Ron Pollack2013-06-20T02:30:40-04:00Ron Pollackhttp://www.huffingtonpost.com/author/index.php?author=ron-pollackCopyright 2008, HuffingtonPost.com, Inc.HuffingtonPost Blogger Feed for Ron PollackGood old fashioned elbow grease.New Premium Tax Credits: A Health Care Game Changertag:www.huffingtonpost.com,2013:/theblog//3.31097512013-04-22T17:15:20-04:002013-04-22T17:15:26-04:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/Help Is at Hand: New Health Insurance Tax Credits for Americans," Families USA's latest report on nearly 26 million Americans becoming eligible for new premium tax credits, this new help will soon make private health insurance much more affordable.
Premium tax credits will be available to individuals and families with incomes up to 400 percent of poverty, which translates to $45,960 for an individual and $94,200 for a family of four. The tax credits will ensure that moderate-and middle-income individuals and families will not have to spend more than a set percentage of their incomes on health insurance.
The size of the credits will be determined on a sliding scale based on income, so those who have lower incomes will receive a more substantial benefit than those with higher incomes. The tax credit will be used to purchase health coverage from a range of plans in new health insurance marketplaces, otherwise known as "exchanges."
The tax credits will act like subsidies, in that individuals and families will receive help as they buy insurance, rather than having to wait until they file taxes to receive reimbursement through a tax refund. And the help is available to individuals and families even if they don't owe any taxes. The size of the tax credit is calculated based on one plan offered in the new state marketplaces -- the so-called "silver reference plan." However, once the size of the credit is determined, it can be used toward the purchase of any private plan in the marketplace that the individual or family chooses to purchase.
Here is an example of how the tax credit size is calculated (view the infographic).
The Johnsons, a family of four (two adults, two children under age 18), with an annual income of $35,300 (about 150 percent of poverty): If the annual premium for the silver reference plan for family coverage in the state marketplace in the Johnsons' zip code is $12,500, the family's out-of- pocket contribution for premiums for a silver reference plan would be about $1,410 (about $118 a month). The remainder of the family's premium for the silver reference plan would be covered in the form of a tax credit of $11,090. (That amount could also be credited toward premiums for a more or less expensive plan of the family's choice).
Taking a deeper look at the people who will be eligible for the premium tax credit, our report estimates that, in 2014, a large majority of those eligible for these new premium tax credits -- about 88 percent -- will be in working families. All age groups will benefit from the tax-credit premium subsidies, from hard-working Americans supporting their families to young adults who are just starting their careers.
The tax-credit subsidies have become a health care game changer. These tax credits will help make health coverage affordable for a huge number of uninsured families. Moderate- and middle-income families won't have to worry about being priced out of the health coverage and care they need. This assistance will also bring peace of mind to individuals and families who may have a pre-existing condition or who change jobs and experience a subsequent drop in income.
As we draw closer to the start of the open enrollment period in October, it is essential that states across the country work to inform their residents of this opportunity for assistance. Come January 2014, comprehensive, affordable health coverage will finally become a reality for millions of Americans.
If you would like more information on national, state, or county-level estimates of the number of people eligible for the new premium tax credits, I invite you to read Families USA's Help is At Hand report.]]>Health Care After the Electiontag:www.huffingtonpost.com,2012:/theblog//3.21174382012-11-13T14:47:07-05:002013-01-13T05:12:01-05:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/
First, the Affordable Care Act (aka Obamacare) will move forward. Throughout the primary and general elections, Obamacare's future was anything but certain. With the President's reelection and the Supreme Court's ruling last June, it is clear that this historic law will be implemented, most of it by January 2014.
But while the debate about Obamacare's future is essentially decided, the hard work of implementing it continues. Ultimately, how well it is implemented will determine whether the law is a success.
Obamacare's core provisions were designed to ensure peace of mind for America's families. Irrespective of new family circumstances -- an unexpected illness, the loss of a job or a divorce -- Obamacare promised that affordable, high-quality health coverage should always be available.
The key measure of fulfilling this promise will be the number of currently uninsured people who gain health coverage. The nonpartisan Congressional Budget Office projects that more than 30 million Americans will do so.
Getting there from here, however, will not be easy. Recent surveys have found that more than three-quarters of those without health coverage are unaware of how the law can help them. So, a robust public education campaign, collaboratively initiated by the private and public sectors, will be needed. Since the first enrollment period begins in October 2013, that initiative must begin soon.
Second, the health care safety net will be strengthened. For low-income adults, the Medicaid safety net is badly frayed, letting many low-income adults fall through. The national median income eligibility level for impoverished parents is only 63 percent of the federal poverty level, a mere $12,027 in annual income for a family of three. For adults without dependent children, the situation is even worse: In 43 states, no coverage is available, even for the penniless.
Beginning in January 2014, states will have the option to raise Medicaid eligibility to 133 percent of poverty, and they will receive unprecedented federal help to do so. From 2014 through 2016, the federal government will pick up all of the costs for covering newly eligible people; thereafter, the federal contribution will gradually decrease to 90 percent. This is a bargain few states will refuse.
