By Rand Wilson and John Horgan
http://labornotes.org/index.shtml
from Labor Notes, #328, July 2006

Frustrated by the lack of action on health care reform at the national level, activists are working for state-level reforms that could be models for a future, more sympathetic federal government.

Massachusetts recently gained national prominence when a reform bill was signed into law. Unfortunately, the “breakthrough” solution that has been trumpeted as reaching near universal coverage is a false promise.

Like most states, Massachusetts has a serious health care crisis. The number of uninsured is rising (state estimates are as high as 750,000 people), costs are the highest in the country, and bargaining for contracts is often stalemated over employers’ cost shifting demands.

Last year a number of large unions and the state AFL-CIO were drawn into a coalition that sought to expand coverage for the uninsured.

Although coalition allies believed in winning reforms that would improve the system, the coalition also included elite leaders from the private insurance industry, doctors groups, and hospitals.

This strange alliance meant that from the outset the coalition was committed to crafting a plan that would not upset the special interests most responsible for the current mess. (And for a little extra insurance, these special interest groups spent $7.5 million on lobbyists to make sure that the outcome of any reforms wouldn’t jeopardize their profits and power.)

BACKROOM DEALING
Behind closed doors with top legislative leaders, the reform coalition’s leaders crafted a plan. It did make some modest gains by undoing cuts in state Medicaid programs that benefit the poorest people. And the largest pool of uninsured people–low-wage, often part-timer or temporaries –will be eligible for subsidized insurance plans.

However, the combination of an individual and employer mandate to achieve these gains has dangerous consequences. Under the legislation, employers with more than 10 workers who do not make a “fair and reasonable” contribution toward employee health insurance will only be required to contribute a fee of up to $295–per year.

The Massachusetts legislation has the potential to seriously erode employer-based coverage. In effect, it tells employers: pay $295 a year and let the taxpayers subsidize care for your workers.

But wait, it gets worse. If a company’s employee uses the state’s “free care pool” more than three times or its employees as a group use the pool more than five times a year, there is an additional “free rider”
surcharge.

This creates an incentive for employers to fire employees who use the free care pool and to hire only younger, healthier workers. It encourages employers to avoid hiring workers with health problems. It will discourage uninsured workers from seeking care and lead uninsured workers to pay out of pocket for care rather than risk applying for coverage from the free care pool.

Another downside of the bill is the “individual mandate” that essentially transfers the entire burden of paying for the uninsured to taxpayers and the uninsured themselves. It will require many working families to pay for coverage they simply cannot afford.

Finally, it pits families making over $60,000 — who are not eligible for subsidies, but are required to purchase insurance–against families that make less and are eligible for state subsidies.

By establishing a new public consensus that individuals are primarily responsible for health coverage, these proposals will make dropping coverage more acceptable. The public will be asked to fund subsidies for private insurance companies to offer low-cost insurance for low- and moderate-income adults. These plans will inevitably wind up being “catastrophic” health plans, leading to more personal bankruptcies.

To its credit, the state AFL-CIO issued a strong statement condemning the final bill and the national AFL-CIO provided a powerful written critique.

HEALTH CARE AS A RIGHT
Jobs with Justice and other activists have been campaigning for a state constitutional amendment to make health care a right.

The campaign gathered more than 70,000 signatures to put the initiative on the ballot and won its first approval from the state constitutional convention in 2004. It needs another “yes” vote at a second constitutional convention to advance to the November ballot.

Anticipating a May 10 vote, over 200 supporters rallied outside the statehouse and delivered 2,500 postcards to legislators, but elected officials postponed the convention until July 12.

[To learn more about Jobs with Justice campaign, go to www.healthcareformass.org.]

[Rand Wilson is a union organizer. John Horgan is a union steward at Verizon.]

In a June 16th speech at the Brookings Institute in Washington, Andrew Stern, SEIU President, attacked a Canadian style single payer health care system as irrelevant to the U.S. A report on his speech, filed by Press Associates (PAI), was posted on the International Labor Communications Association (ILCA) website at:
http://www.ilcaonline.org/ht/display/ArticleDetails/i/14557

Video and Transcript of Stern’s speech.
http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=1768

John Horgan, a Boston area telephone worker, wrote the following response to Stern. Horgan works for Verizon where he is a union steward in IBEW Local 2222. He is active in the Greater Boston Jobs with Justice Health Care Committee. He and other health activists have won 8 out of the 10 Massachusetts representatives to co-sponsor HR 676, Conyers’ single payer health plan. He can be reached at jahorg@verizon.net.

