PNHP

How would a Medicare buy-in and a public option be designed?

How would a Medicare buy-in and a public option be designed?

Designing a Medicare Buy-In and a Public Plan Marketplace Option

By Linda J. Blumberg and John Holahan
Urban Institute, September 2016

Medicare is an attractive basis for developing an insurance alternative (either a direct buy-in or a public option based in some way on Medicare rates) because the program generally has lower provider payment rates and lower administrative costs than private insurers. However, Medicare’s structure and cost-sharing requirements are different from private insurers’ as well. A Medicare-related proposal could provide more plan choice for those eligible, which would have a significant effect where few or even only one insurer offers coverage in the nongroup insurance market. Depending upon how the proposal is structured, it could reduce costs for younger adults in the private insurance market as older adults leave the risk pool. However, designing such programs raises myriad issues, each with specific implications for costs and benefits to different age groups.

Medicare Buy-In for 55- to 64-Year-Olds

We assume that a Medicare buy-in option would offer enrollees the same covered benefits and cost-sharing structures offered to current Medicare beneficiaries. Even so, a buy-in directly into the existing Medicare options would lead to questions necessitating policy decisions:

*  Would potential enrollees have the choice of traditional Medicare, Medicare Advantage, or both?
 
*  Would eligibles be able to choose between a Medicare option and Marketplace-qualified health plans for which they are currently eligible, or would Medicare be their only option outside of employer-sponsored insurance?

*  Would enrollees be allowed to make separate purchase decisions for Medicare Parts A, B, and D, or would they have to purchase all if they purchase any? How will consumers respond to offers of coverage that, unlike private insurance options, have no out-of-pocket maximum? Would Medigap or some other supplemental plans be available to the 55- to 64-year-olds?

*  How would the unsubsidized cost of coverage be determined? For example, what premium would be charged to individuals with high incomes? Would 55- to 64-year-olds be charged the same premiums as those age 65 and older, even though the premiums would not reflect the cost of coverage for those enrolled? Or would actuaries set premiums based on the benefits provided and cost-sharing requirements for each component? Would the high income surcharges in the current Medicare program apply to the buy-in population?

*  Assuming that 55- to 64-year-old enrollees would not pay the same premiums as current-law Medicare enrollees, would premiums reflect the health care costs of only the 55- to 64-year- olds enrolling? Or would premiums be set to reflect enrollees’ health care costs being shared by others? For example, their costs could be shared with other nongroup market enrollees or perhaps with current-law Medicare enrollees, but that would require the development of a mechanism for achieving it.

*  Would the 55- to 64-year-olds buying in to Medicare be eligible for financial assistance similar to that for Medicare beneficiaries today (e.g., 75 percent of Medicare Part B costs for all but the high-income beneficiaries? Would they be eligible for ACA-like financial assistance, advanced premium tax credits and cost-sharing reductions? Or would no financial assistance be offered at all? If subsidies are provided, how would they be structured? Would actuarial differences between Medicare and Marketplace silver coverage be taken into account, affecting both advanced premium tax credits and cost-sharing reductions?

*  Would 55 to 64 year olds with access to an affordable employer insurance plan be permitted to enroll in a Medicare buy-in option?

A Public Option for All Age Groups

A public option is a qualified health plan that would be sold through the ACA’s government-created Marketplaces (either federal or state). The public option would bear health insurance risk like other insurers, complying with the ACA’s insurance reforms (e.g., modified community rating, guaranteed issue, and essential health benefits) and offering coverage in the same actuarial value tiers.

A public option avoids complexities associated with a Medicare buy-in for 55- to 64-year-olds. Because the option would be structured and operated in much the same way as any other Marketplace-qualified health plan, it would not have different actuarial values, cost-sharing structures, or premium structures than other Marketplace options. The appropriateness of applying a Marketplace subsidy structure to a Medicare product would not be an issue, and risk-sharing questions across different age groups would not arise. Yet several design decisions would remain:

*  How would provider payment rates be set? Would they be set consistent with Medicare rates, set consistent with Medicare rates plus some percentage, or based on some other fee schedule? Many states have self-insured plans for their employees; this is another potential platform for creating a public option offered in a state Marketplace.

*  If rates are set at the Medicare level (or at some other level that falls below those paid by private insurers), what leverage would the plan have to ensure sufficient provider participation? How does a state’s leverage compare with that of the federal government in this respect?

*  Should public options be set up in all geographic areas or only those with high premiums, high premium growth, or otherwise weak insurer or provider competition? If the latter, who will judge appropriate locales, and by what metric will an area’s appropriateness be assessed?

From the Summary

Regardless of the approach taken, providers are likely to resist new insurance options that may move more patients into plans paying lower rates. While this is to be expected, it highlights the perpetual quandary of health care cost containment. Health care spending and its growth cannot be reduced without either paying less, on average, per unit of service rendered or reducing the quantity of services provided. No matter the strategy for containing costs, achieving that goal will take money out of the pockets of providers. To protect providers financially means abdicating cost-containment efforts of any type.

http://www.urban.org…

***

Comment:

By Don McCanne, M.D.

There is considerable enthusiasm for expanding on the advances of the Affordable Care Act by adding a Medicare buy-in for those 55 to 64, and by adding a public option – an insurance program run by the government competing with private health plans. What is lacking in this discussion is a precise description of either proposal considering that there are a multitude of policy options that must be decided on in order to construct these programs.

In this Urban Institute paper, Linda Blumberg and John Holahan discuss some of the design options, and there are many more. Each option has its own advantages and disadvantages, so it is inevitable that the eventual design would forge a compromise between benefits and deficiencies. Building these two programs on top of our highly fragmented financing infrastructure inevitably perpetuates inefficiencies.

Each program would require an act of Congress. We need only to look at the insurance industry influence in the legislative process that developed the designs for the private insurance exchanges under ACA, for the Part D Medicare drug program, for the private Medicare Advantage plans, for the privatization  of the Medicaid programs, for the previous public option proposals that never got off the ground, and for the co-op model that is failing in the marketplaces, and it will be obvious that the Medicare buy-in and public option will be designed to maximize the leverage of the private insurance industry at a cost to potential enrollees and taxpayers. The insurers will introduce features that are designed to make public programs noncompetitive or even cause them to fail.