Ensuring optimal state Medicaid expansions will require governors to feel secure that the federal government's fiscal support for Medicaid will remain strong and stable. It is therefore essential that the upcoming federal budget deliberations help instill that confidence and that federal Medicaid funding not be cut.
Third, Medicare's solvency will continue to be strengthened, and the program will not be converted to a voucher system. According to the Medicare trustees, the program's hospital trust fund will remain solvent through 2024 -- a significant improvement from past projections. But Medicare's expected budget growth suggests the program needs further strengthening to give current and future beneficiaries a sense of security.
President Obama has emphatically opposed a House-passed proposal to reduce projected Medicare spending by converting it to a voucher system. If such a proposal were offered again, it would likely receive very short shrift. But in the context of a balanced approach to the federal budget, the President and Congress must seriously consider improving the program's fiscal future.
Genuine opportunities exist to strengthen Medicare. For example, efforts to improve coordination of care for beneficiaries with chronic health conditions can be expanded, thereby improving care quality while eliminating wasteful spending. Since roughly half the people enrolled in Medicare have incomes below 200 percent of poverty ($22,340 for an individual), these and other proposals should focus on improving care, not simply shifting costs to beneficiaries.
Fourth, health system changes to moderate unsustainable health care costs must be strengthened. Bending the cost curve is not only essential to meet new public health commitments, but it is also necessary to keep job-based insurance and other private coverage affordable.
The most recent congressional debates about health care costs have not been constructive. They have focused almost exclusively on shifting costs of public programs to states and consumers -- cost shifts that would be difficult to bear and that would fail to meaningfully address system reform.
Instead, we need to move away from fee-for-service medicine to reduce wasteful care. Payment structures must be aligned to ensure that providers deliver the right care at the right time. Pricing should be more transparent. Preventive and primary care deserve far more emphasis. And consumers need to be empowered to make health care decisions with their providers.
These changes should and will receive greater attention in the years ahead.]]>Remembering Paul Wellstonetag:www.huffingtonpost.com,2012:/theblog//3.20055142012-10-23T13:45:47-04:002012-12-23T05:12:01-05:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/
Paul was one of those rare and refreshing people whose humanitarian ideals consistently guided his actions as a public leader. Throughout his almost dozen years in the United States Senate, it was those ideals, rather than personal political expediency, that animated his actions as well as his caring, compassionate voice.
The last time I saw Paul -- at a health care forum we both addressed in Minneapolis, a few days before his death -- I asked him about the vote he had just cast opposing congressional authorization of the war in Iraq. His vote, less than one month before Minnesotans would go to the polls to decide his very close reelection race, was vintage Paul. It predictably placed his reelection prospects in further jeopardy: He was one of only five senators up for reelection, and the only one in a predictably tight race, who voted against the war.
I have seen news accounts that Paul, after casting this vote, said to his wife, "I just cost myself the election." But, in our totally private discussion before the forum, I heard something quite different: After repeating his all-too-prescient reasons that a war in Iraq would be harmful, his indomitable optimism shone through. He had faith that his fellow Minnesotans, whether they supported or opposed the war, would be respectful of the conscientious basis of his position and vote. Win or lose -- and he really thought he would win -- he felt secure that he did the right thing.
My most frequent contacts with Paul occurred in the context of health care reform. As an active member of the U.S. Senate Committee on Health, Education, Labor, & Pensions, he spoke eloquently, passionately, and frequently about the need for fundamental change that would result in all Americans gaining access to high-quality, affordable health coverage and care. He believed it was unconscionable for the richest nation in the world to leave tens of millions of people without the health care they need.
As he tried to galvanize public support for fundamental reform, he also worked hard to achieve incremental improvements in America's health care system. He was a leading voice in support of the Patients' Bill of Rights -- legislation that would empower patients and their doctors to stop insurance company abuses, for example by providing prompt, fair hearings when insurers improperly denied coverage for needed health treatments.
Most notably, however, Paul teamed up with Republican Senator Pete Domenici to promote mental health research, funding, and treatment. The two senators co-sponsored and promoted the Mental Health Parity Act, a groundbreaking law designed to ensure that health coverage of mental illnesses be provided on par with coverage of other medical illnesses. He also co-authored, with Republican Representative Jim Ramstad, the Fairness in Treatment Act to establish parity in treatment for those suffering from alcohol and drug addiction.
Paul's energetic leadership, and his passion and eloquence, inspired many millions of people across the country. As a result, he was in constant demand as a speaker at countless forums. I remember most vividly Paul's appearance in January 2002 as the closing speaker at our annual Health Action conference for health care activists from around the country.
Before his Saturday lunchtime speech, Paul flew to Washington from another engagement the night before in Minnesota. When he arrived, he was in extreme physical pain due to his chronic back problems -- problems that apparently arose from his competitive wrestling bouts at the University of North Carolina as the undefeated Atlantic Coast Conference wrestling champion. We found a quiet place for Paul to lie down so that his back pain would ease.
No one attending Paul's lunchtime speech could have guessed that Paul had been in excruciating pain. His speech was laced with good humor, thoughtful content, and inspirational words of encouragement. It was a tour de force, and he received a warm, enthusiastic, and long-lasting standing ovation. It was the perfect, inspirational ending for activists returning to their communities so they would continue to work energetically in common cause with Paul.
