairness and openness in the process. We must be sure that the reform we end up with will be in the best interests of all patients.

About CHCF: http://www.chcf.org/aboutchcf/

Kaiser Daily Health Policy Report on the New York Times article on employers’ health care costs, and on the USA Today debate on managing costs (requires registration): http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=16431&dr_c at=3

California Healthline on the New York Times article on employers’ health care costs, and on a substitute USA Today article on reducing costs by exercising and eating well (requires registration, and limited to California residents): http://www.californiahealthline.org/members/basecontent.asp?contentid=48118& collectionid=3&contentarea=23810

USA TODAY
3/6/2003
Editorial/Opinion

USA TODAY’s view:

Affordable remedies ignored as nation’s health woes soar

Perhaps the best measure of the depth of the nation’s health care troubles is this: Amid terror warnings, possible war with Iraq, a faltering stock market and a sluggish economy, a new poll says the public’s top worry is rising health care costs.

Some achievable steps:

* Lowering drug costs. * Cutting hospital bills. * Providing affordable insurance. * Helping consumers cut costs.

None of these cost-saving ideas alone will solve the nation’s health care problems. But bipartisan cooperation to enact them could prime the pump for more comprehensive reforms, improve the competitiveness of the health care marketplace and make consumers more aware of medical costs.

The country’s rising concerns about a broken health care system can’t be ignored indefinitely. Small repairs today can pave a path for bigger solutions tomorrow.

For the full USA TODAY editorial: http://www.usatoday.com/news/opinion/editorials/2003-03-05-our-view_x.htm

Opposing view:

Nationalize health care By Don McCanne

The continuing rise in health care costs is proof that our existing system of competing health plans has been incapable of controlling costs. Decades of attempts to improve coverage through a hodgepodge of private plans and public programs have resulted only in higher costs and greater numbers of uninsured. Current proposals that build on our existing system promise only higher costs and the perpetuation of the profound administrative waste that is unique in the world. We spend more on paperwork in our health care system than we do for our entire military budget – almost $400 billion.

Single-payer national health insurance, by contrast, would slow the growth of health-care costs well into the future. And it would ensure that everyone has access to comprehensive health care services.

What do we really want out of our health care system?

* We want affordability. Placing our health care system on a single budget would provide a mechanism to finally corral health care costs for all of us.

* We want our health-insurance dollars to be spent on patients, rather than private-health-plan bureaucracies. By eliminating administrative waste caused by the health plans and the costly burden they place on the system, we would free up more than enough to pay for coverage of the uninsured and truly comprehensive benefits for all.

* We want our health insurance always to be there. With a universal insurance program, we would never lose coverage because of a change in employment, early retirement or a financial setback that makes premiums unaffordable.

* We want to be free to choose our physicians and hospitals instead of being penalized for failing to use the provider chosen by the insurance company.

* We want to have access to care whenever we need it rather than when and where the insurance company dictates.

The marketplace will not serve us well in health care if we depend on health plans. They would continue to compete based on the price of their premiums. But with rising costs, plans can keep their premiums competitive only by shifting costs to patients in the form of fewer benefits and greater out-of-pocket payments. This would threaten the financial security of those with the greatest health care needs.

On the other hand, competition based on quality would be beneficial. Since we would have free choice of doctors and hospitals, the providers themselves would be motivated to compete for patients based on the quality of their services.

A single-payer system, funded at our current level of spending, would provide high-quality, comprehensive, affordable health care for everyone. But we can achieve this only if we throw out the wasteful, ineffective middlemen – the health plans – and spend the money on patients instead.

Don McCanne, M.D., is president of Physicians for a National Health Program.

http://www.usatoday.com/news/opinion/editorials/2003-03-05-oppose_x.htm

The White House
March 4, 2003
President to Announce Framework to Modernize and Improve Medicare

Excerpt from the Executive Summary:

Option 1-Traditional Medicare

Those who are satisfied with the current Medicare system will continue receiving their care as they do today with help for the high costs of prescription drugs. These beneficiaries will gain access to discounted drugs through a prescription drug discount card-estimated to achieve savings of 10-25% on the cost of prescription drugs-as well as coverage to protect them against high out-of-pocket prescription drug expenses. These new benefits will be provided at no additional premium.

Option 2-Enhanced Medicare

Enhanced Medicare will give seniors the same types of choices that are available to members of Congress and other federal employees. In every area of the country, Medicare beneficiaries will have multiple health plans from which to choose. These plans will offer prescription drug benefits, full coverage of preventive benefits, protection against high out-of-pocket drug costs, and cost sharing that does not penalize participants who need the most medical care. Again, the decision to choose Enhanced Medicare will be entirely up to each senior, and participants will be able to choose any doctor or any hospital they want for the treatment and care they need.

