By Mark Gruenberg
PAI Staff Writer
A PAI news analysis

NEW YORK (PAI)–With the Democratic-run 110th Congress set to open on Jan. 4 and with several top Democrats making clear health care will be part of the agenda, battle lines are already forming around competing plans.

And unionists, their families and their allies have an interest in the outcome, since if lawmakers undertake radical revision of the nation’s $2 trillion health care system, it could also determine the future of employer-based health insurance.

That insurance covers almost everyone. Exceptions include those on Medicaid, the elderly on Medicare and 47 million uninsured. But private health insurance has a high cost for workers: Large deductibles, increasing co-pays, at least 20 percent of its funds wasted on overhead, and insurers’ demands for hospitals to cut staffing and care.

Worst of all, the private insurers feature company bean-counters ordered to both pocket workers’ hard-earned money while denying coverage. That denial kills people.

The coming fight on health care has multiple sides:

• On one side is the private health insurance industry. Insurers and their allies–including the pharmaceutical companies that get a $140 billion windfall from GOP President George W. Bush’s prescription drugs law–will lobby for the status quo, and their own pockets, using advertising spin, outright lies, and huge campaign contributions.

• On another side is Bush. He and his business backers want to shove more of the health insurance costs onto workers. They claim, wrongly, that forcing workers to make decisions on how to spend their money on health care will induce “competition,” which will moderate prices. Health care inflation has been running in double digits yearly.

• On third side are the state of Massachusetts, Sen. Ron Wyden (D-Ore.), Service Employees President Andy Stern, Families USA President Ron Pollack and Safeway CEO Steve Burd. They espouse a plan, which Wyden crafted and which is similar to legislation passed and signed in the Bay State last year, which requires individuals to buy health insurance, just as they buy car insurance. Wyden plans to use his Senate Finance Committee seat–the panel handles health legislation–to push his plan.

Wyden claims individuals could pay for insurance because his “Healthy Americans Act” would require employers to take the money they now pay insurers to cover workers and instead give it to them as raises. Wyden’s bill does not say how it would guarantee that.

States would set minimum coverage standards that all insurers must meet before they can sell policies, and there would be subsidies for the poor and working class. What neither Wyden nor Massachusetts have is any method of controlling health care costs.

• On the fourth side are advocates of government-run single-payer health coverage, similar to Medicare or to Canada’s system. They include Senate Health, Education, Labor and Pensions Committee Chairman Edward M. Kennedy (D-Mass.) and Reps. John Conyers and John Dingell (both D-Mich.), who will chair important committees in the new Congress. Dingell’s committee is one of those handling health care.

All three, along with the Steel Workers and Physicians for a National Health Plan (PHNP), advocate some form of universal health care that cannot be taken away when workers switch jobs. They, especially Conyers, would virtually abolish the private insurance industry, cutting overhead and duplication, while allowing wide consumer choice of physicians and hospitals, advocates say. But their big political problems are cost, and who pays. Solutions range from payroll taxes to elimination of waste.

USW President Leo Gerard is a particular advocate of single-payer government-run health care. Like other union leaders, he’s seen health care costs damage negotiations and destroy raises for his members. By contrast, Gerard, a Canadian, knows the edge firms and individuals there have from government-run single-payer health care.

The debate over health care has been relatively dormant ever since the insurers’ lies and a business-backed Senate GOP filibuster doomed President Clinton’s health care plan. Debate started to rise during the campaign and took a recent heated turn with Wyden’s proposed Healthy Americans Act. Stern, backing Wyden, warned “the perfect should not be the enemy of the good,” but PNHP says the Wyden plan is far from good.

PHNP New York research director Len Rodberg calls Wyden’s scheme “one of the most radically destructive proposals ever put forward to address the failings of the American health care system. It would eliminate the system of employer-based health insurance on which more than 90 percent of the insured depend today.” Everyone would have to buy insurance–a windfall for the companies–with the subsidies for the poor afterwards.

Rodberg also targeted Wyden’s lack of cost controls: “Literature from Wyden (says) the Healthy Americans Act relies on competition to drive down costs and promote quality. But nothing would make competition among insurers work any better than it has.” Wyden’s reliance on the insurers could lead to fewer of them and less competition.