Stern dismisses single-payer and wonders why business isn’t leading the fight for healthcare reform

After reading an article by Mark Gruenberg, a staff writer for Press Associates Inc., it was important to watch the Kaiser network video of S.E.I.U President Andrew Stern for a firsthand account of Mr. Stern’s comments on health care.

It was obvious that President Stern is as troubled about the out of control costs of health insurance as any American. It was also obvious President Stern has no constructive solution. He spoke of the health care crisis in America without offering a single constructive idea as to how this crisis can be addressed. Instead he blames politicians and business for their lack of leadership on this issue. He also belittles the concept of a single-payer system while complaining that American business can’t compete with countries that have single-payer systems.

First to address the question of why business leaders are not out in the street demanding health insurance reform… after the tax breaks, the cost shifting, and the gutting of the health-care plans, the business of American business is simply business. The American workers are out on the streets, but American business is out of the country. In President Sterns’ labor pool you can’t janitor, doctor, or nurse etc…from out of the country. He represents a service based membership that works inside the U.S. in jobs that don’t compete in the global market. The car industry, as well as many other industries, competes globally. What is the major difference between a G.M. worker in Canada and one in the U.S.? The benefit cost of health insurance.

Now to answer the question why is health insurance so expensive? Let’s start with the big ticket item of administrative costs… 39% of every dollar in this private employer-based model of health insurance goes to administrative costs. This model leaves 45 million uninsured, millions more underinsured and is also a cost driver of the insurance premium.

Premiums for health insurance policies are subject to the size of the liability pool. The larger the shared liability pool, the cheaper the premium. This is because the burden of the ill is disbursed across a larger number of people. Mr. Stern illustrates this exact point when he refers to the Federal Employee Health Benefit Plan.

A single-payer solution is the only way to reduce costs, (Medicare administrative costs are 3%), guarantee universal coverage (eliminate means testing, not worth the bureaucratic funding), and mandate quality care. The sorry excuse of a tax fear is no reason for condemning single-payer. As to real estate taxes … towns are breaking under the for profit burden of health insurance for their employees; state taxes could use relief brought about by a 36% savings in state employee health plans; federal employee health benefits could be even less expensive if the shared liability pool grew to every citizen in the country… thus reducing our federal tax dollars on the portions currently going to federal employee benefits.

A single-payer system would reduce concession bargaining, lower the likelihood of strikes, and reduce taxes with the cost savings it would create. This would be funded by the tax dollars we already pay, the tax dollars businesses don’t have to pay currently, as well as the fair share from businesses that have long skipped out on their fair share.

We have many leaders in Congress as well as in the Labor movement demanding a national single-payer plan. They have provided the single payer solution in H.R. 676. They choose to be constructive and take stands, not to sit on the sidelines and condemn. They are the leaders, and it is through their efforts that this crisis will be resolved.

John Horgan ibew 2222 boston
___________________________________________________________________

This discussion article was circulated by:

All Unions Committee for Single Payer-HR 676 c/o Nurses Professional Organization
1169 Eastern Parkway #2218
Louisville, KY 40217
(502) 636 1551
nursenpo@aol.com

HR 676 now has 72 congressional co-sponsors in addition to John Conyers, Jr. (D-MI).
It would institute a single payer health care system in the U.S. by expanding a greatly improved Medicare system to every resident.

HR 676 would cover every person in the U. S. for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, chiropractic and long term care. HR
676 ends deductibles and co-payments. HR 676 would save billions annually by eliminating high overhead and profits of the private health insurance industry and HMOs.

HR 676 has been endorsed by 155 union organizations including 28 central labor councils, two state AFL-CIO federations (KY and PA), and
3 area labor federations.

For further information and a complete list of union endorsers contact Kay Tillow at nursenpo@aol.com (502) 636 1551.

