PNHP

California financial crisis, health students, and single payer

California financial crisis, health students, and single payer

Brown Unveils Budget Plan With Extensive Spending Reductions

California Healthline
January 11, 2011

(Gov. Jerry) Brown’s proposed budget would reduce spending by about $135.7 million by enacting changes to Healthy Families, California’s Children’s Health Insurance Program.

Brown’s budget also proposes $1.7 billion in cuts to Medi-Cal, California’s Medicaid program.

http://www.californiahealthline.org/articles/2011/1/11/brown-unveils-budget-plan-with-extensive-spending-reductions.aspx

And…

Labor is out-organized at budget protest

By Michael J. Mishak
Los Angeles Times
January 10, 2011

If today’s budget protests are any indication, organized labor needs to get, well, organized.

After Gov. Jerry Brown unveiled his budget, a handful of labor leaders gathered on the north steps of the Capitol to talk about the concerns of workers and recipients of In-Home Supportive Services and other programs that would see steep cuts. They didn’t get very far.

George Popyack, of the American Federation of State, County and Municipal Employees, was explaining how shifting state services to local governments could compromise quality when he was drowned out by hundreds of students descending on the steps for a separate demonstration in support of single-payer healthcare. Reporters and a camera crew turned to observe the students, who were chanting through bullhorns and banging drums.

“Well, we just lost the camera,” Popyack said.

http://latimesblogs.latimes.com/california-politics/2011/01/if-todays-budget-protests-are-any-indication-organized-labor-needs-to-get-well-organized-after-gov-jerry-brown-unvei.html

For report on the single payer rally by Erica Mu of KALW (audio and transcript):
http://kalwnews.org/audio/2011/01/10/could-single-payer-be-future-healthcare-california_782712.html

California Health Professional Student Alliance (CaHPSA):
http://www.cahpsa.org/CaHPSA/Lobby_Day.html

Comment: 

By Don McCanne, MD

California’s budget crisis is a disaster. The draconian budget cuts will especially impact the state’s health and human services programs, including Medi-Cal and the Children’s Health Insurance Program. The good news is that California’s health professional students are not going to put up with it. They showed up by the hundreds to demand the enactment of a single payer system.

The future of our health care system is in good hands.

A Predictable Tragedy in Arizona

We emptied state mental hospitals starting in the 1960s without providing adequate treatment alternatives.

By E. FULLER TORREY
The Wall Street Journal
January 12, 2011

The killing of six people in Tucson is one more sad episode in an ongoing series of tragedies that should not be happening. The alleged shooter, Jared Lee Loughner, is reported to have had symptoms associated with schizophrenia—incoherent thought processes, delusional ideas, erratic behavior—and almost certainly was seriously mentally ill and untreated. The fact that he was barred from his college until he was evaluated by a psychiatrist would appear to confirm the nature of the problem.

The truth is that these tragedies are happening every day throughout the United States. The only reason this episode has received widespread publicity is because there were multiple victims and one victim was a member of Congress. Such senseless killings have become increasingly common over the past 30 years, starting in about 1980, when Allard Lowenstein, coincidentally a former congressman, was killed by Dennis Sweeney. Sweeney was a young man with untreated schizophrenia who had been Lowenstein’s protégé in the civil rights movement. Congress was also prominently involved in 1998, when Russell Weston, who also had untreated schizophrenia, killed two policemen while trying to shoot his way into the Capitol Building in Washington, D.C.
 
These tragedies are the inevitable outcome of five decades of failed mental-health policies. During the 1960s, we began to empty the state mental hospitals but failed to put in place programs to ensure that the released patients received treatment after they left. By the 1980s, the results were evident—increasing numbers of seriously mentally ill persons among the homeless population and in the nation’s jails and prisons.

Over the past three decades, things have only gotten worse. A 2007 study by the U.S. Justice Department found that 56% of state prisoners, 45% of federal prisoners, and 64% of local jail inmates suffer from mental illnesses.

A 2008 study out of the University of Pennsylvania that examined murders committed in Indiana between 1990 and 2002 found that approximately 10% of the murders were committed by individuals with serious mental illnesses. There are about 16,000 homicides a year in this country. Using the Indiana study as a guide, roughly 1,600 of them are likely committed by people with serious mental illnesses.