When you hear people advocate for a Medicare buy-in or for the public option – and those people are everywhere – demand that they show you their model that was distilled from the multitude of policy options. (Be sure to read the Blumberg and Holahan paper so that you understand at least some of the issues.) Without such a model, the design will default to the private insurers.

Once advocates present their definitive model then analyze it to see how well it meets our reform goals. Will it ensure that everyone is covered? (No) Will it slow the increase in health care costs? (No) Will it ensure that everyone has free choice of health care professionals and institutions? (No) Will it remove financial barriers to care? (No) Will it fill in all of the gaps in coverage of our traditional Medicare program? (No)

Efforts to enact a single payer national health program are rejected because the program supposedly is not politically feasible. Does anyone really believe that a Medicare buy-in and a public option would be politically feasible in a Congress dominated by conservatives and neoliberals? It’s not the goal of a single payer model that needs to be changed; it’s the politics. That takes work. A lot of it.

A Productive Life of Caring

Quentin D. Young Festschrift

By John Geyman, M.D.
Northwestern Magazine, Summer 2016

Quentin Young ’48 MD was an eloquent and persistent voice and advocate for social justice in U.S. health care from the time he entered medicine more than 70 years ago until his last breath recently at age 92. He lived at least five lives in one, always in defense of health care as a human right. He was a consistent moral compass for the medical profession, always ready to defend medicine against the incursion of those who commercialize and exploit the system for their gain over the care of patients. He excelled all along the way as a clinician, teacher, administrator, and as a fierce advocate for health care reform in the public interest.

In this Festschrift we will look at the body of his work over his long and productive career, drawing partly from his 2013 book, Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause, 1 and some of his other writings along the way. Because of his prodigious efforts over the years, it is only possible to touch on some of the highlights.

Early Years

Quentin was born in Chicago in 1923, the first-born of a Jewish couple who had moved there shortly before. His dad had graduated from Fordham University in pharmacology, wanted to go to medical school but could not afford it. His mother wanted to name her son after Quentin Roosevelt, the World I flyer killed over France in 1917, and was able to get permission to name him that instead of after a deceased relative. The family lived in a modest house just half a mile west from the University of Chicago.

As a youngster, Quentin read a lot, and was bumped up two grades at his elementary school. He had many friends, and was an active member of the Jack and Jill Players, a well-known children’s acting troupe that performed onstage and on the radio. That led in later years to a long association with the Chicago public radio station WBEZ, where he would host a show and appear frequently on others.

Entering high school at 16 in 1936, in the middle of the Great Depression, Quentin became fully aware of rampant unemployment and labor-management struggles as well as Hitler’s rise in Germany, Mussolini’s invasion of Ethiopia, and the Spanish civil war. He gave credit to his parents, as New Deal Democrats, for his social and political conscience, and soon became active in the American Student Union at Hyde Park High, an anti-Nazi, progressive group. He went on to the University of Chicago in 1940, attracted by the curriculum instituted by President Hutchins, the “Chicago Plan,” requiring all students to take two-year courses in the humanities, the natural sciences, the social sciences, and reading, writing and criticism.

Sometime during his first or second year in college, Quentin decided that he wanted to be a doctor, for these reasons:

Because medicine was the profession most in keeping with my system of beliefs. It was a livelihood that offered the opportunity to do good (not that every doctor takes up that offer). Yes, it was a relatively tough academic ride, but if you could make it to the end and get your license, you could earn a comfortable living. And, if you chose, you could go to work every day and be a decent, caring, supportive person practicing your profession. 2

Army experience

At the time of the Pearl Harbor attack on December 7, 1941, Quentin was 17, was anti-isolationist and wanting to join the military and fight, especially against Hitler. He was too young to enlist, and was pre-med. Two years later, at 19, though he could likely have secured a student deferment, he enlisted in the Army. His first choice was the infantry, but he was too nearsighted.  His second choice was the artillery, but he was assigned to the medical department, hoping to be trained as a medic on the front lines.  But the Army instead put him into the just established Army Specialized Training Program (ASTP). He was sent to Cornell University in Ithaca, New York, to complete pre-med studies, then back near home to medical school at Northwestern University, starting in 1944 and graduating in 1948, when he was a civilian again and married with two children.

Graduate medical education at Cook County Hospital 1948-53

There was no question about where he would take his graduate training. Cook County Hospital, with 3,400 beds, was with Los Angeles County and Bellevue in New York, among the largest and best teaching hospitals in the country. He had taken medical student rotations there during medical school, and liked the emphasis on service and seeing everything that happens in medicine. He wanted to become a general internist, and spent the next three years there after his two-year internship, plus a year in West Virginia in 1951, completing his residency training in 1953.

True to his nature throughout his medical school and residency years, Quentin spent time agitating for better conditions for both his colleagues and patients. He became active in the Association of Interns and Medical Students (AIMS), lobbying for the end to racial and gender discrimination in  medical schools, better policies to address unwanted pregnancies, other health issues, and national health insurance. AIMS ran counter to the AMA and more conservative deans of medical schools, with its sequel in 1952 becoming the less progressive American Medical Students Association (AMSA), as it is known to this day. In 1951, Quentin founded the Committee to End Discrimination in Chicago’s Medical Institutions (CEDCMI).

Quentin was inspired by Cook County Hospital, which he described as “like a loving mother with arms outstretched to embrace all who sought her care. Without barrier and with no exclusionary questions asked, County stood poised to help all comers and usually the care was very good.” And this is what he learned at County:

I am convinced that until we, as a nation, have a system of universal health care, including everyone—everybody in, nobody out—until we provide that, we as a society just provide care through a system like County. [In his 2013 book, he said]: Sadly, all these years later, this is still the case. 3

Practice years

Quentin hoped to set up practice in a neighborhood near the steel mills on Chicago’s far South Side and serve blue collar workers, but that plan was thwarted by potential landlords who wouldn’t rent him office space, fearing that the powers that be would not want a physician on the premises treating union men and women. So instead, he joined another physician in Hyde Park, where he already had many friends. He welcomed the socioeconomic and racial diversity of Hyde Park. He enjoyed being a generalist primary care physician in a way that he had seen modeled at Cook County. As he said, “My joy and comfort mostly lay in seeing all kinds of people with all kinds of illnesses.” 4

Civil Rights Activist

Taking time from his own practice, Quentin’s political activism increased even more when he met and marched with Dr. Martin Luther King, who had settled in Chicago’s ghetto on the West Side in 1966 in order to fight for open housing and an end to segregation in the public school system. They had first met in Mississippi during the Freedom Summer of 1964. Quentin had been an early organizer of a new group in Chicago, the Medical Committee for Human Rights (MCHR), that provided medical services that summer, during the march from Selma to Montgomery the next year, and at other later events to forward the cause of civil rights. MCHR, with its membership of physicians, dentists, nurses, and social workers, had responded to a call from organizers of the Mississippi Summer Project to join these marches, both to bear witness and provide services as needed. Quentin was just one or two people away from Dr. King on these marches, and was the first to treat him when he was hit in the head by a rock and sustained a large scalp laceration. Many of the marchers were jailed, often with wounds. MCHR physicians were generally well treated by the police, who let them accompany those arrested into jail cells to determine the extent of their injuries, if any. MCHR would loudly proclaim any who were uninjured, which helped to reduce possible jailhouse violence. 5 Quentin later served as national chairman for MCHR from 1967 to 1968 and from 1971 to 1973.