THE CITIZENS HEALTH CARE WORKING GROUP LISTENED TO THE AMERICAN PUBLIC WITH ONE EAR

By Len Rodberg, Ph.D.
Physicians for a National Health Program, NY Metro Chapter

The Citizens Health Care Working Group was created by the Medicare Modernization Act of 2003 to provide opportunities for the American public to “engage in an informed national debate to make choices about the services they want covered, what health coverage they want and how they are willing to pay for coverage.”After a long and involved process, which included the holding of community meetings in some 40 communities across the country as well as receipt of thousands of online and written individual responses, the CHCWG has issued a set of Interim Recommendations (at www.citizenshealthcare.org) and invited comments on them on a form provided at that site.The deadline for comments is August 31,2006. A month later, the Group will issue final recommendations for consideration by the President and Congress.

The legislation creating the Working Group directed it to submit “an interim set of recommendations on health care coverage and ways to improve and strengthen the health care system based on the information and preferences expressed at the community meetings”(Emphasis ours). (Sec. 1014(h)(4)(D)) The principal recommendation of the Working Group is “It should be public policy that all Americans have affordable health care.” This followed from the central message that it heard in these meetings, which it described as follows: “Across every venue we explored, we heard a common message: Americans should have a health care system where everyone participates, regardless of their financial resources or health status, with benefits that are sufficiently comprehensive to provide access to appropriate, high-quality care without endangering individual or family financial security” (Emphasis in original).

Accordingly, the Group went on to make the historic pronouncements that (1) “It should be public policy, established in law, that all Americans have affordable health care coverage” and (2) “Assuring health care is a shared social responsibility.” (Emphasis ours) However, in their subsequent elaboration, the Working Group seems to ignore, in very important respects, the clearly expressed views of those attending the community meetings. Some key examples:

1. The recommendations assert that “no specific health care financing mechanism is optimal.” This conflicts with the views of large majorities of respondents who supported a publicly-funded national program. Twenty-five of 29 community meetings supported “Create a National Health Program” as the most heavily favored answer to the question “If you believe it is important to ensure access to affordable, high quality health care coverage and services for all Americans, is most important to you/which of these proposals would you suggest for doing this?”(Appendix B, p.7). On-line, 72.2% of respondents — far more than chose any other option — agreed with the option “Create a national health plan, financed by taxpayers, in which all Americans would get their health insurance.”(Appendix C, p. 6) And the CHCWG reported, in “Dialogue with the American People,” that “when asked to evaluate different proposals for ensuring access to affordable high quality health coverage and services for all Americans, individuals at all but four meetings ranked …[this option] highest.” (p. 41)

2. The CHCWG recommends that a “core” benefit package be defined for all Americans. This seems to have been an assumption of the Working Group rather than a response to the views expressed in community meetings or by individual respondents, who were never asked whether they supported the idea of limited coverage to basic or “core” services. In fact, the Working Group reports in “Dialogue with the American People” that “many participants…were also concerned about arbitrary limits on coverage and were not comfortable with bare-bones benefit packages.”(p.2) Moreover, “individuals voiced support for a fairly comprehensive basic benefit design” (p. 10) And these comprehensive services should be affordable; the Working Group reported that “a commonly expressed view was that a simpler system [such as the national program favored by the large majority of respondents] would result in lower administrative costs.” (p.3)

The concept of limiting benefits to “core” services grew out of Congress’s charge to the Working Group to determine “what trade-offs are the American public willing to make in either benefits or financing to ensure access to affordable, high quality health care coverage and services”. However, the clear answer from the public, as expressed in the community meetings and individual responses, was that simplification of the system and cost savings through information technology, quality improvement, and regulation of prices would make such trade-offs unnecessary (“Dialogue” p. 30; online poll items 8e and 12c). As the CHCWG reported in “Dialogue with the American People.” “Although worded in a variety of ways, the single most common response to the question about trade-offs can be summarized as ‘No trade-offs’.”(p. 34)

3. Beyond its proposed limitation to core services, the CHCWG’s discussion of Recommendation 1 suggests that even for core services they are thinking of means-tested co-payments. Community meetings and individual respondents rejected this approach. The Working Group says, “Financial assistance will be available to those who need it.” Three paragraphs later they comment that certain financial protections “such as those against catastrophic [and impoverishing] health care expenditures” may need to wait until some efficiency gains are realized. And, in discussing Recommendation 5, they call for providing consumer information on cost sharing in federally funded health programs.