“Why should millions who now receive insurance from employers, including members of unions which fought for decades for those benefits, give up this coverage for the uncertainties and inequities of the private for-profit insurance market? In the face of continuing increases in the cost of health care exceeding general inflation as well as the

growth in average wages, why should workers want to take over responsibility for paying for their health care? It is not the employer base that is collapsing, it is the entire system of private insurance which is becoming increasingly unaffordable,” he says.

Malcolm Berko
Copley News Service

Dear Mr. Berko: When you spoke at the fundraiser for our church about the future of our country, you pointedly said that we must have a single-payer health care system. You noted that there are 41 million uninsured in the country who can’t afford health care. You said they must have medical access but (and the following are your words) “the health insurance industry’s intentional high costs exclude them from participation.”

Are you nuts or something? How can you preach such socialistic ideas in a capitalistic society? They would be able to afford health care if they were worth more to their employers so they would be paid better. Do you know how much our leftist government has screwed up our country? And it would do the same without a private health care system if we allowed it to happen.

You have no idea of the wonderful things that health insurance companies like Aetna have done to help Americans. Their contributions to health care are unequaled in any other country in the world. You shouldn’t preach left-wing, pinko communist ideas to people who invite you to their homes. Shame on you.

C.S.
Elkhart, Ind.

Dear C.S.: Why do I suspect that my friend Charming Charlie, the insurance agent from Kokomo asked you to write? And why do I believe that you may be employed by one of the Big Eight (Aetna, Cigna, Coventry, Health Net, Humana, WellPoint, the Blues or United) health companies?

I’m not going to touch your comment about the federal government except to say that the voters are as much to blame as those they elect. My dad, who voted in 19 presidential elections, said, “We get what we pay for.” And your comments about the health care industry’s “wonderful things” are true because no other country in the world allows private industry to make tens of billions of dollars a year from the suffering of its citizens.

I’d like to know why you don’t “gritch” about a $30,444 hospital bill plus $3,882 in medical supplies for an appendectomy patient who had a five-day stay. And how fair is a $7,809 emergency room charge to X-ray and cast a fractured fibula? But I’d really like to know why Aetna and Blue Cross paid those outlandish charges without a peep (but nickel and dime every doctor) using our premium dollars.

There’s the problem: It’s not the doctors nor the government but rather the insurers themselves. Their pockets are so heavily lined with our premium dollars that paying a huge hospital bill is no more meaningful to them than would be the advent of another fly to a slaughterhouse.

Now would you please tell Charming Charlie that last year the Big Eight reported net profits of $19 billion plus free cash flow of $22 billion? Holy moly! That’s $41 billion – easily enough to pay the health care costs for all of those 41 million uninsured. And I think you ought to tell Charming Charlie that the top five officers at each of the Big Eight health insurance companies received $237 million in compensation last year. That’s a shameful use of our premium dollars. Those Big Eight health insurers employ more than 300,000 people, each of whom is paid a salary with benefits averaging $40,000. Well, that number computes to $12 billion and not a penny of that is used for health care. Certainly a shameful use of our premium dollars.

And then there are billions of dollars spent each year for desks, computers, rent, utilities, thousands of tons of paper and millions of paper clips. Those billions are not spent on health care but they are paid with your premium dollars. Can you imagine how many hundreds of thousands of telephones are owned by Aetna, Cigna, United, Health Net, Coventry, WellPoint, Humana and the Blues? Then count the myriad thousands of copy machines, computers, cubicles, pencils, legal pads and so on, all of which are shamefully paid with premium dollars that could be used for medical costs.

Finally, one must count the commissions paid to people like you who sell health insurance policies. It’s estimated that last year the Big Eight paid close to $12 billion in commissions, shamefully using premium dollars that could be used to pay doctors, hospitals, drug companies and other health care providers.

And that’s just the Big Eight. There are countless smaller companies selling health care policies, shamefully skimming billions from your premium dollars. Tell this to Charming Charlie.

So, like it or not, those tens of billions of wasted premium dollars persuasively argue for a single-payer government-controlled health care system. It’s obvious from those wasted billions that health care premiums would be less by half with a single-payer system.

Please address your financial questions to Malcolm Berko, P.O. Box 1416, Boca Raton, FL 33429 or e-mail him at malber@adelphia.net.

Copyright 2007 Copley News Service

Visit Copley News Service at www.copleynews.com.