Paul is still missed by so many of us. I suspect, however, that his cheerful, good soul is comforted by the fact that his leadership for fundamental health care reform has finally resulted in landmark legislation that will provide health coverage for tens of millions of uninsured Americans. He helped pave the way for that historic victory.]]>The Denver Medicare Debate: Substance vs. Styletag:www.huffingtonpost.com,2012:/theblog//3.19424692012-10-05T10:31:16-04:002012-12-05T05:12:01-05:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/
No, what matters most to American families is the substance of what the candidates said. And when it comes to health care, Governor Romney and President Obama offer a clear choice for consumers.
Let's take a quick look at five points from last night that sum up the Mitt Romney-Paul Ryan health care plan.
Medicare's Future: Voucher-Care
Governor Romney made it clear that he supports changing Medicare into Voucher-care. What's that? Well, under this plan, seniors would receive a government voucher to cover a portion of private insurance premiums.
Unfortunately, the value of that voucher would be limited and, as premium costs increase, it would shrink over time. That means seniors will be forced to use their retirement savings to pay for any remaining health care costs, which could have a potentially devastating impact on their finances.
What's more, this plan would fundamentally change Medicare, so that rather than having a clear set of benefits that our parents and grandparents can depend on, they'd be left to the mercy of insurance companies just when they are most vulnerable and in need of care.
Destabilizing Medicare
One perhaps funny comment from Governor Romney last night was that he has five boys, and so, despite his sons' best efforts, he "knows" that repeating something over and over again to try and convince folks doesn't make it true.
For some reason, Governor Romney didn't appreciate it when his sons tried that in their youth, but he has no problem doing the same thing when it comes to ObamaCare.
Over and over, Governor Romney made the false claim that ObamaCare cuts $716 billion from Medicare. Well, just because you say it over and over again doesn't make it true.
Obamacare stabilizes the Medicare program by adding eight years to the Medicare hospital trust fund. And rather than cutting benefits that seniors and people with disabilities need, it protects those benefits by reducing wasteful spending by insurance and pharmaceutical companies.
The real threat to Medicare comes from Governor Romney's plan to repeal ObamaCare. If that happens, the measures ObamaCare took to strengthen the Medicare hospital trust fund disappear, putting the future of Medicare in doubt.
Impact on Current Medicare Beneficiaries
When talking about Medicare, Governor Romney told 60-year-olds to "stop listening" because his plan wouldn't affect them at all. To anyone out there who is approaching their golden years or who has a loved one nearing retirement, my message is simple: "listen up!"
The cornerstone of the Romney-Ryan health care plan is a full repeal of ObamaCare. That might make for a good sound bite that appeals to the extreme right, but the real-world impact it would have would be devastating.
By repealing ObamaCare, Governor Romney's plan would cut existing prescription drug benefits for seniors and people with disabilities who have high medicine costs, and it would slap out-of-pocket fees on preventive services like check-ups, mammograms, and colonoscopies that are free thanks to ObamaCare. Already, 25.7 million Medicare beneficiaries have received free preventive services to keep them healthy, but Governor Romney's plan to repeal ObamaCare would mean beneficiaries would again face out-of-pocket costs for those services. If that's not an impact on current Medicare consumers, I don't know what is.
Turning Medicaid into a Block Grant
Despite what Republican leaders, including Governor Romney, might want you to think of Medicaid, it's an absolutely critical program that helps seniors afford long-term care, ensures that women and children have access to basic health services, and helps people with disabilities afford health coverage.
Governor Romney claims he would "improve" the program by turning it into a block grant. Block-granting Medicaid would mean massive cuts of federal funds from the program-by nearly 33 percent at the end of the next 10 years-which would mean millions of people would lose access to health coverage. I fail to see how gutting Medicaid's budget and taking health care away from millions of seniors, women, and children improves the program.
INCREASING the Number of Uninsured Americans
One final point: Governor Romney made the false claim that 20 million people will lose health insurance under Obamacare. The nonpartisan Congressional Budget Office has found that Obamacare actually expands coverage to 30 million more Americans.
Governor Romney's plan to repeal ObamaCare, coupled with his Medicaid cuts, would take coverage away, resulting in 78 million Americans being uninsured at the end of the decade.
The Bottom Line
As I said, style aside, Governor Romney and President Obama showed that the choice Americans will face next month about the future of health care in this country is clear. We can either continue down our current path and support ObamaCare, a program that is protecting consumers, expanding coverage, and putting people before insurance company profits, or we can go with the Romney-Ryan plan that slashes Medicare; takes health care protections away from seniors, women, and children; and leaves people at the mercy of insurance companies.
When you think about it that way, who "won" or "lost" based on style doesn't really matter, does it?]]>Shopping for Health Care Just Got a Lot Easier!tag:www.huffingtonpost.com,2012:/theblog//3.18933672012-09-19T11:05:31-04:002012-11-19T05:12:02-05:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/
I think you'll agree that health insurance is one of the most important and expensive products we buy. And for those consumers who don't have law degrees, comparison shopping for this essential item can be one of the biggest challenges.