In Arizona, public mental-health services are among the worst in the nation. In a 2008 survey by the Treatment Advocacy Center, Arizona ranked next to last among all states in the number of psychiatric hospital beds per capita. If you don’t have hospital beds and outpatient clinics to treat mentally ill people, those people don’t get treated. Thus the tragedy was somewhat more likely to happen in Arizona because mentally ill individuals are less likely to receive treatment there. Although Arizona is the worst state, except for Nevada, in psychiatric-bed availability, there is no state that currently has enough beds for its mentally ill population, according to the Treatment Advocacy Center study. This tragedy occurred in Arizona, but it could easily have happened in any state.

The big picture is even scarier. Based on Arizona’s 2010 population and on estimates by the National Institute of Mental Health of the number of individuals with untreated schizophrenia at any given time, there are today in Arizona over 21,000 individuals with untreated schizophrenia. Most of them, thankfully, are not violent. But a small number of them—about 10% according to my meta-analysis of relevant studies—do become violent, usually because of their delusional thoughts and what their voices (auditory hallucinations) are telling them. This situation holds in every state. It is thus not a question of if such tragedies will occur but rather when and how often.

Mr. Loughner’s delusions fixated on Arizona Congresswoman Gabrielle Giffords, one of 12 seriously injured in the shooting. Some have speculated on the possible relationship of our acrimonious political climate to the incident. It is, however, unlikely that there is any such relationship, since similar tragedies occur in politically harmonious times as well.

The motivation for such killings is usually based on psychotic thinking, not political thinking. Dennis Sweeney killed Allard Lowenstein because he believed that Lowenstein had implanted a transmitter in his teeth that was sending messages to him. Russell Weston stormed the Capitol because he believed the government had hidden a machine there that could reverse time.

The solution to this situation is obvious—make sure individuals with serious mental illnesses are receiving treatment. The mistake was not in emptying the nation’s hospitals but rather in ignoring the treatment needs of the patients being released. Many such patients will take medication voluntarily if it is made available to them. Others are unaware they are sick and should be required by law to receive assisted outpatient treatment, including medication and counseling, as is the case in New York under Kendra’s Law. If they do not comply with the court-ordered treatment plan, they can and should be involuntarily admitted to a hospital. Arizona has such a provision in its laws, but it is almost never used.

Ultimately, it is important to hold state officials responsible for not providing sufficient resources to treat those who suffer from serious mental illnesses. For almost two centuries, it has been an accepted function of state government to protect disabled persons and to protect the public from individuals who are potentially dangerous. State governments have been very effective in emptying the hospitals in an effort to save money but remarkably ineffective in providing treatment for seriously mentally ill individuals living in the community.

Dr. Torrey is the founder of the Treatment Advocacy Center and the author of “The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens” (W.W. Norton, 2008).

California financial crisis, health students, and single payer

Brown Unveils Budget Plan With Extensive Spending Reductions

California Healthline
January 11, 2011

(Gov. Jerry) Brown’s proposed budget would reduce spending by about $135.7 million by enacting changes to Healthy Families, California’s Children’s Health Insurance Program.

Brown’s budget also proposes $1.7 billion in cuts to Medi-Cal, California’s Medicaid program.

http://www.californiahealthline.org/articles/2011/1/11/brown-unveils-budget-plan-with-extensive-spending-reductions.aspx

And…

Labor is out-organized at budget protest

By Michael J. Mishak
Los Angeles Times
January 10, 2011

If today’s budget protests are any indication, organized labor needs to get, well, organized.

After Gov. Jerry Brown unveiled his budget, a handful of labor leaders gathered on the north steps of the Capitol to talk about the concerns of workers and recipients of In-Home Supportive Services and other programs that would see steep cuts. They didn’t get very far.

George Popyack, of the American Federation of State, County and Municipal Employees, was explaining how shifting state services to local governments could compromise quality when he was drowned out by hundreds of students descending on the steps for a separate demonstration in support of single-payer healthcare. Reporters and a camera crew turned to observe the students, who were chanting through bullhorns and banging drums.