The primary purpose of health care reform is to ensure that financial barriers do not keep anyone from receiving necessary care. But because the CHCWG has largely failed to focus on any cost control strategy other than limiting covered services to a “core” set, their recommendations are potentially harmful to people’s health. Shared social responsibility at the level of system financing means that people contribute according to their ability. But the CHCWG’s recommendations abuse this principle when they extend it to mean cost sharing at the point that someone needs health care. The threat of facing out-of-pocket costs would deter many from getting needed care. Justifying cost sharing at the point of service delivery is a socially irresponsible way to apply the principle of shared social responsibility.

Comments on the Interim Recommendations

Recommendation 1: It should be public policy that all Americans have affordable health care.

We applaud this recommendation. It is encouraging to see an entity created by the U.S. Government supporting the concept of universal health care, the principle that everyone in this country should have access to the health care they need without facing financial barriers that would discourage them from seeking care. We believe it is long past time for the United States to move toward this goal, which every other advanced country has already achieved.

We do not, however, accept the idea, which the CHCWG supports, that Americans should have access to only a “core” set of services, with the wealthy able to buy their way into more services. Other, less wealthy countries have shown that comprehensive services can be made available to everyone without creating such a two-class system. An American system should also provide access to a comprehensive set of services, without bias or exclusion.

Further, the concept of making “financial assistance available to those who need it” suggests that this will be a means-tested system. We believe that everyone should have access to health care without having to face such demeaning examinations of their finances.

We believe there should be a universal, government-financed system of national health insurance that will make health care available to everyone. This country has the financial means to do this; in fact, many studies show that we can do this without spending any more than now.

Recommendation 2: Define a “core” benefit package for all Americans.

As we have stated above, we do not accept the concept of this recommendation. Experience with Medicare in this country, and with the health systems of many other countries, has shown that comprehensive benefits can be provided without excessive spending and without creating a two-class system, one for those who can afford only “core” services and another for those who can afford to buy more. We need to avoid such a two-tiered system; this country should move as quickly as possible to a single system for all.

Recommendation 3: Guarantee financial protection against very high health care costs.

A comprehensive, publicly-financed system could provide access to a full range of services without need for any special “catastrophic” coverage such as this recommendation suggests. Further, since such a system will facilitate access to low-cost primary care, this will reduce the need for the high-cost services that this recommendation addresses.

Recommendation 4: Support integrated community health networks.

We support this recommendation. Such networks are an efficient, community-friendly way of providing services.

Recommendation 5: Promote efforts to improve quality of care and efficiency.

We strongly support this recommendation. We believe that creating a universal, publicly-financed system will provide the best means of achieving this, since this will enable the quality of care to be measured and the current wasteful administrative costs of private insurance to be eliminated.

Recommendation 6: Fundamentally restructure the way palliative care, hospice care and other end-of-life services are financed and provided.

We strongly support this recommendation as well. We are a humane society, and we should show treat our people humanely throughout their lives, including at the end of life.

By Catherine Arnst
Business Week
JULY 17, 2006

Raymond B. Roemer, 83, has earned his membership in “the greatest generation.” A flight engineer during World War II, his B-24 was shot down over Potsdam during a bombing run. He managed to parachute out, but the jump landed him in enemy territory. Roemer spent 11 months in a German POW camp until he was liberated by General George S. Patton’s troops in April, 1945.

A month later he came home to Buffalo with a Purple Heart and a few crushed vertebrae from that parachute jump. He married his high school sweetheart, started a successful metal-fabricating business, and signed up for health benefits with Blue Cross/Blue Shield. He can afford to be treated at any of some 20 well-regarded hospitals in the area, but Roemer has made what what may seem a bizarre choice. He goes to the Veterans Affairs Medical Center in Buffalo, a hulking, gray edifice first opened in 1950. He doesn’t go just for his service-related injuries, either. His primary care doctor is at the VA, he fills his prescriptions there, and he uses the hospital for his vision and hearing needs. He even persuaded his 59-year-old son and business partner, Nicholas, a Vietnam War vet, to enroll with the VA.