Chief of Medicine at the County 1972-1981

All was going well in his practice and political activist work until 1972, when Quentin was recruited to his old home, the County, to help fix desperate problems the hospital was having. The newly elected Republican Governor Richard Ogilvie, with the support of the state legislature, was planning to downsize the hospital to 500 beds, more as a community hospital with full-time staff, and with “links to neighborhood health centers.” That would eliminate County’s mission as a long-time teaching hospital, and where would all its patients go for care? This plan prompted a firestorm of protest from attending physicians, department chairs, and house staff as the politics became intense. The chairman of the Department of Medicine at County, Quentin’s medical school classmate, Dr. Rolf Gunnar resigned. That department alone had 450 beds, 70 interns, more than 200 residents, fellows in many other specialties, and many attending physicians.

Quentin agreed to take on this challenge, to save County as he had known it. Before accepting, he demanded that the hospital establish health care clinics in the neighborhoods, with resources for comprehensive care. His immediate challenge was to ward off mass resignations of house staff, which brought a strike in 1975. Under dire circumstances, he needed to settle the strike and continue to recruit the most competent house staff, attending physicians and departmental chairs to maintain the County’s teaching excellence. Despite having the strong support of senior physicians and the house staff as he dealt with these problems, he was fired twice (temporarily) by the commission and administrator that had been established by the Governor. Persisting through his ten years as Chief of Medicine at County, Quentin outlived the commission that had fired him, succeeded in averting any further strikes by the house staff, saved his Department as a leading teaching service, started a new program in occupational medicine, and established four vital community health centers in surrounding neighborhoods.

Despite these successes, County was still in big trouble. It was an old facility and in financial crisis, largely due to its serving a large working poor population without Medicaid (the cutoff then was $4,600 annual income for a family of four). In view of this crisis and seeing an inadequate political response to it, Quentin offered his resignation after ten years, citing underfunding, the threat of privatization, denial of unionization benefits to the County’s workforce, problems with the Jail Health Service, and mismanagement by the Hyatt Hospital Management Association. As he said at the time:

I have decided to resign because of a series of developments [above mentioned] have convinced me that unless there is new support and remedy of these situations, it would not be possible for this wonderful and historic institution to continue its mission, offering health care to the hundreds of thousands of sick poor in this area who depend on it. 6

Health and Medicine Research Policy Group

Based on his experience and beliefs, it was only natural that Quentin, soon after leaving County, established the Health and Medicine Research Policy Group (HMRPG), an “action think tank” with the goal to positively influence the health system in Chicago and Illinois. As he said at the time: “it would be independent of any institution, we would oppose the exploiters of the health system—specifically corporations—and the board would be a working board, not a membership one.” This group set about to “RESEARCH the major medical, political, and social determinants of illness…EDUCATE the public about the hazards inherent in the existing health care system…Analyze HEALTH POLICY decisions to identify and expose the corporate beneficiaries of the existing system. [Such work would serve as] “the foundation to advocate changes in the system…Quentin served as the chairman of the HMRPG board continuously since 1981 as it grew by 2013 to a board of thirty active members with an annual budget of more than $1 million and a staff of a dozen people. This is what he said after this 32-year experience with HMRPG:

We have accomplished what we have by joining with others who share our vision. Policy change is hard and can only be done by building coalitions, conducting solid research, and articulating a clear vision to the media, policy makers and the public. I never expected this group to accomplish so much and to be a leader in so many spheres. But it has, and I am proud that I have been the leader of such a robust action-think tank for these 32 years. 7

Here are two examples of Quentin’s prescient concerns in 1975 and 1984 about the threat of the growing for-profit private enterprise in U.S. health care, all of which has come to pass:

Since the sale of health services for profit is counterproductive, the major elements in the therapeutic system should be dealt with as public utilities with standards established nationally but control vested locally. Included in such a system would be production and distribution of drugs, hospitals, and nursing homes, physician and other professional services, laboratory services, and financing arrangements. 8

[Once for-profit providers have the stage], their monopoly behavior so odious to this nation could easily be the most serious new distortion of our vast health resources. The for-profit moves to add vertical consolidation (combining hospitals, psychiatric units, health maintenance organizations, home health care and even hospices) to the massive horizontal consolidation of the big chains are harbingers of a for-profit dominance in our system of health care from birth to grave. 9

Chicago Public Radio

Acting on his leadership role in education of the public, Quentin put on still another hat from 1983 to 2005 as Talk Show Host of WBEZ Radio’s “Speaking of Health and Medicine.” In these regular one-hour shows, as the program’s medical contributor, he would speak to issues of the day, interview policy makers, and take listeners’ phone calls on subjects ranging from immunizations to the segregated health system in Chicago. 10

American Public Health Association (APHA)

Quentin’s leadership extended way beyond Chicago and Illinois. He served as president of the American Public Health Association in 1988. Founded in 1872, this Washington, D.C. based organization has a membership of more than 25,000 health care workers with a mission to “protect all Americans and their communities from preventable, serious health threats and strive to assure that community-based health promotion and disease prevention activities and preventive health services are universally accessible in the United States.” 11

Physicians for a National Health Program (PNHP)

As an early member of PNHP, formed by co-founders Drs. David Himmelstein and Steffie Woolhandler in 1988, Quentin rose to its presidency from 1991 to 1993 before serving as its National Coordinator for the next twenty-plus years. PNHP has endorsed single-payer national health insurance from its beginnings as an improved Medicare for All program. The 2010 Affordable Care Act has fallen far short of the nation’s needs. As Quentin said in 2013:

Conventional wisdom suggests we should wait and see how the Obama administration’s health law plays out. But we’ve seen how comparable reforms have fared on the state level: they’ve invariably failed, chiefly because they can’t control costs. Meanwhile, more millions suffer and tens of thousands die each year from lack of adequate coverage. Tragically, this picture will not be significantly improved by the new health law. But it’s never too late to do the right thing. 12

Quentin Young’s Legacy

After this long and productive career, we might wonder when and how his passion for leadership toward fairness and reform started. He answered this in his 2013 book:

I think that whatever organizational leadership I’ve demonstrated has its roots in my childhood. Recall, I was double promoted in grade school—a very bad thing. Getting out of grade school at age 12 and high school at age 16, I had to rely on something other than physical prowess and athletic skill to make my way in my peer group…When I went to University of Chicago, I was 16…If you were willing to give it the time, you could have a leadership role. That happened successfully as time went on…And there’s this: I always loved a battle. Still do. I’ve never tired of the good fight. 13

Over his entire career, Quentin naturally rose to leadership positions in most every effort he tackled. Table 1 lists just some of his top leadership positions over the years. He received widespread recognition and awards, including the Ethical Humanist Society’s Humanist of the Year award in 1976, the Doctor of Humane Letters at Columbia College in 1972 and at the University of Illinois in 1997, and Alumnus of the Year at Northwestern University in 2010.

Table 1

This is what Margie Schaps, Executive Director of HMPRG over many years, had to say after Quentin’s passing:

Quentin’s extraordinary intellect, his moral compass, combined with his total recall of history always led us to a clear path as we tried to solve the challenges in front of us. He taught me that the lessons of history should never be forgotten—that fighting for social justice, racial justice, for health justice is not new. We must learn from struggles that came before us, learn from the failures, and build upon the successes. Quentin taught me to always stand in solidarity with the struggles of working men and women, that no rally was too small to attend, that any opportunity to get our message across was worth taking, that every individual injustice is an injustice to all of us. In his words, you could get a lot accomplished if you didn’t have to take the credit and if you linked arms with others in struggle. 14

Drs. Mardge Cohen and Gordy Schiff trained with Quentin in the 1970s, then worked with him for many years afterwards at Cook County Hospital. Here’s how they describe his mentorship:

He always found time for us and everyone else, which is a model for us and we strive to be mentors for others. We would call him when we needed input into key professional, personal and political decisions. He listened, got it immediately and helped tremendously. From his witty and prescient metaphors to his lessons in talking truth to power and information sharing to his commitment to a doctor-patient partnership, Quentin taught/showed us what it really meant to listen, empower and partner with patients to make them better and to make a better world. 15

Here’s how Quentin ends his own 2013 book, words that are timeless as we face the future:

From my adolescent years to the present, I’ve never wavered in my belief in humanity’s ability—and our collective responsibility—to bring about a more just and equitable social order. I’ve always believed in humanity’s potential to create a more caring society…It’s been a lifelong, driving force to promote equality and the common good. I’ve spent a lifetime trying to help others—in my daily rounds, in my clinic, as a hospital administrator, at demonstrations, in my work with health advocacy groups—and it all adds up to a deeply rewarding career. Few people have such good fortune…I retain a terrible reputation for excessive optimism. The glories of humankind’s ingenuity and inventiveness have not yet been exhausted. The future can be bright, but only if we work to make it so. 16

Some of Quentin Young’s Leadership Positions

1955-1957, President, Southside Branch, Chicago Medical Society

1972-1981, Chairman, Department of Medicine, Cook County Hospital

1981-2016, Chairman of the Board, Health and Medicine Policy Research Group

1983-1984, President designate, Chicago Board of Health

1987-2016, Clinical Professor of Preventive Medicine, University of Illinois Medical Center

1989-1991, Chairman, Human Rights and Medical Practice Subcommittee, American College of Physicians

1991-1993, President, Physicians for a National Health Program

1993-2014, National Coordinator, Physicians for a National Health Program

1997-1998, President, American Public Health Association

References

1. Young, QD. Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause. Friday Harbor, WA. Copernicus Healthcare, 2013, pp. 3-12.
2. Ibid # 1, p. 13.
3. Ibid # 1, p. 36.
4. Ibid # 1, 45, 124.
5. Ibid # 1, 55-65.
6. Ibid # 1, 179.
7. Ibid # 1, 182, 196.
8. Young, QD. Structural reforms in health-care delivery. Ann Intern Med 135: 909, 1975.
9. Young, QD. Impact of for-profit enterprise on health care. Journal of Public Health Policy 5 (4): 452, 1984.
10. Ibid # 1, 233-234.
11. Ibid # 1, 231.
12. Ibid # 1, 72.
13. Ibid # 1, 75.
14. Schaps, M. Remembering the extraordinary intellect and moral compass of Quentin Young. Health and Medicine Policy Research Group, March 10, 2016.
15. Ibid # 1, 178.
16. Ibid # 1, 239, 242.

John Geyman, M.D. is professor emeritus of family medicine at the University of Washington School of Medicine in Seattle, where he served as chairman of the Department of Family Medicine from 1976 to 1990.

http://www.northwestern.edu…

Gerald Kominski discusses the politicians’ proposals and the future of U.S. health care

“The Presidential Candidates: Their Health Plans”

By Dr. Gerald Kominski
Director, UCLA Center for Health Policy Research
Professor, UCLA Fielding School of Public Health
The UCLA Center for Health Policy Research
Health Policy Seminar Series, September 27, 2016

Excerpt at 0:52:24 of the video:

Question: Will the U.S. move to universal health care in the next ten years or so?

Gerald Kominski: Wow! I’ve spent my entire career talking about the history of the effort to get universal health care in the United States. And, again, I’m looking at Mark Peterson whose written about this extensively as well and knows the history. Our history is that we have been trying to do this now for 120 years in the United States. We’ve made progress, but the progress is glacial. Having said that, we never stop fighting for that. First of all, that’s why we’re in Public Health. It’s why this center – The Center for Health Policy Research – does what it does, and it’s why thousands of people across the country, across the state…millions of people are working towards this goal. But the next ten years are very difficult…we are so divided politically right now, it is very, very difficult to imagine the scenarios that lead us to true universal access through, say, a single payer system in the next ten years. But I’m an optimist, and I believe that there are people in this room who will one day see a single payer system in this country. Now I may not be around, but some of you will be. And we’re getting there. It just takes a long time.