“Well, we just lost the camera,” Popyack said.

http://latimesblogs.latimes.com/california-politics/2011/01/if-todays-budget-protests-are-any-indication-organized-labor-needs-to-get-well-organized-after-gov-jerry-brown-unvei.html

For report on the single payer rally by Erica Mu of KALW (audio and transcript):
http://kalwnews.org/audio/2011/01/10/could-single-payer-be-future-healthcare-california_782712.html

California Health Professional Student Alliance (CaHPSA):
http://www.cahpsa.org/CaHPSA/Lobby_Day.html

California’s budget crisis is a disaster. The draconian budget cuts will especially impact the state’s health and human services programs, including Medi-Cal and the Children’s Health Insurance Program. The good news is that California’s health professional students are not going to put up with it. They showed up by the hundreds to demand the enactment of a single payer system.

The future of our health care system is in good hands.

A conservative and a liberal on single payer

Buckle Up for Round 2

By David Brooks
The New York Times
January 6, 2011

Over all, there is a strong likelihood that the current health care law will face an existential threat over the next five years. Each party should be preparing contingency plans.

After the trauma of the last two years, many people wish the issue would go away. But it’s not going away, especially since costs will continue to rise.

When the crisis comes, Democrats will face an interesting choice — to patch the Obama system or try to replace it with something bigger. The administration may want a patch, but by a ratio of nearly 2 to 1, according to a CNN poll, Democratic voters would prefer a more ambitious law. Liberals could logically say that the mistake was trying to create a hybrid system, rather than moving straight to a single-payer one.

http://www.nytimes.com/2011/01/07/opinion/07brooks.html?ref=opinion

And…

ObamaCare Repeal: GOP Should Be Careful What It Wishes For

By Robert B. Reich
The Wall Street Journal
January 7, 2011

Nonetheless, there’s a great irony in the Republican assault. The federal government wouldn’t be nearly as vulnerable to these political and legal obstacles had the health-care law been built upon the framework of Social Security or Medicare — public insurance financed by payroll taxes — as many Democrats had initially urged. Not only are these programs enormously popular — “Don’t take away my Medicare!” was a rallying cry among some conservative populists during the debates over the health-care law — but they also rest on a more widely accepted relationship among the individual, the government and the market.

Americans are accustomed to paying for public insurance through their payroll taxes. Such payments aren’t viewed as federal mandates that encroach upon individual freedoms, or as payoffs to private companies likely to make even more money from mandatory purchases of their products, but as well-deserved entitlements.

Set against this background, the current Republican attack on mandatory coverage is curious because it raises the essential question of how society would otherwise spread health-care risks. If successful — either in Congress or in the courts — a Republican victory could turn into a Pyrrhic one by opening the way to the alternative model, based on the system Americans seem to prefer: payroll taxes and public insurance.

http://online.wsj.com/article/SB10001424052748704723104576062350518299650.html

Comment: 

By Don McCanne, MD

Above are yet two more examples of a common theme. Conservative New York Times columnist David Brooks and liberal Berkeley Professor Robert Reich both imply that the opposition to the government mandate to purchase expensive private health plans may drive us to a much more logical and effective solution for financing health care: single payer (public insurance financed by taxes).

If so many individuals across the political spectrum believe that single payer is likely the inevitable outcome then why aren’t we taking a more serious look at it right now, before people are dragged, screaming and kicking, and then locked into the private insurance exchanges?

Carrying the metaphor further, their screaming should die down by the time they are transferred to the paupers’ prisons.

Metaphors are often used to appeal to the emotions. In this instance, it certainly isn’t humor. There is nothing funny about a government mandate that forces you to buy an overpriced private insurance product that takes away your choices in health care.

So which emotion? Depression? Anger? Rage? We have just seen once again the potential for tragic consequences of the latter. Please. Let’s fix our health care financing system before we’re all in a rage.

A conservative and a liberal on single payer

Buckle Up for Round 2

By David Brooks
The New York Times
January 6, 2011

Over all, there is a strong likelihood that the current health care law will face an existential threat over the next five years. Each party should be preparing contingency plans.

After the trauma of the last two years, many people wish the issue would go away. But it’s not going away, especially since costs will continue to rise.