If you wish to read this article, please click here or purchase a copy of the July 17th edition of Business Week or visit their website at: www.businessweek.com

UAW Convention Resolves to Fight for Single Payer Health Care and Calls for Passage of the Conyers Bill

Two thousand delegates to the 34th International Convention of the United Auto Workers (UAW), meeting in June, strongly endorsed a single payer health care system and called for passage of legislation introduced by Congressman John Conyers that would implement such a system.

The resolution states, “The best solution to our nation’s health care crisis is a comprehensive, single-payer plan to provide quality health care to every man, woman and child in the United States.” Under the section titled “The Solution” the resolution continues: “Legislation to establish a single-payer system for the United States has been introduced by Congressman John Conyers, Jr.”

The resolution spells out the Conyers bill: “The United States National Health Insurance Act, also known as ‘Expanded and Improved Medicare for All,’ would cover every person in the US for all necessary medical care, including prescription drugs….” The resolution notes that the Conyers legislation would end deductibles and co-payments.

“The question isn’t whether we can afford to have universal, single-payer health care; the question is, can we afford not to?” states the UAW resolution.

The UAW set forth an indictment of our current health care system. “Many Americans instinctively claim that the U.S. health care system is No. 1. Regrettably, this is not close to the mark. While we excel in the development of technologies, we still have a dysfunctional system when it comes to actually providing care-the only meaningful standard. Despite the Cadillac prices, our health care system delivers a defective product.”

The resolution sadly noted the 100,000 hospital deaths each year from preventable errors, the 46 million uninsured who suffer mortality rates 25% higher than the insured, and the poor ranking of the US behind other industrialized countries in life expectancy, infant mortality, and childhood immunization.

The UAW warned that the problem will worsen as more health insurers switch to for-profit status. The resolution states: “Rather than a social good, health care becomes just another commodity; a $1.7 trillion market with ample opportunity to siphon off exorbitant profits and executive salaries at the expense of health care services. In 2003 the median total compensation for the CEOs of health insurers was just over $14 million….”

The UAW blasted the ideologues who claim that Americans overuse their health plans and should be forced to pay more out of pocket as the way to lower costs. The union dispelled these claims by showing that Americans don’t demand more health care services and already pay more out of pocket than people in most other countries.

The UAW condemned Health Savings Accounts as a cruel hoax that shifts the costs to the sick, the disabled, and the aged. The resolution also exposed the myth that malpractice litigation is the cause of health care inflation by showing that malpractice costs are less than 2 percent of total health care spending.

The final section of the resolution, headed “Mobilizing for Change” declares: “We must not allow our frustrations with the political process to weaken our efforts to solve the health care crisis;” and “We will continue to educate, organize, mobilize and lobby in support of a universal, single-payer health care system.”

The full UAW Convention resolution is available from the UAW or from:

Kay Tillow
All Unions Committee for Single Payer Health Care-HR 676 c/o Nurses Professional Organization
1169 Eastern Parkway #2218
Louisville, KY 40217
(502) 636 1551
nursenpo@aol.com

HR 676 now has 72 congressional co-sponsors in addition to John Conyers.

HR 676 has been endorsed by 154 union organizations including 28 central labor councils, two state AFL-CIO’s (KY and PA), and 3 area labor federations. The full list of union endorsers and a sample resolution are available at the contact information above.

by S.R.Collins, Commonwealth Fund

Executive Summary

Invited Testimony before the Committee on Ways and Means U.S. House of Representatives Hearing on “Health Savings Accounts,” June 28, 2006

Thank you, Mr. Chairman, for this invitation to testify on health savings accounts (HSAs). The Committee is to be commended for focusing attention on the manifold problems currently confronting the U.S. health care system: steady growth in the number of uninsured Americans, rising health care costs and premiums, wide variation in the quality and cost of care, and inefficiencies in the delivery and administration of care.

Some maintain that HSAs, coupled with high-deductible health plans (HDHPs), are an important part of the solution for the cost, quality, and insurance problems that plague the U.S. health care system. Asking families to pay more out-of-pocket, the reasoning goes, will create more prudent consumers of health care, driving down growth in health care costs and improving the quality of care as providers compete for patients. And the tax incentives of HSAs will lure previously uninsured people into the individual market, reducing the numbers of families without health insurance.