In the article, “On the Front Lines of Care: Primary Care Doctors’ Office Systems, Experiences, and Views in Seven Countries” (Health Affairs Web Exclusive, Nov. 2, 2006), the authors report on survey results that reveal striking differences in primary care practice internationally–differences that highlight the importance of having national policies in place to support primary care. According to the survey, U.S. physicians are among the least likely to have extensive clinical information systems or quality-based payment incentives, the least likely to provide access to after-hours care, and the most likely to report that their patients often have difficulty paying for care.

The 2006 Commonwealth Fund/Harris Interactive survey included more than 6,000 PCPs in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States (including more than 1,000 U.S. physicians).

For many people, the primary care physician (PCP) is their first point of contact with the health care system, as well as their main source of preventive and essential care. Recognizing the central role of PCPs in health care, international initiatives to improve health system performance have focused on developing systems and policies to enhance the effectiveness and efficiency of primary care practice. These include the use of clinical information systems, which assist doctors in treatment decisions and enable them to provide patient-centered care; multidisciplinary care teams and disease management programs for patients with chronic illness; and enhanced access to care, such as after-hours appointments.

Use of Information Technology
The survey revealed stark differences in PCPs’ access to information systems. Only 28 percent of U.S. doctors and 23 percent of Canadian doctors said they used electronic medical records (EMRs), compared with overwhelming majorities of doctors in the Netherlands (98%), New Zealand (92%), the U.K. (89%), and Australia (79%).

Canadian and U.S. doctors are also the least likely to have systems that provide decision support, such as computerized alerts about potentially harmful drug doses or interactions. Only 10 percent of Canadian doctors and 23 percent of U.S. doctors receive computerized alerts; rates elsewhere ranged from 93 percent (Netherlands) to 40 percent (Germany). Furthermore, at least two of five U.S. and Canadian doctors find it “very difficult” or “impossible” to identify patients overdue for a test or preventive care, versus one of five or fewer in the other countries.

Patients’ Access to Care
Doctors in the U.S. were least likely to say that their practices allow patients to see a nurse or doctor after regular office hours, without going to an emergency room–just 40 percent have such arrangements. In contrast, between 95 percent and 76 percent of doctors in the other countries provide after-hours care.

U.S. doctors were the most likely to report their patients have difficulty paying for care. Half (51%) of U.S. PCPs reported that patients often have difficulty paying for medications, compared with between 7 percent and 27 percent in the other countries.

Availability of Financial Incentives
Despite growing U.S. interest in financial incentives to improve performance, U.S. primary care doctors are among the least likely to receive such incentives. Just 30 percent reported receiving, or having the potential to receive, payments for managing chronic disease, achieving clinical targets, enhancing preventive care, or other quality improvement activities. The U.K. stands out as a leader in this regard: 95 percent of its doctors receive, or are able to receive, financial incentives for improved performance.

Chronic Care Management
Regarding the highly important dimension of managing chronic disease, a high proportion of doctors in all countries (25% to 30% or more), except Germany (7%), said they are not well-prepared to care for patients with multiple chronic conditions. There are wide variations in the use of care teams and systems known to improve outcomes for such patients.

Conclusions
Primary care physicians in the seven countries share many common challenges, among them improving coordination of care for patients with chronic disease. Yet, the survey highlights sharp differences in the availability of incentives, IT capacity, use of care teams, and patient access to care. These divergent experiences often reflect their country’s underlying policy choices, and the extent to which policies in place are national in scope. As physicians’ responses suggest, national policies in support of primary care matter. The U.S.–which lags well behind in use of health IT–appears to be the only country without a national IT plan. Moreover, the difficulty U.S. patients experience in paying for care signify a failure of the U.S. health insurance system to support primary care. “Cohesive, broad-based policy changes in the United States,” the authors conclude, “could lead to improved absolute and relative performance.”

Facts and Figures:

* Of 14 health information system functions assessed in the survey (e.g., automated alerts/reminders, electronic prescribing), fewer than one of five U.S. and Canadian physicians reported their offices supported seven or more of these functions. In the other countries, 59% to 83% of doctors reported such multifunctional capacity.

* Use of clinical teams to manage chronically ill patients varies widely, ranging from 73% in the U.K. to 25% to 38% in Canada, the U.S., and Australia.