Why? Well, for one thing, when we're shopping for this product, we're trying to compare health insurance options by using brochures and promotional materials that are different for every plan.
Or we're searching the web for information and coming away unsatisfied: Was I looking at the right criteria to choose a good plan? Did Google really know the best way to define those terms I didn't know? Do I understand what those terms mean in the context of this plan? It's difficult to find the information you need.
Then, when we finally have our policy in hand, we see so much legalese that most of us have trouble deciphering exactly what's covered, when it's covered, and what our share of the costs are. Unfortunately, by that time we're wiping through the pages scrambling to find out why we've had a claim denied.
Wouldn't it be nice, if we had information like that on a can soup? Benefits, costs and coverage limitations listed like calories, cholesterol content, and carbohydrates? A simple summary that lets us look at the next brand and compare?
Is it possible for insurance companies to give us something that takes this important and complex product and lets us understand what we really have?
Yes it is! The Affordable Care Act gives us a new comparison "label" for insurance policies called the Summary of Benefits and Coverage, and it will be available for all health insurance policies in a matter of days.
Here's the kind of information you'll find in the Summary of Benefits and Coverage: how much you'll have to pay for services before your plan starts paying and whether that amount is different depending on the service, limitations on how much you will pay and how much the plan will pay, your coverage for essential health services and the difference in cost if you use a participating provider or a non-participating provider, which services are excluded, what key terms mean and why they matter. You'll also find real life examples of approximately how much you'll pay in common medical scenarios, such as managing Type 2 diabetes.
Now I don't want to oversimplify the shopping process. You won't wake up the morning of September 23 and know everything about every insurance plan. You'll still have important questions. But, you'll be a much more informed shopper and a smarter health care consumer.
If you'd like more information about how the Summary of Benefits and Coverage can aid your search for health coverage, I invite you to check out Families USA's report, "Decoding Your Health Insurance: The New Summary of Benefits and Coverage.
For more healthy living health news, click here.]]>Mary Brown Doesn't Have Unpaid Broccoli Billstag:www.huffingtonpost.com,2012:/theblog//3.13470252012-03-16T14:30:29-04:002012-05-16T05:12:01-04:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/claimed in court she "doesn't have insurance" and "doesn't want to pay for it," filed for bankruptcy in Florida last fall. Among the debts she and her husband list are $4,500 in unpaid medical bills. No one should be gloating about Ms. Brown's misfortune. Earlier reports said her family's auto repair business failed due to the weak economy, compounded by the 2010 BP Gulf oil spill. But her experience shows both why we need the Affordable Care Act, and why the constitutionality of the law should be obvious.
Our modern economy is full of uncertainty. No one knows which businesses will thrive and which will fail. Small businesspeople, to their credit, take a gamble every time they start up an enterprise. That's part of what makes the American economy so resilient. But even with the best intentions and hard work, you can still run into bad luck. Businesses fail. People get sick. A lot of them end up at the doctor or hospital, and, if they don't have adequate insurance, they incur some pretty hefty bills.
So what happens if you can't pay your bills? In Mary Brown's case, you end up in bankruptcy court to seek relief from your creditors. There is nothing wrong with that, either. We don't have debtors prisons in America -- instead, bankruptcy proceedings give people a chance to clean their financial slates and start over. But just because the bills are discharged doesn't mean they go away. The doctors and hospitals that Mary Brown owes will have to write off her unpaid bills as a loss or as charity care. Those write-offs get passed along to insurers in the form of higher health care bills, and then on to the rest of us in the form of higher premiums. Four years ago, when fewer people were uninsured, those costs already added over $1,000 to the cost of a family's insurance premiums.
This connection -- between unpaid medical bills and higher premiums for everyone -- is not hypothetical. It happens every day, everywhere in the country. And it's a key reason why Congress enacted the Affordable Care Act, and why it has the power to do so. Mary Brown's decision not to have health insurance was a conscious economic decision. It left her with health care bills she now cannot pay. Those costs will be passed onto the rest of us. To say that her decision has no impact on interstate commerce, that it's somehow "inactivity" and therefore not something Congress can affect, as opponents of the law have argued, is to willfully ignore reality.
But you know what Ms. Brown likely doesn't owe? Thousands of dollars in unpaid broccoli bills. One of the most persistent lines of attack against the Affordable Care Act is that if Congress can require most people to obtain insurance or pay a penalty, they can pretty much force anyone to buy anything, and pretty soon we'll all be mandated to buy broccoli. But, as others have pointed out, health care is not broccoli. Broccoli expenses are not a factor in 62 percent of bankruptcies; medical bills are. Grocers don't have to write off the cost of giving away thousands of dollars of free broccoli and pass the cost along to everyone else by jacking up food prices. We all know that's not how the world works. The market for broccoli works pretty well. The market for health care does not.
Apparently, however, the right-wing politicians who scream that the government is going to force us all to buy broccoli can't tell the difference between a stalk of broccoli and a hospital bill. The Congress that passed the Affordable Care Act could. That's why we have an Affordable Care Act, and not an Affordable Broccoli Act. And for the past 75 years, the Supreme Court has followed the principle that it's up to Congress, not the courts, to figure out what economic markets are working in this country and which ones need intervention. Let's hope today's justices follow the same principles. Justice may be blind, but it should still be able to tell the difference between an MRI and a vegetable.