But while it is comforting to believe that such a simple idea could help solve our health care problems, nearly all evidence gathered to date about HSAs and HDHPs points to the contrary. Indeed, there is evidence that encouraging people to join such health plans might act as salt on a wound, exacerbating some of the very maladies that undermine our health care system’s ability to perform at its highest level.

Higher Patient Cost-Sharing Is the Wrong Prescription

• Americans already pay far more out-of-pocket for their health care than citizens in any other industrialized country.
• Real per capita out-of-pocket spending has been steadily rising since the late 1990s. Combined with sluggish growth in real incomes, families are spending increasingly more of their incomes on medical costs.
• There is considerable evidence that high out-of-pocket costs lead patients to decide against getting the health care they need.
• Rising out-of-pocket costs reduce people’s ability to save for the future.

Early Experience with HSA-Eligible HDHPs Reveals Low Enrollment, Low Satisfaction, High Out-of-Pocket Costs, and Cost-Related Access Problems

• Few people are currently enrolled in HSA-eligible HDHPs; those who are enrolled are much less satisfied with many aspects of their health care than adults in more comprehensive plans.
• People in these plans allocate substantial amounts of income to their health care, especially those who have poorer health or lower incomes.
• People in HDHPs are far more likely to delay, avoid, or skip health care because of cost. Problems are particularly pronounced among those with poorer health or lower incomes.
• People in these plans are more cost-conscious consumers of health care: they are more likely to ask for lower-priced drugs and more likely to discuss with their doctors different treatment options and the cost of care.
• Few Americans in any health plan have the information they need to make decisions. Just 12 to 16 percent of insured adults have information from their health plan on the quality or cost of care provided by their doctors and hospitals.

Patients’ Use of Information Alone Is Not Likely to Dramatically Reduce Health Care Costs or Improve Quality

• It is unrealistic to expect that even with adequate information and patient financial incentives, the transformation of health care system will be driven by patients’ choice of provider. Patients are in the weakest position to demand greater quality and efficiency.
• Most health care costs are incurred by very sick patients, often under emergency conditions. Shopping for the best physician or hospital is impractical in such circumstances.
• Payers, federal and state governments, accrediting organizations, and professional societies are much better positioned to insist on high performance.

HSAs Will Not Solve Our Uninsured Problem

• Economists Sherry Glied and Dahlia Remler estimate that under current law, fewer than 1 million currently uninsured people are expected to gain coverage as a result of HSAs. This is primarily because 71 percent of uninsured Americans are in a 10-percent-or-lower income tax bracket and would thus benefit little from the tax savings associated with HSAs.

New Proposals to Expand HSAs May Fragment Group Insurance Markets, Increasing the Number of Uninsured

• Additional tax incentives proposed by the Administration’s 2007 fiscal year budget aim to equalize the tax treatment of HSAs in the individual market to those in the employer market, with premium tax deductibility and tax credits. Economist Jonathan Gruber estimates that the Adminstration’s proposals would actually increase the number of uninsured Americans by 600,000. While 3.8 million previously uninsured people would become newly insured through HSA-eligible HDHPs in the individual market, many employers, especially small employers, would drop coverage. Some 8.9 million people would lose their employer-based health insurance.

What Needs to Be Done
We as a nation should focus on more promising strategies for expanding coverage, improving affordability, and lowering costs. These strategies include:

• Expanding group insurance coverage, with costs shared among individuals, employers, and government. This could be done by expanding employer-based coverage, eliminating Medicare’s two-year waiting period for coverage of the disabled, letting older adults “buy in” to Medicare, and building on Medicaid and the State Children’s Health Insurance Program (SCHIP) to cover low-income parents, young adults, and single adults.
• Ensuring affordable coverage for families by placing limits on family premium and out-of-pocket costs as a percentage of income (e.g., 5% of income for low-income families).
• Greater transparency with regard to provider quality and the total costs of care.
• Pay-for-performance incentives to reward health care providers that deliver high quality and high efficiency.
• Development of “value networks” of high performing providers under Medicare, Medicaid, and private insurance.
• High cost care management and disease management.
• Improved access to primary care and preventive services.
• Investment in health information technology.

Citation: S. R. Collins, Health Savings Accounts: Why They Won’t Cure What Ails U.S. Health Care, Invited Testimony Committee on Ways and Means U.S. House of Representatives Hearing on “Health Savings Accounts,” June 28, 2006