The President’s framework will ensure that the benefits offered under Enhanced Medicare are sufficiently attractive to seniors, relative to traditional Medicare, to guarantee that Enhanced Medicare is a viable system.

Option 3-Medicare Advantage

Seniors will also have the option of enrolling in low-cost and high-coverage managed care plans, similar to those available today under Medicare. Medicare Advantage will include plans that offer a subsidized drug benefit, and all plans will be able to offer extra benefits, as many private plans do today.

Excerpt from the Conclusion:

To improve, Medicare must have the benefit of modern health care delivery systems and methods that have proven successful in the private sector. The President’s initiative will introduce private sector innovation and competition to the Medicare system to help keep costs reasonable, ensure high quality care and begin to address Medicare’s long-term financial challenges.

While Medicare must be modernized and improved to meet the needs of its current participants, the program must also be made sustainable for future generations. Given the financial challenges Medicare faces in the future, changes to the Medicare program we make today must not exceed our nation’s means to deliver them tomorrow.

http://www.whitehouse.gov/news/releases/2003/03/20030304-1.html

Comment: To understand the administration’s proposal, we must keep in mind what this program to “modernize” Medicare is intended to accomplish. Regardless of all of the rest of the rhetoric, the sole intent is to reduce the federal (taxpayer) contribution to the health care of the Medicare beneficiaries. Period. All of the wonderful, free-market rhetoric is designed to distract us from this precise goal. With that in mind, let’s look at the three options offered (though not in order).

Option 1 – Traditional Medicare: The traditional Medicare program is inadequate. The lack of pharmaceutical coverage is a glaring example. The traditional Medicare program needs more funds, precisely what the administration is avoiding. So we will see no recommendations for an expansion of benefits in the traditional program.

But to meet campaign promises, they propose introducing a worthless discount prescription card, and they propose to provide the wealthy with protection for high drug costs by providing coverage only after spending many thousands of dollars on drugs. For very low income individuals, they’ll cover up to $600 worth of drugs. It is uncertain if this paltry coverage reflects the value that they assign to the unfortunate individuals in this sector of society.

A second reason that they do not want to add more benefits to the traditional program is that want to use those benefits to lure beneficiaries out of the traditional program and into private plans.

Option 3 – Medicare Advantage: This is the current Medicare + Choice program. It was a failure. It worked only as long as the plans could limit their exposure to high costs by selectively marketing to a healthy sector. But the plans failed to provide the administrative efficiencies promised, and ended up costing the government more, on a risk adjusted analysis. The only way that it could be salvaged is to increase taxpayer funding beyond that of the traditional program, again the opposite of the administration’s goal. They’ve decided to let this program fade away.

Option 2 – Enhanced Medicare: As promised, this is the proposal similar in design to the Federal Employees Health Benefit Plan, “the plan that the members of Congress have.” This is basically the Breaux-Frist-Thomas-Jindal premium support proposal. It is a defined contribution concept, though some defenders dispute the terminology.

An important sentence in the White House release: “Beneficiaries who enroll in an average priced plan in their region would pay a premium for the medical portion of their coverage equal to the Part B premium.” Clearly this confirms that individuals who desire more comprehensive benefits, or who wish to reduce their financial exposure, will have to bear the costs of that additional coverage in the form of higher premiums. So the wealthy are well cared for in this proposal.

What about those individuals who do not have the resources to purchase more comprehensive coverage? What will their program offer? A clue: “To provide an array of choices in benefit design and to encourage plan innovation, plans will be free to structure their offerings differently, provided the benefit meets a basic federal standard. “Plan innovation with flexibility in offerings” should make us worry. Spartan plans will surely become the “averaged priced” plans. And we can only speculate that an administration that doesn’t have any money for anything else, certainly will not have enough money to fund more than the very lowest tier of services that is the “basic federal standard.”

Then the politicians will ask why we should be spending more on traditional Medicare patients than we do on the “basic federal standard.” And of course their solution will be to cut funding of the traditional program.

This scheme does not reduce the costs of health care; it merely shifts the costs from the federal government to the Medicare beneficiary. The majority will be unable to afford their portion of costs should they be faced with a major medical disorder.

Should Medicare policy be crafted to improve the utilization of resources for the benefit of patients, or should it be designed simply to reduce federal funding of the program? It looks like the Bush administration has decided that Medicare should be added to list of programs to be sent off to the guillotine for a blunt trimming.

The New York Times
March 2, 2003
A New Health Plan Works, at Least for the Healthy
By Beth Kobliner

Last fall, Mrs. Welborn, 32, a senior training specialist in corporate development, signed up for a new kind of health coverage, called a health reimbursement arrangement, or H.R.A. As part of the plan, her employer, CompuCom Systems, an information technology service provider in Dallas, has given her a $2,000 health care savings account that she can use to pay for medical care.