]]>A Big Week in the Courts for Health Care, Especially for Medicaidtag:www.huffingtonpost.com,2011:/theblog//3.10844322011-11-11T10:58:36-05:002012-01-11T05:12:01-05:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/decision from the DC Circuit Court of Appeals is a big win for supporters of the law. It's the third appellate court to reject challenges to the law. In June, the Sixth Circuit upheld the law. In September, the Fourth Circuit tossed out another case, holding that it was premature to challenge the individual responsibility provision because it functions like a tax and taxes cannot be challenged before they are imposed. So as more courts look at Affordable Care Act, the more the Eleventh Circuit's August ruling striking down the individual responsibility provision looks like an outlier.
Second, as noted by others, the DC opinion is written by Judge Laurence Silberman, a leading conservative jurist appointed to the bench by Ronald Reagan. Judge Silberman is a conservative's conservative -- member of the Federalist Society, on the short list for the Supreme Court during the Reagan and George H.W. Bush administrations, and awarded the Presidential Medal of Freedom by President George W. Bush. But Judge Silberman's ruling is unambiguous. It methodically dismantles every argument made by opponents of the law, and concludes that if one follows the last century of Supreme Court precedent -- which conservatives claim courts should do -- the individual responsibility provision is unquestionably constitutional. Like the Sixth Circuit decision from June written by Judge Sutton, Tuesday's opinion lays out a clear roadmap for conservative Justices on the Supreme Court to follow in upholding the law. Even the one judge who disagreed with the majority in the DC case, Judge Kavanaugh (a conservative George W. Bush appointee), did not vote to strike down the law. Instead, he would have dismissed the case as premature, along the lines of the Fourth Circuit case -- meaning all three judges thought this case should be dismissed.
Tuesday's decision is particularly timely because on Thursday the Supreme Court is expected to confer and decide if and when to hear the several Affordable Care Act cases coming out of the Courts of Appeal from around the country. It seems certain they will agree to review the Eleventh Circuit case that struck down the individual responsibility provision. That case is now in conflict with three other cases (the Sixth, Fourth, and DC Circuit cases), and the federal government has requested a review. The Supreme Court will likely also consider what sections of the Affordable Care Act are at risk if the individual responsibility provision were to fail, as well as the question of whether all the cases are in fact prematurely brought. These are all vital questions with huge implications for the health and well-being of our country.
There is also another issue before the Court this week that may get less attention, but is of particular importance to those of us who care about making life better for lower-income Americans. As I noted when the Eleventh Circuit issued its opinion in August a central component of the coverage expansion in the Affordable Care Act is the extension of Medicaid coverage to all low-income Americans. Today, many low-income parents and most low-income adults without children cannot get Medicaid. Starting in 2014, all these people will be eligible for Medicaid coverage that could potentially save their lives.
The 26 states in the Eleventh Circuit case have asked that this expansion of Medicaid be declared unconstitutional because it is "coercive" of the states -- even though between 90 to 100 percent of the costs of that expansion are paid for by the federal government. This argument has been rejected at every level in this case, and previous expansions of Medicaid have always been upheld. But the states have asked the Supreme Court to review this issue yet again. We'll know soon what the Court decides. If they decide not to hear the Medicaid issue, it means that portion of the Eleventh Circuit decision stands, and the Medicaid expansion can roll out as planned in 2014. Millions of the most vulnerable Americans will finally have access to affordable health insurance. After a decade where poverty has increased substantially, this is the kind of action Americans need. Let's hope the Supreme Court doesn't get in the way.
]]>Silver Linings in the Health Care Rulingtag:www.huffingtonpost.com,2011:/theblog//3.9291292011-08-17T17:38:25-04:002011-10-17T05:12:01-04:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/Friday's decision on the Affordable Care Act by the 11th Circuit Court of Appeals feels familiar. Most major pieces of social legislation have been challenged in the courts, often as an infringement of individual liberty. The Social Security Act in the 1930s and the Civil Rights Act of 1964 were struck down by lower courts as unconstitutional before being upheld by the Supreme Court. Today, those laws are part of the fabric of American society. I'm confident the Affordable Care Act will be as well. And while the court struck down part of the Affordable Care Act, buried in the more than 300 pages of opinions are some important positive developments.
The 11th Circuit struck down the individual responsibility provision by a 2-1 vote, finding it to be beyond Congress's authority under the Constitution's commerce clause. As a practical matter, this ruling has no immediate impact. In June, the Sixth Circuit Court of Appeals reached the opposite conclusion and upheld the individual responsibility provision. On the scoreboard, we're tied, 1-1. The Fourth Circuit is likely to issue a ruling in Virginia's challenge to the law in the next few weeks. Basically, this all just means that what we have assumed all along is true -- it will ultimately be up to the Supreme Court to resolve the issue. And most constitutional experts continue to believe that if the high court follows existing precedents, it will uphold the law.