* The U.K. stands out for their ability to track medical errors: 79% of U.K. doctors have systems to document all adverse events, compared with 7% to 41% in other countries (37% in the U.S.).

Citation: C. Schoen, R. Osborn, P. Trang Huynh, M. Doty, J. Peugh, K. Zapert, On The Front Lines of Care: Primary Care Doctors’ Office Systems, Experiences, and Views in Seven Countries, Health Affairs Web Exclusive (Nov. 2, 2006):w555–w571.

By Deborah Burger, RN
January 10, 2007

With Gov. Arnold Schwarzenegger unwrapping his long-anticipated healthcare package Monday and talk about reform building in Sacramento, Californians may well be wonder if our long healthcare nightmare is finally coming to an end.

Sadly, virtually none of the proposals now being touted in the Capitol is universal, strengthens quality of care or reduces rising costs to consumers.

The sole exception is a single-payer approach, as contained in a bill by state Sen. Sheila Kuehl, D-Santa Monica, that was vetoed by Schwarzenegger in September, but will be reintroduced soon.

Under single-payer, one public entity collects all the financing and pays for all medical services through the existing private-care delivery system, with adequate funding for our doctors, hospitals, clinics and other care.

All the other approaches are fundamentally flawed. They continue to rely on a wasteful insurance industry whose focus is on making money by denying care to those who need it the most and other market-based mechanisms that created the current mess.

Californians should be especially wary of legislation requiring individuals to buy insurance. The likely result is to criminalize the uninsured, and saddle far too many with cut-rate plans with huge out-of-pocket costs and caps on payments that expose you to financial ruin in the event of a serious illness or major accident.

There’s a better way, the course charted by every industrialized nation in the world. That’s the main reason why the U.S. spends more than the 21 other wealthiest countries on healthcare yet Americans trail them all in life expectancy, infant mortality and a host of other health barometers.

Here’s 10 ways a similar, single-payer-type system, would benefit all Californians, not only those who profit in healthcare:

1. Everybody in, nobody out. Universal means access to healthcare for everyone, period — the desire of 81 percent of all Californians, as reported in a recent Field Poll.

2. Portability. Even if you are unemployed or lose or change your job, your health coverage goes with you.

3. Uniform benefits. No Cadillac plans for the wealthy and Moped plans for everyone else, with high deductibles, limited services and no protection in the event of a catastrophe. One standardized level of comprehensive care no matter what size your wallet.

4. Prevention. By removing financial roadblocks, a single-payer system encourages preventive care that lowers an individual’s ultimate cost and pain and suffering when problems are neglected, and societal cost in the overutilization of emergency rooms or the spread of communicable diseases.

5. Choice of physician. Most private plans restrict what doctors, other caregivers or hospital you can use. Under a single-payer system, patients have a choice and the provider is assured a fair reimbursement.

6. Ending insurance industry interference with care. Caregivers and patients regain the autonomy to make decisions on what’s best for a patient’s health, not what’s dictated by the billing department or the bean counters. No denial of coverage due to pre-existing conditions or cancellation of policies for “unreported” minor health problems.

7. Reducing administrative waste. One third of every healthcare dollar in California goes for paperwork, such as denying you care, and profits, compared to about 3 percent under Medicare, a single-payer, universal system.

8. Cost savings. Numerous studies suggest a single-payer system would produce the savings needed to cover everyone, largely by using existing resources without the waste. Taiwan adopted a single-payer system in 1995, boosting health coverage from 57 percent to 97 percent with little if any increase in overall healthcare spending.

9. Common sense budgeting. The public system sets fair reimbursements applied equally to all providers while assuring all comprehensive and appropriate healthcare is delivered, and uses its clout to negotiate volume discounts for prescription drugs and medical equipment.

10. Public oversight. The public sets the policies and administers the system, not high-priced CEOs meeting in secret and making decisions based on what inflates their compensation packages or stocks.

While our politicians debate inferior alternatives, it’s up to all of us to insist that Californians deserve the best.

Deborah Burger is president of the California Nurses Association.

Neither state goes far enough. People will still lack care.

By Don McCanne
USA Today

Americans need more than affordable insurance; they need affordable health care. California Gov. Arnold Schwarzenegger plans to copy the Massachusetts reform in shrinking the numbers of uninsured people by forcing them to buy stripped down, bare-bones policies.