Video, with PowerPoint:
http://healthpolicy.ucla.edu…

***

Comment:

By Don McCanne, M.D.

In this seminar Gerald Kominski discusses the health care proposals of presidential candidates Democrat Hillary Clinton and Republican Donald Trump plus those of Libertarian Gary Johnson and Green Party candidate Jill Stein.

Health policy wonks and others certainly understand the complexity of the proposals of the two leading candidates and even that of Libertarian Gary Johnson, as described by Professor Kominski. But he was able to describe Jill Stein’s proposal in full in one brief, elegant sentence. Here is his full description of her plan (at 0:41:12 of the video):

“Jill Stein, the Green Party candidate, is for a Medicare for All plan, basically a single payer plan with no copayments, no deductibles, basically free health care for all Americans.”

That’s it!

Wow!

Physicians for a National Health Program is a nonpartisan educational organization. It neither supports nor opposes any candidate for public office.

Why Health Insurance Industry Consolidation Is Bad For Your Health

By Wendell Potter
The Huffington Post, Sept. 29, 2016

You undoubtedly have heard that some of the country’s biggest health insurers have decided to leave several Obamacare markets, which means that tens of thousands of us will be affected next year.

You probably haven’t heard — at least not lately — that some of the biggest health insurers are moving full steam ahead to merge with each other, which means that tens of millions of us — yes, millions — will be affected next year. And not in a good way. If the consolidation happens as planned, many of us will find ourselves in health plans with much worse patient satisfaction and customer complaint scores.

Here’s some context: Executives of UnitedHealthcare, Aetna and Humana made headlines this summer when they announced plans to quit selling policies on several Obamacare exchanges at the end of the year because they haven’t yet figured out how to turn a profit on that business. That means people enrolled in those companies’ Obamacare plans will have to pick a different insurer for 2017.

If That’s Not Bad Enough

That’s a big inconvenience for those folks, of course. But far more of us, including several million who are enrolled in employer-sponsored plans, will be more than inconvenienced if state and federal regulators approve the Anthem-Cigna and Aetna-Humana mergers.

Employers, consumer groups, the American Medical Association and many other organizations have told regulators they think those mega mergers are not in the public’s best interest. The U.S. Justice Department and several state officials agree. They filed a lawsuit in July to stop both of them. Nevertheless, the mergers are far from dead.

That should worry us. A lot. That’s because the acquiring companies, Anthem and Aetna — but Anthem especially — have higher customer complaint ratios and lower patient satisfaction scores than other companies, as recent reports by the state of California’s Office of the Patient Advocate (OPA) show. And if the Anthem-Cigna merger goes through, Anthem, with the worst scores overall, would become the nation’s biggest health insurer.

“Your Call Is Not Important To Us”

Take a look at OPA’s Annual Health Care Complaint Data Report, which provides a wealth of information about the complaints California regulators received in 2014, the most recent year for which data were available for analysis.

Anthem scored the worst by far of any of the other health plans operating in the state. Data provided to OPA by the Department of Managed Health Care, which has jurisdiction over most of the state’s HMOs, showed, for example, that Anthem had 12.28 complaints per 10,000 enrollees. Compare that with Kaiser Permanente, the nonprofit company that rivals Anthem in terms of enrollment in California. Kaiser had just 4.50 complaints per 10,000. In other words, Anthem had nearly three times as many complaints as Kaiser.

Anthem also led the pack in the ratio of complaints received by the California Department of Insurance. That department said Anthem had a whopping 47.64 complaints per 10,000. Cigna, the company Anthem is trying to buy, had just 2.69 complaints per 10,000.

And it’s not just in California that Anthem has generated an inordinate number of complaints about how it treats its customers. It appears to be nationwide. In fact, the Department of Justice cited Anthem’s less than stellar reputation in its lawsuit to block its takeover of Cigna. This is from a September 20 story in the Hartford Courant about the status of the proposed $54 billion deal:

The federal government claims that many large employers dislike Anthem and that doctors fear the company because its large customer base gives it leverage in negotiations.

The Department of Justice complaint says that although Cigna can’t get as low prices from hospital systems and doctors in some markets as Anthem does, “Cigna competes vigorously with Anthem for large groups by offering exceptional customer service, innovative wellness programs that lower its members’ utilization of health care, and provider-collaboration programs with hospitals and doctors. By contrast, many large-group employers believe that Anthem provides poor customer service and is far less innovative. Soon after the merger was announced, two prospective customers complained to Cigna: “We hate Anthem and you guys are about to become them.”

When it comes to how patients rate their experience with their HMOs, another report by the California Office of the Patient Advocate shows that the big for-profits involved in the proposed mergers also get much lower scores than their nonprofit competitors. Nonprofit Kaiser Permanente’s HMOs were the only ones rated “excellent.”

Earlier this month, a Harvard Law watchdog group filed complaints with the U.S. Department of Health and Human Services against seven big insurers — including Anthem, Cigna and Humana—alleging that they all were in violation of anti-discrimination laws pertaining to the coverage of HIV/AIDS treatments. The allegations involved refusing to cover vital medications that HIV/AIDS patients need and requiring high-cost sharing for other medications used to treat HIV/AIDS.

“When an insurer requires chronically ill patients to pay a disproportionate share of the cost of medication, it violates federal law,” said Robert Greenwald, clinical professor of law at Harvard Law School.

The American Medical Association has become one of the most vocal opponents of the mega-mergers, particularly the Anthem-Cigna deal. On September 21, the AMA released a report showing that Anthem’s “market power” would be significantly increased in several states and numerous metropolitan areas — especially in California — if the deal is approved.

Despite all of this, the mergers could still happen. A U.S. District Court has set a November 21 trial date for the lawsuit the Department of Justice has filed to stop the Anthem-Cigna merger. The Aetna-Humana trial is scheduled to start on December 5. Both trials likely will go on for several weeks. If the Department of Justice loses, millions of Americans will soon find themselves enrolled in health plans administered by companies with some of the industry’s worst quality and customer satisfaction scores. That’s something not only to worry about but also to try keep from happening. The last thing we need is for Anthem and Aetna to be more in control of our lives.