But Friday's decision is just as important for what it did not do. The appeals court refused to strike down the entire Affordable Care Act, as the lower court had done. Instead, it explicitly found that even if the individual responsibility provision fails, the rest of the law is not affected. The important gains we've already achieved, like protection for children with pre-existing conditions, tougher regulation of insurance premiums, and filling the Medicare doughnut hole, remain in place. And the important work ahead, such as building state health care exchanges, planning for tax credits to make insurance affordable, and eliminating restrictions for everyone with pre-existing conditions, can continue uninterrupted.
On Medicaid, the news is doubly good. A central component of the coverage expansion in the Affordable Care Act is the extension of Medicaid coverage to all low-income Americans. Today, many low-income parents and most low-income adults without children cannot get Medicaid. Starting in 2014, all these people will be eligible for Medicaid coverage that could potentially save their lives. The 26 states that brought this case had challenged the Medicaid expansion as unconstitutionally "coercive" of the states -- even though between 90 to 100 percent of the costs of that expansion are paid for by the federal government. The court rejected this argument, noting that the states' objections seemed to be "more rhetoric than fact." Because this is the only case nationally in which the Medicaid claim is raised, there's a reasonable chance that the Supreme Court will not even review the issue, and the Medicaid coverage that will make such a profound difference in the lives of low-income people will roll out in 2014 as scheduled.
All this is not to minimize the potential harm of Friday's decision. The Affordable Care Act includes the individual responsibility provision so that people will not show up at the hospital without insurance and expect the rest of us to cover their bills through higher insurance premiums. The law makes coverage available and affordable through market reforms and subsidies, and in turn, it expects everyone to get coverage or pay a penalty. In a fundamental error, the court majority says it's just speculation that the uninsured might someday use health care they can't afford and as a result cause higher costs for those with insurance. But common sense and economic analyses tell us that it's not speculation, it's a fact. And if it were allowed to stand, the ruling could cause substantial increases in health care premiums.
Friday's ruling is undoubtedly a disappointment for all of us who care about ensuring access to high-quality, affordable health care for all Americans. But amidst the Monday morning quarterbacking, we should not despair either. This is just another round in a long process -- one in which we will ultimately prevail.
]]>A False Choicetag:www.huffingtonpost.com,2011:/theblog//3.8947122011-07-14T16:49:00-04:002011-09-13T05:12:02-04:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/
In three weeks, Congress will be faced with a choice: come to a sensible agreement with the president on how to address our deficit, or allow America to default on its debt, ruining our fragile economy, eliminating jobs and destroying our global credit.
What is truly heart-wrenching about this crisis is that we brought it on ourselves. And now, rather than rallying together to solve a common problem, the right wing is embracing recklessness as a political tactic.
Simply put, they are willing to risk the honor of the United States and the well-being of every single American to try to impose an extreme agenda that flies in the face of not only common sense but common decency.
As so often happens in times of economic struggle, it is programs that help the neediest among us -- seniors, children, people with disabilities -- that end up in the crosshairs. And this time, unfortunately, is no different.
In proposing these reckless cuts, Republicans would take away home-based care for seniors, forcing them out of their homes in their golden years. They would prevent seniors who need nursing home care from being able to afford it. And they would stop sick children from seeing a doctor if their family has no other coverage.
Incredibly, this proposal won't even cut health care costs. Instead, it merely shifts the burden of costs onto the shoulders of state governments. However, states can't handle that burden and, hence, will undoubtedly cut care for seniors and people with disabilities needing nursing home and other long-term care, and for sick children who need to see a doctor.
It makes no sense to cut the health lifeline for seniors, people with disabilities, and low-income children. It makes even less sense to cut federal spending in a way that does nothing to rein in health costs but merely shifts those costs onto the shoulders of those who cannot bear them.
To the extent that savings are to be achieved, there are a multitude of other options available. Billions of dollars can be trimmed from our deficit if right-wing congressional members would agree to eliminate tax breaks for corporate jets, or huge giveaways to Big Oil, or loopholes that allow companies like General Electric to pay $0 in federal taxes despite growing corporate profit.
Of course, there are changes to the health care system that can both improve health care quality and reduce our deficit. For instance, we can improve efficiency through better care coordination (for example, coordination between Medicare and Medicaid for people participating in both programs), as well as lower drug costs for these vulnerable people.
Instead, unfortunately, Republican leaders want the onus to be placed on middle-class and moderate-income families. As a result, they are making outrageously false claims, like the brazen assertion that Medicaid is "worse than having no coverage at all." They persist in these falsehoods despite concrete evidence that the program ensures that the most vulnerable among us receive critical preventive and primary care, can find and keep a regular doctor, seek medical care more often and are considerably less depressed and more financially stable.
Cutting Medicaid -- especially through cost shifts to states that ultimately fray the lifeline for seniors, children and people with disabilities -- makes no sense. We should strengthen America's economy in a fair and balanced way, and Medicaid cost shifts to people who can't bear those costs are precisely the wrong direction for our nation.]]>"Not Intended as a Predictive Economic Analysis"tag:www.huffingtonpost.com,2011:/theblog//3.8842752011-06-27T12:10:01-04:002011-08-27T05:12:01-04:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/ Washington Post opinion pages last week, then you likely came across an op-ed co-authored by Republican Senator Rob Johnson (WI) and Republican pundit and former advisor to the McCain campaign, Douglas Holtz-Eakin.