With premiums for family coverage now averaging $10,000 a year, the only way that states can make premiums affordable is to strip down the plans, which then forces policyholders to pay out of pocket when they get sick. High deductibles, co-payments and benefit reductions are destroying the financial protection that insurance should provide.

Half of U.S. bankruptcies are a result, in part, of medical illness or medical bills. Three-quarters of Americans who are forced into medical bankruptcy had health insurance at the onset of the illness that bankrupted them. Worse, suffering and death can occur when patients cannot afford the care that their private insurance does not cover.

The big winners in the Schwarzenegger and Massachusetts health plans are private health insurance firms. The new insurance mandates will hand them billions in wasteful administrative fees that do not occur in government insurance programs such as Medicare. Private insurers will continue their cream-skimming, enrolling primarily the low cost, healthy workforce and their families, while leaving the costs of the unprofitable sick and elderly to the taxpayers.

State health programs are interdependent on federal programs such as Medicare, Medicaid and the Veterans Affairs’ system, and are regulated by federal laws. The states alone cannot enact the structural changes that would be required to cover everyone and control costs. They are limited to building on the existing system by tweaking it to nominally expand coverage to the uninsured.

Money is not the problem. We already are spending enough on health care to provide high-quality, comprehensive services for everyone. But our inefficient, private-sector insurance bureaucracies have failed and need to be replaced with single-payer national health insurance. Every other developed nation has covered its citizens through some form of non-profit national health insurance.

Don McCanne, M.D., is a senior health policy fellow of Physicians for a National Health Program.

By PAUL KRUGMAN
Published: January 12, 2007
New York Times

A few days ago. Gov. Arnold Schwarzenegger unveiled an ambitious plan to bring universal health insurance to California. And I’m of two minds about it.

On one side, it’s very encouraging to see another Republican governor endorse the principle that all Americans are entitled to essential health care. Not long ago we were wondering whether the Bush administration would succeed in dismantling Social Security. Now we’re discussing proposals for universal health care. What a difference two years makes!

And if California – America’s biggest state, with a higher-than-average percentage of uninsured residents – can achieve universal coverage, so can the nation as a whole.

On the other side, Mr. Schwarzenegger’s plan has serious flaws. Maybe those flaws could be fixed once the principle of universal coverage was established – but there’s also the chance that we would end up stuck with those flaws, the way we ended up stuck with a dysfunctional system of insurance tied to employment.

Furthermore, in the end health care should be a federal responsibility. State-level plans should be seen as pilot projects, not substitutes for a national system. Otherwise, some states just won’t do the right thing. Remember, almost 25 percent of Texans are uninsured.

To understand both what’s right and what’s wrong with Mr. Schwarzenegger’s plan, let’s compare what he’s proposing with the plan he rejected. Last summer, the California Legislature passed a bill that would have created a single-payer health insurance system for the state – that is, a system similar to Medicare, under which residents would have paid fees into a state fund, which would then have provided insurance to everyone.

But the governor vetoed that bill, which would have bypassed private insurance companies. He appears to sincerely want universal coverage, but he also wants to keep insurance companies in the loop. As a result, he came up with a plan that, like the failed Clinton health care plan of the early 1990s, is best described as a Rube Goldberg device – a complicated, indirect way of achieving what a single-payer system would accomplish simply and directly.

There are three main reasons why many Americans lack health insurance. Some healthy people decide to save money and take their chances (and end up being treated in emergency rooms, at the public’s expense, if their luck runs out); some people are too poor to afford coverage; some people can’t get coverage, at least without paying exorbitant rates, because of pre-existing
conditions.

Single-payer insurance solves all three problems at a stroke. The Schwarzenegger plan, by contrast, is a series of patches. It forces everyone to buy health insurance, whether they think they need it or not; it provides financial aid to low-income families, to help them bear the cost; and it imposes “community rating” on insurance companies, basically requiring them to sell insurance to everyone at the same price.

As a result, the plan requires a much more intrusive government role than a single-payer system. Instead of reducing paperwork, the plan adds three new bureaucracies: one to police individuals to make sure they buy insurance, one to determine if they’re poor enough to receive aid, and one to police insurers to make sure they don’t discriminate against the unwell.