When the crisis comes, Democrats will face an interesting choice — to patch the Obama system or try to replace it with something bigger. The administration may want a patch, but by a ratio of nearly 2 to 1, according to a CNN poll, Democratic voters would prefer a more ambitious law. Liberals could logically say that the mistake was trying to create a hybrid system, rather than moving straight to a single-payer one.

http://www.nytimes.com/2011/01/07/opinion/07brooks.html

And…

ObamaCare Repeal: GOP Should Be Careful What It Wishes For

By Robert B. Reich
The Wall Street Journal
January 7, 2011

Nonetheless, there’s a great irony in the Republican assault. The federal government wouldn’t be nearly as vulnerable to these political and legal obstacles had the health-care law been built upon the framework of Social Security or Medicare — public insurance financed by payroll taxes — as many Democrats had initially urged. Not only are these programs enormously popular — “Don’t take away my Medicare!” was a rallying cry among some conservative populists during the debates over the health-care law — but they also rest on a more widely accepted relationship among the individual, the government and the market.

Americans are accustomed to paying for public insurance through their payroll taxes. Such payments aren’t viewed as federal mandates that encroach upon individual freedoms, or as payoffs to private companies likely to make even more money from mandatory purchases of their products, but as well-deserved entitlements.

Set against this background, the current Republican attack on mandatory coverage is curious because it raises the essential question of how society would otherwise spread health-care risks. If successful — either in Congress or in the courts — a Republican victory could turn into a Pyrrhic one by opening the way to the alternative model, based on the system Americans seem to prefer: payroll taxes and public insurance.

http://online.wsj.com/article/SB10001424052748704723104576062350518299650.html

Above are yet two more examples of a common theme. Conservative New York Times columnist David Brooks and liberal Berkeley Professor Robert Reich both imply that the opposition to the government mandate to purchase expensive private health plans may drive us to a much more logical and effective solution for financing health care: single payer (public insurance financed by taxes).

If so many individuals across the political spectrum believe that single payer is likely the inevitable outcome then why aren’t we taking a more serious look at it right now, before people are dragged, screaming and kicking, and then locked into the private insurance exchanges?

Carrying the metaphor further, their screaming should die down by the time they are transferred to the paupers’ prisons.

Metaphors are often used to appeal to the emotions. In this instance, it certainly isn’t humor. There is nothing funny about a government mandate that forces you to buy an overpriced private insurance product that takes away your choices in health care.

So which emotion? Depression? Anger? Rage? We have just seen once again the potential for tragic consequences of the latter. Please. Let’s fix our health care financing system before we’re all in a rage.

A pause

By Don McCanne, MD

Instead of contemplating a health care Quote of the Day today, let’s take a moment to consider what each of us might do to harness the energy behind the forces that would destroy social solidarity, and bring us all together in efforts to heal our social problems such as our sick health care system that leaves so many suffering and dying.

Cost-sharing: Effects on spending and outcomes

By Sarah Goodell, M.A. and Katherine Swartz, Ph.D.  
The Synthesis Project
Harvard School of Public Health
Publisher: Robert Wood Johnson Foundation
Published: December 2010

This brief examines how cost-sharing affects the use of services, whether some patients are more sensitive to cost-sharing than others, and whether reduced use of services as a result of cost-sharing has an effect on health outcomes. All of these issues factor into whether and how cost-sharing could be used to reduce the rate of growth of health care spending.

Click here to download the paper.

A pause

Instead of contemplating a health care Quote of the Day today, let’s take a moment to consider what each of us might do to harness the energy behind the forces that would destroy social solidarity, and bring us all together in efforts to heal our social problems such as our sick health care system that leaves so many suffering and dying.

U.S. has 'death panels'

By JOHNATHON ROSS
The Blade (Toledo, Ohio), Jan. 9, 2011

The American health care system is severely dysfunctional. We spend about twice as much per person on health care as other wealthy democracies, yet our medical outcomes are mediocre by comparison.

Some 45,000 Americans a year die because they lack health insurance. Thousands more needlessly suffer and die from preventable causes. Others go bankrupt because of medical bills.

Health-care reform is touted as a way to change what’s wrong with our system. But the law leaves private health insurers in the driver’s seat. That doesn’t augur well for change.

During the reform debate, the Tea Party gossip was that government “death panels” would pull the plug on Granny. That is nonsense.

New regulations simply allow me, a primary-care general internist, to bill the government for the time I spend discussing with my Medicare patients specific end-of-life issues, such as having a durable power of attorney for health care and a living will. These are common-sense things that any decent doctor should do.

But this isn’t to say that death panels that ration health care don’t exist. They do, in the forms of private health insurance companies and Republican-dominated state legislatures.