At first glance, the piece, entitled "Coming Soon: A Bigger, Costlier Obamacare," certainly seems alarming. In fact, if you read the first paragraph, you'd note that the authors claim (falsely) that our health care law will lower our quality of care and greatly increase our national debt.
Before I address these false claims, I'd like to quickly note that Mr. Holtz-Eakin is also a former director of the Congressional Budget Office (CBO). This is important because, as a former director, he presumably respects CBO estimates (more later).
OK, now that that's been said, let's take a look at what's really going on here.
A major provision included in the Affordable Care Act involves the creation of health insurance exchanges. Think of exchanges like the orbitz.com for the uninsured. The idea is, if you don't receive health coverage through your employer, you can purchase it as an individual through the exchanges.
But, in their op-ed, these opponents of health care rely on a "study" produced by the firm McKinsey and Company, which implies that many employers will eliminate benefits to employees, pay a penalty, and dump their workers into the new health insurance exchanges.
Citing the misleading study, Holtz-Eakin and Sen. Johnson say:
A recent employer survey by McKinsey & Co. found that more than half of all American companies are likely to "dump" their workers into the government-run exchanges. If half of the 180 million workers who enjoy employer-provided care wind up in the exchanges, the annual cost of Obamacare would increase by $400 billion by 2021.
This is pretty powerful stuff. Except of course for one teeny, tiny, little detail: It's not true.
Don't believe me? Take a look at the statement McKinsey released when pressed to share their methodology:
The survey was not intended as a predictive economic analysis of the impact of the Affordable Care Act. Rather, it captured the attitudes of employers and provided an understanding of the factors that could influence decision making related to employee health benefits.
The study -- according to McKinsey's own belated statement -- actually tells us nothing about how the Affordable Care Act will affect employer behavior.
But worse than that, the survey failed to even fairly measure the factors that might influence employer behavior. The survey first "educated" the respondents about the Affordable Care Act, then asked questions. Obviously, if the "education" is incomplete and biased, the survey results are unreliable. Just as one example, the survey failed to point the following out to respondents: if employers drop coverage, employees will be unhappy because they will lose an important tax break (the value of employer-based insurance is not taxed).
So what's actually true?
Late last week, Avalere Health released an analysis citing research from the CBO, the Lewin Group, RAND, and the Urban Institute that shows most employers won't, in fact, suspend health benefits to employees. They provide a few main reasons:
Employers offer health benefits to recruit and retain employees. The presence of exchanges does not change this motivation.
Employers offer health benefits to boost worker productivity.
There are many intangible reasons why employers offer coverage to employees, such as the value employees assign to the benefit, and the feeling amongst some employers that offering health benefits is the "right thing to do."
By the way, the co-author of the January 2011 Urban Study? Bowen Garrett. Senior expert and chief economist at McKinsey's Center for U.S. Health System Reform. Here's what McKinsey's own leading expert on the Affordable Care Act wrote about the impact of the ACA on employer-based coverage:
Some have claimed that the ACA will greatly increase health care costs for employers and that many employers would drop ESI coverage as a result. Our results show the opposite -- the ACA has little effect on overall ESI coverage and overall spending on health care would be slightly lower under the ACA... [W]e believe claims that ACA would cause major declines in ESI coverage are exaggerated.
Consider this analysis provided in the Avalere study from Booz & Company:
Employers that consider dropping coverage and paying the associated penalty will need a significant cost-value differential to offset the risks to employee morale and retention. Although some employers might save money by dropping coverage and paying penalties, many report that the savings may not be worth the potential downside. Many large employers, particularly those with more than 500 workers, and jumbo-sized companies also report a moral obligation to retain employee health insurance coverage.
So, what's the point of all this? It seems when it comes to discussing health care, Senator Johnson and Mr. Holtz-Eakin are taking a page from the conservative playbook: Cite a misleading and inaccurate study, share it far and wide in the media, and try to scare the American people.
It's something we've come to expect from politicians who are looking to score political points with the right-wing base, but it's not something we'd expect from a self-proclaimed economist and a former director of the CBO.
]]>Affordable Care Act 'Ultimately Will Be Upheld in Its Entirety'tag:www.huffingtonpost.com,2011:/theblog//3.8735602011-06-09T14:22:13-04:002011-08-09T05:12:01-04:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/
But let's start from the beginning. There have been approximately two dozen suits filed against the Affordable Care Act's individual responsibility provision. All but two of the cases decided so far by federal district courts threw out those challenges, most on procedural grounds but several on the constitutional merits.
But Florida judge Roger Vinson, weighing in on a 26-state lawsuit against the new law, took his anti-health reform stance to the extreme. In February, he ruled that because he found the individual responsibility provision unconstitutional, the entire law should be thrown out with it.
Roger Vinson's ruling is simply conservative judicial activism run amok. Long-standing judicial principles make clear that courts should deal with constitutional challenges as narrowly as possible -- a principle Judge Vinson cited in his opinion and then did the exact opposite. Additionally, experts from both sides of the aisle have said his ruling goes too far.