The plan’s supporters say that it would save money all the same. Those who are currently uninsured would receive preventive care, which is often cheaper than waiting until they show up in emergency rooms. Insurers would spend less money trying to weed out high-risk clients and more money actually paying for health care: the plan would require that insurers spend at least 85 percent of premiums on health care, considerably more than most of them do now.

Still, why all the complexity? The smart, well-intentioned economists who devised the plan think they’re being more politically realistic than single-payer advocates – that it’s necessary to placate the insurers. But that’s what Bill and Hillary Clinton thought, too – only to find that their plan’s complexity confused the public, while the insurance industry went all-out to defeat it anyway.

So am I for or against the Schwarzenegger plan? That’s a tough question. As a practical matter, however, I suspect that the real question is what to do after the plan founders from its own complexity. And the answer is, damn the insurers – full speed ahead.

Golden State Gamble

By PAUL KRUGMAN
Published: January 12, 2007
New York Times

A few days ago. Gov. Arnold Schwarzenegger unveiled an ambitious plan to bring universal health insurance to California. And I’m of two minds about it.

On one side, it’s very encouraging to see another Republican governor endorse the principle that all Americans are entitled to essential health care. Not long ago we were wondering whether the Bush administration would succeed in dismantling Social Security. Now we’re discussing proposals for universal health care. What a difference two years makes!

And if California – America’s biggest state, with a higher-than-average percentage of uninsured residents – can achieve universal coverage, so can the nation as a whole.

On the other side, Mr. Schwarzenegger’s plan has serious flaws. Maybe those flaws could be fixed once the principle of universal coverage was established – but there’s also the chance that we would end up stuck with those flaws, the way we ended up stuck with a dysfunctional system of insurance tied to employment.

Furthermore, in the end health care should be a federal responsibility. State-level plans should be seen as pilot projects, not substitutes for a national system. Otherwise, some states just won’t do the right thing. Remember, almost 25 percent of Texans are uninsured.

To understand both what’s right and what’s wrong with Mr. Schwarzenegger’s plan, let’s compare what he’s proposing with the plan he rejected. Last summer, the California Legislature passed a bill that would have created a single-payer health insurance system for the state – that is, a system similar to Medicare, under which residents would have paid fees into a state fund, which would then have provided insurance to everyone.

But the governor vetoed that bill, which would have bypassed private insurance companies. He appears to sincerely want universal coverage, but he also wants to keep insurance companies in the loop. As a result, he came up with a plan that, like the failed Clinton health care plan of the early 1990s, is best described as a Rube Goldberg device – a complicated, indirect way of achieving what a single-payer system would accomplish simply and directly.

There are three main reasons why many Americans lack health insurance. Some healthy people decide to save money and take their chances (and end up being treated in emergency rooms, at the public’s expense, if their luck runs out); some people are too poor to afford coverage; some people can’t get coverage, at least without paying exorbitant rates, because of pre-existing
conditions.

Single-payer insurance solves all three problems at a stroke. The Schwarzenegger plan, by contrast, is a series of patches. It forces everyone to buy health insurance, whether they think they need it or not; it provides financial aid to low-income families, to help them bear the cost; and it imposes “community rating” on insurance companies, basically requiring them to sell insurance to everyone at the same price.

As a result, the plan requires a much more intrusive government role than a single-payer system. Instead of reducing paperwork, the plan adds three new bureaucracies: one to police individuals to make sure they buy insurance, one to determine if they’re poor enough to receive aid, and one to police insurers to make sure they don’t discriminate against the unwell.

The plan’s supporters say that it would save money all the same. Those who are currently uninsured would receive preventive care, which is often cheaper than waiting until they show up in emergency rooms. Insurers would spend less money trying to weed out high-risk clients and more money actually paying for health care: the plan would require that insurers spend at least 85 percent of premiums on health care, considerably more than most of them do now.

Still, why all the complexity? The smart, well-intentioned economists who devised the plan think they’re being more politically realistic than single-payer advocates – that it’s necessary to placate the insurers. But that’s what Bill and Hillary Clinton thought, too – only to find that their plan’s complexity confused the public, while the insurance industry went all-out to defeat it anyway.

So am I for or against the Schwarzenegger plan? That’s a tough question. As a practical matter, however, I suspect that the real question is what to do after the plan founders from its own complexity. And the answer is, damn the insurers – full speed ahead.