This has also been published by HEAL California.

http://www.huffingtonpost.com…

Wellmark Blue Cross and Blue Shield placing greater squeeze on patients

Wellmark announces individual ACA market changes in Iowa and South Dakota

Wellmark, September 28, 2016

Wellmark Blue Cross and Blue Shield announced today it will make changes in the individual Affordable Care Act (ACA) market in Iowa and South Dakota.

For the past two years, Wellmark members with individual ACA plans have endured double-digit increases. In addition, Wellmark has lost approximately $99 million over the same time period in the individual market in Iowa and South Dakota.

“Wellmark’s mission is to create affordable health insurance for people to access quality health care. And, for the majority of the past 75 years, we’ve been able to achieve that,” said Wellmark Chairman and CEO John Forsyth. “However, it’s apparent that continuing to offer plans with broad networks, combined with the rich benefits of the ACA, is not consistent with managing continually rising costs. While we could seek additional premium increases to mitigate rising costs, this is not sustainable for our members’ pocketbook.”

Iowa changes

In Iowa, Wellmark will narrow its product choices to offer plans that are lower priced and encourage health care delivery by Iowa providers. Specifically, Wellmark will no longer offer gold tier plans nor will the company promote individual under 65 plans that use its Preferred Provider Organization (PPO) network in Iowa.

Wellmark will also continue its plans to introduce a new, simplified HMO plan called Blue Simplicity℠. This plan is like no other on the market today and is designed to help consumers understand the true value of care through simple copay plans – providing members with transparency and predictability of cost as they seek and use medical services.

South Dakota changes

In South Dakota, Wellmark will no longer offer individual Affordable Care Act (ACA) plans effective Jan. 1, 2017.

“Although the ACA has done many positive things, it has also had its challenges and those challenges vary by state,” said Forsyth. “Fortunately, in 2017, the ACA gives states the ability to begin addressing those challenges with the goal of stabilizing the individual under 65 health insurance market. We look forward to working with Iowa and South Dakota policymakers on those solutions in the near future.”

https://www.wellmark.com…

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Comment:

By Don McCanne, M.D.

The largest health insurer in Iowa, Wellmark Blue Cross and Blue Shield, is discontinuing their more comprehensive gold tier plans and is discontinuing the promotion of its PPO plans with wider provider networks. They are also introducing a new HMO plan “designed to help consumers understand the true value of care through simple copay plans” (i.e., making them better shoppers by having to bear more of the costs). These changes are compounding the two problems plaguing insurance purchasers today: requiring higher out-of-pocket spending for health care, and narrowing the selection of health care providers covered by the plans.

This is a one-way path designed to keep insurance premiums as competitive as possible. As Chairman and CEO Forsyth states, “continuing to offer plans with broad networks, combined with the rich benefits of the ACA, is not consistent with managing continually rising costs.” Insurers are not going to cover more out-of-pocket costs by increasing the actuarial value of their plans (percent of costs they will pay), and they are not going to expand their networks when they can negotiate lower prices by promising provider exclusivity.

Look, as long as we leave these people in charge, we can anticipate that they will engage in strategies that will protect and improve their own market advantage. If we had our own public program, our stewards who work for us would be engaging in strategies that would ensure our access to the health care that we need. There really is a difference. If only for selfish reasons, we should prefer the latter. The fact that it helps everyone else is a bonus.

America needs to adopt VA’s prevention-based approach to health care to improve outcomes

By W.T. “Bill” McKibben
The Buffalo News, Sept. 25, 2016

The Veterans Affairs health care system is America’s favorite political football. We love our vets and are quick to pick up on any failure to care for them or treat them well. We were all stunned by reports of vets dying while waiting to see a doctor. A closer look reveals that they were waiting to be accepted into the VA health care system and be assigned to a primary care doctor. The image of sick and dying vets already within the VA system waiting for care is simply false.

Worse, this myth has been unfairly projected onto the doctors and all those delivering care to the vets in the system. The truth is vets in the system never wait when they need to see a doctor. The VA’s prevention-based approach is very different from the greed-driven, treatment-based system most Americans are stuck with.

A doctor’s appointment for those in the VA system, whether it’s with a vet’s primary physician or a specialist, is never for anything urgent, it’s for a regular checkup, follow-up, specialist consult or a routine medical test.

When vets need immediate care, they don’t call for an appointment. Instead, they just head to one of the system’s 1,700 medical centers and clinics. Not just for emergencies, that’s where vets go for a cold, the flu, or anytime they need to see a doctor. The VA’s facilities are set up to act as immediate care centers as well as standard emergency rooms.

Altogether the VA operates America’s largest integrated health care system, serving nearly 9 million vets annually. It has hundreds of clinics plus 152 medical centers that have full hospital facilities, as well as emergency room/immediate care centers.

The major difference in the care that vets receive – and the source of its superiority – is the VA’s focus. The VA utilizes the system prevalent in every developed nation in the world except America: the prevention-based system as opposed to the treatment-based system most Americans have. Our nation spends twice as much as any other nation in the world on health care. And yet our outcomes rank down among the Third World countries.

When a provider’s only revenue source is to treat or medicate, that’s what he does; and sadly too often greed takes over. Overtreatment and overmedication trigger thousands of deaths and health issues in America every year, but not at the VA. Just like providers all over the world, those at the VA – some of the most skilled medical practitioners in America – are paid to prevent health care issues, not just to treat them.

The VA’s prevention-based approach delivers much better outcomes. Better than Medicare, even though the VA has a more vulnerable patient base. The VA is treating a bunch of beat-up old folks and some horrifically beat-up younger vets. By comparison, Medicare patients, in general, are much healthier than our vets. Yet even with that disadvantage, the VA gets better outcomes than Medicare, and it does it for less – nearly 40 percent less per patient.

It’s clear that we need to follow the rest of the developed nations on this planet and make some dramatic changes. We need to adopt a single-payer, prevention-based system. Big Pharma hates this idea, for-profit hospitals hate this idea and, sadly, even some health care providers hate this idea.

We spend twice as much as any other nation on health care with more than half the cost coming out of taxpayer funds. That would lead one to believe that with a more cost-efficient single-payer system, we might find that we have been paying for a better system all along and throwing away half of what we currently spend. It’s time we got our money’s worth.