For insurers, denials of care are a matter of record. A California-based study in 2009 showed that big insurers denied one of every five claims. Every claim that is denied helps pad insurance companies’ bottom line. But the consequences of such denials can be catastrophic to real people.

In Texas, Republican Gov. Rick Perry and GOP legislative leaders say they are thinking about canceling their state’s participation in Medicaid. The Texas Medicaid program covers about 3.4 million poor people.

A decision to drop out of Medicaid would result in an estimated 3,400 annual deaths in Texas, on top of the 6,100 deaths in the state each year caused by a lack of health insurance, recent research suggests. And who knows how much suffering and disability would result for those who do not die, but go without needed care?

Arizona’s Republican-dominated Legislature has canceled Medicaid coverage for about 100 patients who need organ transplants. Two of those patients already have died, so this is truly the decision of a death panel.

Lawmakers claim the policy will save about $4.5 million. But what about the human cost? Just about all of these patients are likely to die over the next four years without coverage. At least some would survive if they kept Medicaid coverage and found matching donors.

There is a way out of this. We can insure all Americans at a reasonable cost by enacting a nonprofit, single-payer national health insurance program — an improved “Medicare for all.”

Clinical decisions would be made by doctors and patients, not by insurance company bureaucrats or bought-and-paid-for politicians. Administrative savings would allow comprehensive coverage for everyone, with no increase in U.S. health spending.

Single-payer financing would streamline the health-care bureaucracy, saving $400 billion a year on administrative and insurance overhead. That would be enough to insure everyone and still eliminate all co-pays and deductibles.

The health-care law defers state experimentation until 2017. But Ohio and other states should get to work now with single-payer reform. Let’s get moving. Our lives depend on it.

Johnathon Ross is past president of Physicians for a National Health Program and an executive committee member of the Single Payer Action Network in Ohio.

http://www.toledoblade.com/article/20110109/OPINION04/110109579

Single payer is tried, tested; it’s Mass. plan that’s risky

Letters
The Boston Globe, Jan. 9, 2011

On last Sunday’s editorial page, the Globe supports two courses toward controlling health care costs: It backs Governor Patrick’s efforts to change the health care industry’s fee-for-service system to “global payments,” and it suggests that Vermont’s plan to implement a single-payer health care system should be supported as an experiment, or “a laboratory of democracy.”

The Globe seems to have mixed up its rationales, as almost every developed nation in the world has a single-payer health care system or something close to it, and we have mountains of evidence that such a system works at controlling costs while delivering the same or better outcomes. The Massachusetts plan to implement payment reform, however, is highly experimental, and there is little evidence supporting the hope that it would effectively control our costs.

A 2009 Urban Institute survey of the evidence on global payment reform found that the concept would not be a game changer for cost control in the short run, but that further experiments would be welcome. Moreover, we know that fee-for-service is not causing our high and rising health care costs; two recent studies by the state both found that it is rising costs per service, not growing utilization of care, that are driving our costs.

The Globe is correct that Governor Patrick’s commitment to cost control is much needed. Now we need a path to cost control that is proven and not based on a misdiagnosis.

Benjamin Day
Executive director, Mass-Care: The Massachusetts Campaign for Single Payer Health Care
Boston

Vermont applauded for its Medicare-like move

Letters
The Boston Globe, Jan. 9, 2011

I APPLAUD The Globe for showcasing Vermont’s single-payer “laboratory’’ in its Jan. 2 editorial “Vermont: Creating a singular health system.’’ As a third-year medical student at Cambridge Health Alliance, I’ve found that it doesn’t take long to see that the current system is insufficient.

The shortcomings leave patients whom I follow longitudinally with less access to community health centers, substance abuse treatment, and specialty services and testing. Some patients with private insurance have medication bills so weighty that they choose other necessities over pills. A single-payer system would establish a government-run, publicly funded insurance program with privately delivered services that cover all necessary care for everyone.

By implementing a single-payer approach, Vermont would lead the nation toward a cost-effective system to eliminate health care-based inequalities. Though the Globe says doctors have been “wary’’ of single payer, a recent Massachusetts Medical Society survey of doctors in the state showed that more preferred single payer than the current public-private mix. Further, a national survey published in the Annals of Internal Medicine in 2008 showed that 59 percent of physicians support government action to establish national health insurance.

Physicians and medical students are no longer wary bystanders. We are advocates for Medicare for all.