But Mrs. Welborn’s new plan also comes with a hefty deductible of $3,400. That means that if she spends more than her allotted $2,000 in the account this year, she will be liable for the next $1,400 of expenses. After she reaches the deductible, the insurance plan kicks in; it will cover 80 percent of costs, if network doctors are used, and 60 percent if not.

But if any of the $2,000 remains in her account at year-end, she can add it to the next $2,000 CompuCom will set aside for her in 2004. Mrs. Welborn… can have a maximum of $6,000 in her account.

Consumer-driven plans are variations on P.P.O.’S and H.M.O.’s, but with two important differences: they carry considerably higher deductibles, often around $1,500 for individuals and $3,000 for families; and employers cushion these higher deductibles at the front end, by financing individual cash accounts ranging from a few hundred to several thousand dollars.

http://www.nytimes.com/2003/03/02/business/yourmoney/02MEDS.html

Comment: Medical savings accounts (MSAs), tax free medical accounts backed up by high deductible (catastrophic) insurance, have long been supported by those who claim that we will bring health care costs under control only when we make patients sensitive to costs by spending their own funds. Once their medical savings are depleted, then the catastrophic plans will cover all costs. But this is really a fantasy, as we’ll see below.

For several reasons, insurers and employers have been reluctant to offer these products. But an IRS ruling last year authorized the version called health reimbursement arrangement (HRA). One of the features that made HRAs more attractive is that the unused funds could be rolled over from year to year. It is important to note that employers retain ownership of the HRA. Unspent funds on job termination are not converted into a cash or retirement benefit for the employee, but remain with the employer. So it really is a pooled fund source with a low spending cap per individual or family. Since the accumulation of funds will stop when the maximum is reached ($6000 in the example in the article), the family would be motivated to be sure that the funds are spent or they will fail to receive additional contributions and will eventually lose what’s left anyway. Since most healthy families spend less than the amount placed in the HSA, they will be motivated to increase their utilization of health care services, the exact opposite of the intended result.

The high deductible coverage offered with these HSAs also raises concerns. These catastrophic plans are not indemnity plans that “cover 100% of costs after the deductible is met.” They are PPO and HMO managed care plans, using contracted providers. Some plans may allow patients to use their own non-contracted providers, but only with severe financial penalties.

Let’s look at an example using the numbers in the article: a $2000 HSA, with a $3400 deductible, and then a PPO with 80% for network providers and 60% for providers outside of the network. What is not mentioned is that this is 80% or 60% of the allowed fee. The contracted provider is required to adjust off the disallowed balance, but, of course, the non-contracted provider can demand the full fee.

Now let’s say that the patient needs an $85,000 coronary bypass. The university center in town has a cardiovascular surgery program noted for its excellent outcomes. The other hospital in town is being investigated for doing a very large number of bypass surgeries that appear to have been unnecessary. But because of the higher cost of care at academic centers, the charges will be $108,000 instead. Although this may be a somewhat extreme example, it is realistic. And most of us would certainly opt for what we perceive to be better care, especially for our loved ones.

How do the numbers work out? Let’s make one more assumption. The PPO has contracted with the hospital under investigation for a fee of $56,000 for the package, a reasonable fee since the PPO can offer that facility a high volume of insured patients. But the PPO has repeatedly failed to negotiate a similar contract with the academic center, which then remains a non-contracted provider.

The numbers? The employer funded HSA pays the first $2000. The patient pays the next $1400, when the deductible is met. The allowed amount, $56,000, minus the deductible of $3400, leaves a covered amount of $52,600. Since the center is not contracted, the PPO pays 60% or $31,560 and the patient pays $21,040. But the patient is also responsible for the disallowed charges of $108,000 minus $56,000, or $52,000. So this HRA with a catastrophic plan that “covers expenses after the deductible is met,” results in an out-of-pocket expenses for the patient of a total of $84,240. That is quite a tab for an $85,000 procedure, especially for a family with an income of $42,228 per year (median household income 2001, US Census Bureau).

Under the best circumstances, the patient would pay the $1400 share of the deductible and 20% of the contracted rate, with the balance being adjusted off. That would still amount to $11,920, an almost unaffordable amount for a median income household.

Who would elect these plans? Individuals that shop for plans based on premium alone might select them because the premiums for high deductible coverage are lower. Those that are better informed may still elect these plans, gambling that they would remain in good health. But those that develop a major acute medical problem will lose their bet. Individuals with significant chronic disorders would not select HSAs but would select more comprehensive plans. Concentrating higher cost patients into more comprehensive plans will drive up premiums, threatening affordability of comprehensive coverage for the rest of us.

Private indemnity insurance has been priced out of the market and is gone forever. The fragmented system that we are left with can only perpetuate and compound the inequities that characterize our system today. We already have enough money in the system to provide comprehensive services for everyone, but the only way we can ever obtain value for that already invested is to establish a single, equitable risk pool. Why do we keep delaying the inevitable?