W.T. “Bill” McKibben is a Buffalo-based author. He was a Medicare Part B and health care insurer consultant for more than a quarter century.

http://www.buffalonews.com/opinion/viewpoints/america-needs-to-adopt-vas-prevention-based-approach-to-health-care-to-improve-outcomes-20160925

Universal health care would solve crisis of uninsured

By Richard Weiskopf, M.D., Kaye Jaeger, R.N., and Joel Potash, M.D.
Syracuse.com, Sept. 28, 2016

A commentary published Sept. 14 (“How many are insured because of Obamacare? Good question”) points out the challenge of assessing the Affordable Care Act’s impact on closing the insurance gap. Focusing strictly on health “insurance” coverage obscures the crisis in healthcare access across the country that millions continue to live without access to needed health care. In New York, since the passage of the Affordable Care Act, there are still 1.5 million individuals without health insurance and countless more who are underinsured — that is they have insurance but can’t access healthcare they need due to high co-pays, deductibles, and rising drug costs.

In a system dominated by private health insurance corporations, those with high incomes can afford adequate health care, while the poor and many middle class cannot. The consequences are tragic. According to a Harvard study, 45,000 Americans die each year for lack of health insurance. Medical bills contribute to more that 60 percent of all bankruptcies, and most people who file for medical debt related bankruptcy had insurance when they got sick.

What is it like to be uninsured or underinsured? Imagine having asthma or chronic pulmonary disease (COPD) and not being able to afford the medication your doctor prescribes. Beyond daily shortness of breath and chronic cough, untreated respiratory diseases make people more susceptible to pneumonia.

Sudden pauses in medication use are not uncommon and can have serious consequences. For example, a patient who pauses use of hypertension medicine faces an increased likelihood of stroke and heart attack. As healthcare providers, it’s heartbreaking to know that a patient won’t be able to relieve his or her suffering due to financial barriers.

We need to shift our public conversation from discussing issues of insurance to the task of guaranteeing universal access to medically necessary care from cradle to grave.

Under our present system of multiple health insurers, a large amount of the money that private insurance companies collect in premiums is spent on administrative costs and CEO compensation rather than care. The national Medicare program which covers the elderly is much more efficient, allowing a greater portion of the money to be spent directly for health care. Administrative costs in the private insurance infrastructure consume 31 percent of U.S. health spending while Medicare maintains an annual administrative cost of 2 to 3 percent.

An economic analysis conducted in 2015 by economist Gerald Friedman found that implementing a universal public healthcare system, like the one proposed by the New York Health Act, would reduce New York’s health care spending by 25 percent, more than $70 billion, by 2016. The savings would come from reducing burdensome billing expenses, administrative waste, the monopolistic pricing of drugs and medical devices, and fraud. According to Friedman’s analysis, 98 percent of New Yorkers would pay less for health care. But most important, New York Health would provide universal access to healthcare to all New Yorkers.

All of us need health care, regardless of age, income or employment status. The New York State Assembly has passed such a plan with huge majority support. We urge Sen. Dave Valesky to be a champion for universal health care by sponsoring the New York Health Act in the next session and passing it through the Senate.

Dr. Richard Weiskopf is a member of Physicians for a National Health Program (PNHP). Kaye Jaeger is a registered nurse. Dr. Joel Potash is a palliative care physician. All live in Syracuse.

http://www.syracuse.com…

What an Oregon business group gets wrong about single-payer

By Mark Kellenbeck
Portland Business Journal, Sept. 28, 2016

It was with interest that our Health Care for All Oregon membership, 19,000 advocates and 120 organizational members throughout the state of Oregon, read the Guest Opinion in the Sept. 15 issue of the Portland Business Journal by Anthony K. Smith, the state director of the National Federation of Independent Business.

HCAO is particularly committed to expanding our outreach into Oregon businesses of all sizes in order to better understand their needs and concerns about providing their employees’ health care.

We particularly appreciate Mr. Smith’s including a link to NFIB’s website containing the 12 points of further health care reform for which NFIB is lobbying.

There are a number of ideas and opinions contained in Mr. Smith’s piece that HCAO agrees with. At the top of the list is the Affordable Care Act, which HCAO agrees is deeply flawed (we prefer that legislation title to “Obamacare”).

We do not agree, however, with Mr. Smith’s premise that the ACA’s shortcomings are an indictment of single-payer health care. In fact, the ACA’s problems illustrate why single-payer can and will succeed if given a fair chance.

Continue reading…
http://www.bizjournals.com/portland/blog…

Employee health deteriorated under award-winning wellness program

Top wellness award goes to workplace where many health measures got worse

By Sharon Begley
STAT, September 27, 2016

When Idaho’s Boise School District receives the workplace wellness industry’s highest award Wednesday at a celebration in Atlanta, it is expected to be applauded for helping its 3,000-plus employees and their families improve their health and reduce their risk of illness.

It is “an exemplary program,” said Dr. James Fries, an emeritus professor of medicine at Stanford University and member of The Health Project, an industry-sponsored group that makes the annual award. Program participants, he said in an announcement this month, “showed improvements in health behavior,” helping Boise save money on medical costs.

Data collected by the company that sold Boise the wellness program and trumpeted the “Koop Award,” however, cast doubt on that claim. More key measures of health deteriorated than improved. Self-reported quality of health got worse. And health care costs jumped around in a way that suggests any changes were due at least in part to random fluctuations and possibly employee turnover, not any benefits of the wellness program.

This would not be the first time the Koop Award, named for the late US Surgeon General Dr. C. Everett Koop, stirred controversy. Employees in the wellness program that won in 2015, for instance, collectively achieved a lower reduction in smoking than the national average. More gained weight than lost, more raised their total cholesterol level than lowered it, and more had higher blood glucose levels after participating in the wellness program than before.

Such cases reinforce a growing recognition among experts that wellness programs — which constitute an $8 billion a year industry — “don’t lead to any visible results,” Stanford’s Emma Seppala recently wrote in Harvard Business Review. “At best, these initiatives are nothing more than lip service or PR. But at worst, they actually cause more stress.”

https://www.statnews.com/2016/09/27/workplace-wellness-award/

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Comment:

By Don McCanne, M.D.

We still hear that employers are adopting wellness programs in order to reduce the future costs of their health benefit programs by making their employees healthier. There could be no better evidence that these programs do not work than the fact that the top award for a workplace wellness program went to an employer whose employees’ health deteriorated.

If employers really want to do something about controlling health care costs, they should get on the single payer bandwagon. Not only would that eliminate the hassle and expense of administering their health benefit programs, all of their employees would have health care automatically, and future increases in health care costs would be reduced to sustainable levels.