Simeon Kimmel
Jamaica Plain

http://www.boston.com/bostonglobe/editorial_opinion/letters/articles/2011/01/09/vermont_applauded_for_its_medicare_like_move/

Blue Shield of California's rate hikes

Blue Shield of California seeks rate hikes of as much as 59% for individuals

By Duke Helfand
Los Angeles Times
January 5, 2011

Another big California health insurer has stunned individual policyholders with huge rate increases — this time it’s Blue Shield of California seeking cumulative hikes of as much as 59% for tens of thousands of customers March 1.

In all, Blue Shield said, 193,000 policyholders would see increases averaging 30% to 35%, the result of three separate rate hikes since October.

Nearly 1 in 4 of the affected customers will see cumulative increases of more than 50% over five months.

http://www.latimes.com/health/healthcare/la-fi-insure-rates-20110106,0,6975599.story

And…

Statement of HHS Secretary Kathleen Sebelius on Blue Shield of California’s proposed rate increase

U.S. Department of Health and Human Services
January 6, 2011

“The people of California have a right to be concerned when they see this kind of rate increase month after month. We have reached out to California Insurance Commissioner Dave Jones and know he is doing everything in his power to help consumers. We stand ready to assist him and the people of California in any way that we can.”

http://www.hhs.gov/news/press/2011pres/01/20110106b.html

And…

Statement by Blue Shield of California

Blue Shield of California
January 6, 2011

The rate increases reported today cover a period of more than one year and have almost nothing to do with the federal health reform law. These rates reflect trends that were building long before health reform. Our individual market medical costs are rising rapidly due to higher provider prices, increased utilization, and the fact that healthier people are dropping coverage during a bad economy. Health reform will help slow down this trend by expanding coverage, which will keep healthier people in the system, and through quality and cost containment initiatives such as the Independent Payment Advisory Board, Center for Medicare and Medicaid Innovation, Patient-Centered Outcomes Research Institute and other incentives for prevention and coordinated health care.

Even with these rate increases, Blue Shield of California expects to lose tens of millions of dollars on its individual healthcare business in both 2010 and 2011. These new rates meet the federal requirement that 80 percent of premiums are spent on healthcare expenses.

https://www.blueshieldca.com/bsc/newsroom/pr/statement_rates_010611.jhtml

Comment:

By Don McCanne, MD

Last year California’s for-profit Anthem Blue Cross, a division of WellPoint, enraged everyone when they attempted to raise premiums as much as 39 percent. In contrast, Blue Shield of California is a non-profit insurer attempting to compete in a market in which the rules are established by investor-owned insurers, yet they are now calling for premium increases as high as 59 percent. As a provider or a patient, it is difficult to tell the California Blues apart.

That said, the brief statement released by Blue Shield of California explains the reasons for the increases: higher provider prices, increased utilization, and a decline in enrollment in a bad economy resulting in spiraling premiums due to adverse selection. In spite of these premium increases, Blue Shield expects to lose tens of millions of dollars on its individual health plans.

These premium increases are intolerable, but is Blue Shield really to blame? Keep in mind that the average working family of four now uses over $18,000 worth of medical care (Milliman Medical Index), and Blue Shield is trying to sell a product that covers those costs plus its own administrative expenses. With insurer administrative costs at 20 percent for the individual market, that’s about $22,500 that the premium would have to be. To lower the premium, costs are shifted directly to the family through deductibles, co-payments, coinsurance, and paring of benefits, but how much in direct costs can the family bear when median household income is about $50,000?

Blue Shield is facing an impossible situation. They cannot create a product that has both affordable premiums and adequate protection against out-of-pocket medical expenses.

That is why the Patient Protection and Affordable Care Act provides income-indexed subsidies for both premiums and cost sharing, but applying simple math to these subsidies will demonstrate that they are inadequate for the majority of low- and moderate-income families who have health care needs.

If we were to increase the subsidies to a level where they would be adequate, then you would be paying more than an improved Medicare for all would cost since the subsidies would have to pay not only for health care but for all of the administrative excesses of our fragmented system composed of a multitude of private and public plans. If taxpayers are going to pay the bill, we might as well pay the one that is a bargain.

The administrative team at Blue Shield of California is composed of fine people. We should thank them for their dedicated service and offer them job retraining to serve in our expanded and improved Medicare program. For the investors and administrative team at Anthem Blue Cross, we should show them the door.