Any employers reading this who are not yet convinced about single payer would benefit by watching a movie developed by and for the business community, “FIX IT – Healthcare at The Tipping Point.”

http://fixithealthcare.com

Clinton and Trump on healthcare

The Presidential Debate That Wasn’t

By Jeanne Lenzer
The BMJ, Sept. 27, 2016

The 90 minute presidential debate between Hillary Clinton and Donald Trump ended last night without a single word about healthcare. Yet two-thirds of voters said “the future of Medicare and access and affordability of healthcare are top priorities for the candidates to be talking about during the 2016 presidential campaign.”

Clinton, a Democrat, and Trump, a Republican, have both said they support “universal” healthcare and both rely on market forces and private insurers to provide coverage for healthcare. What follows is a summary of what is – and isn’t – known about the candidates’ positions on various healthcare issues, followed by comments from critics right and left.

full, with comments by Dr. Adam Gaffney of PNHP:
http://blogs.bmj.com/bmj/2016/09/27/jeanne-lenzer-clinton-and-trump-on-healthcare/

PNHP note: Physicians for a National Health Program is a nonpartisan educational organization. It neither supports nor opposes any candidate for public office.

What should the candidates tell us about controlling costs?

Editorial: Thank you for that question, Lester

By Merrill Goozner
Modern Healthcare, September 24, 2016

(Question for candidates, proposed by the New York Times): “Health insurance premiums and out-of-pocket costs are rising rapidly. What would you do to control them?”

If I were advising a candidate on how to respond to that question, here’s what I’d recommend he or she say:

(Excerpts)

“Thank you for that question, Lester. I understand why many Americans think their insurance premiums are rising rapidly. There’s been a lot of attention paid to next year’s increases for the individual policies sold on the Obamacare insurance exchanges, which will rise about 9% on average, according to the latest Kaiser Family Foundation survey.”

“Employers are forcing individuals to pick up more of the cost of their plans.”

“The employer portion of your health insurance is going up just 4% next year on average. That means the family share has to go up more than 5.5% to make up the difference.”

“Employers are doing that by putting more of us in high-deductible plans. They’re asking more of us to pay higher co-pays and deductibles. They are raising our portion of the premiums.”

“So what can we do about it? First, we have to recognize this is a big experiment that has been endorsed by economists associated with both political parties. They say by forcing patients and consumers to have more skin in the game, they will become wiser healthcare shoppers.”

“I say, to make that work, we have to have total transparency — in healthcare prices, in insurance prices, in which doctors and hospitals are in health plan networks, in quality ratings, and with good, easy-to-understand information about what constitutes the most effective and cost-effective care. I pledge to work night and day to give consumers the information they need to make smarter choices in the healthcare marketplace.”

“And if some people simply can’t afford to put money into the health savings accounts accompanying these plans, let’s remove some of the tax subsidies given high-income people for their health insurance so we can finance a generous federal match for what lower-income people contribute.”

“Let me now turn to what can we do about those rising individual rates for plans sold on the exchanges. The bottom line is we need more people to sign up. The No. 1 reason why rates are rising is that not enough healthy uninsured people signed up for coverage.”

“We need everyone who is uninsured to jump into the individual insurance pool.”

http://www.modernhealthcare.com/article/20160924/MAGAZINE/309249985/editorial-thank-you-for-that-question-lester

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Comment:

By Don McCanne, M.D.

Merrill Goozner certainly understands the political realities about health policy. To a question on health costs that could be part of tonight’s presidential debate, he suggests an answer for the candidates that aligns with the current financing system under the Affordable Care Act. Unfortunately, because of the restrictions he apparently placed on himself, it’s a terribly deficient answer.

For the problem of high-deductibles he suggests making patients better shoppers through greater transparency in prices, in network composition and in quality ratings. But that would have almost no impact on making the deductibles and other cost sharing more affordable.

He accepts the dubious concept that health savings accounts should accompany these high-deductible plans, and further suggests that the accounts for lower-income individuals be subsidized. Health savings accounts are strictly an administrative tool that increases the complexity and waste in health care financing. When the accounts are depleted, beneficial health care services are forgone – not a desirable outcome. If you are going to have first dollar coverage built into the HSAs, why not instead save administrative hassles and expenses by building first dollar coverage into the insurance program itself?

For the high premiums of the exchange plans, he suggests enrolling more of the healthy to dilute the risk pool. But the low-lying fruit has been picked. The policy community is beside itself in trying to figure out how to bring more into the exchange plans, while having only negligible success in doing so.

Goozner is certainly highly respected by me and others, but we wish that he and others like him would move beyond feeble patchwork solutions and support a program that would make health care accessible and permanently affordable for all. Of course that would be a single payer national health program – an improved Medicare for all. Goozner understands that we won’t hear that from either candidate tonight, but that doesn’t mean that we shouldn’t be asking for that response.

Health care for all

By Charles Bensonhaver, M.D.
The Post and Courier (Charleston, S.C.), Letters, Sept. 25, 2016

In a Sept. 21 letter to the editor titled “Health care slide,” the writer advances the notion that more government intervention will result in deterioration of our health care.

I disagree. What we need is the right kind of government intervention.

Unfortunately, most Americans are unaware that, among the advanced nations in the world, we have the most costly system. It is almost twice as much as the average of other modern nations such as Germany, France, Australia and New Zealand. Furthermore, among the 25 or so advanced countries in the world we are the only one that does not automatically cover everyone.

The anxiety we have about getting sick and being unable to pay for care is very high and is getting worse because more and more of the cost is thrown onto the shoulders of the patient.

Really now, what is insurance for if it doesn’t cover all or nearly all of the cost?

All of this is completely unnecessary. Effective reforms are known.

However, you can be sure that the health insurance companies, the drug companies, the health care equipment companies and the large for-profit hospital chains do not want you to know this.

What we need is to improve traditional Medicare and phase it in as the single-payer system for all Americans.

Our current overhead is huge, and Medicare single payer will dramatically reduce it. Outsized profits will go away.

All citizens will know that their country is there for them when they are ill. We have been there for all of us with free public education for over a century. We can do the same with health care.

The best resource I can give for more information on this reform is the Physicians for a National Health Program. Check out our website at www.pnhp.org.

Dr. Charles Bensonhaver lives on Johns Island.

http://www.postandcourier.com…