Just a few days after Judge Vinson's extreme ruling, the Obama administration appealed his decision, which leads us to round two: Arguments at the 11th circuit court in Atlanta, Georgia. And this morning, three judges heard oral arguments to determine whether Judge Vinson's ruling can stand or whether it should be overturned.
The arguments put forward today by the federal government illustrate why the Affordable Care Act is both constitutional and good policy. As most courts have found, the individual responsibility provision challenged by the Attorneys General is easily within Congress's constitutional commerce clause powers.
All three judges remarked at some point that health care is a "unique" part of commerce. And they're right. Three aspects make it unlike any other part of the economy. First, everyone seeks health care -- even when they don't expect to (such as after an accident, heart attack, stroke, or other unexpected problem). Second, for those needing such care, it must be provided; hospitals and doctors can't turn someone down who is at risk of losing life or limb. Third, when an uninsured person receives such care but cannot pay for it, this results in a direct and substantial cost shift to others with insurance -- a premium add-on that averages over $1,000 for family coverage. This makes health care unique and -- unlike a requirement to purchase any other product -- makes it constitutionally appropriate for Congress to establish a personal responsibility provision.
It seems that the lawyer for the states even understands this fact. He conceded that Congress can require people to buy health insurance when they are at a hospital -- but he said that they could not force someone to buy insurance before then. According to that logic, it's just a timing thing.
The fact of the matter is the individual responsibility provision is good policy. It protects the overwhelming majority of Americans who have insurance. They will no longer have to pay higher premiums to cover the costs of caring for those who refuse to purchase insurance.
To throw out the entire law would do a great disservice to American families, who, for far too long, have been trapped in an unfair system. Thanks to the Affordable Care Act, children can no longer be denied access to insurance because they have a pre-existing condition. Seniors and people with disabilities can receive preventive care services free-of-charge. And insurance companies cannot arbitrarily jack up premiums just to increase their profit margin.
To suggest that Americans are better off without these new rights is ludicrous. Were the court to uphold the District Court's decision striking down the entire law, it could have devastating consequences for America's families.
After hearing today's arguments, however, I am feeling optimistic that this court will reject the Attorneys' General arguments in their entirety and leave the new law in place.
We've taken big strides forward with the Affordable Care Act, now is not the time to take a giant leap back.]]>What Do Republicans Have Against Grandma?tag:www.huffingtonpost.com,2011:/theblog//3.8456822011-04-06T18:04:36-04:002011-06-06T05:12:01-04:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/
But don't be fooled by the Republican rhetoric on the budget. The House Republican proposal that was introduced by Representative Paul Ryan yesterday isn't really about reducing our national debt.
No, the Republican plan is about imposing extreme right-wing ideology on Americans, and the result could spell disaster for millions of seniors, children and families.
In crafting his reckless budget, House Budget Committee Chairman Paul Ryan (R-WI) claims he has a "moral obligation" to cut entitlement programs. But that claim rings false: While Republicans are proposing deep cuts to programs for seniors on the one hand, they're proposing huge, unneeded tax cuts for the wealthiest people in America on the other hand.
This is a debate about fairness and common sense. While the richest in the nation are given huge tax breaks, Republicans hope to slash $1.43 trillion from Medicare and Medicaid over the next 10 years.
This will have a devastating impact on seniors and their families. Medicare is primarily intended for people over 65 years of age, and the Medicaid program is the largest single payer of long-term care, including half of all nursing home costs.
That means the proposal will inevitably result in seniors losing the nursing home and other long-term care that they need at a time when they are the frailest.
It also means younger family members will have to give up their jobs so they can take care of their parents and grandparents full-time, putting a larger financial strain on families who are already struggling in our economy.
But seniors aren't the only ones who would be harmed by the House Republicans' budget proposal.
More than 26 million children depend on Medicaid for access to basic health care services. Cutting billions in funding to this vital program means the most vulnerable Americans will see their safety net disappear.
And as for the future of the program itself, the House Republican proposal essentially ends the program as we know it and converts it to a privatized voucher. In the process, seniors will bear a larger and larger cost burden -- and for many it will be unaffordable.
Beyond the proposed cuts to Medicare and Medicaid, the House Republican budget substantially increases income taxes for middle-class families. It does so by eliminating tax credit subsidies, scheduled to go into effect in 2014, that are designed to help middle-class families pay for health insurance. This means that if you're a family of four with an annual income of $45,000, you stand to lose a tax credit worth $10,400.
So, to recap, the House Republican budget would cut taxes for the wealthiest Americans while:
Dramatically cutting health care services for seniors;
Putting more than 26 million children at risk of losing access to basic health care;
Forcing family members to give up their jobs so they can care for their elder relatives; and
Raising taxes on struggling middle-class families.
You can see what the impact of the House Republican budget would be on your state by clicking here.
And one last point. The budget proposal put forth by the Republican leadership ALSO includes deep cuts to funding that is critical to implementing the Affordable Care Act. It's the latest attempt to derail and eliminate the act, and the damage would be devastating:
Almost 4 million seniors could lose help paying for their prescription drugs;
3.4 million young adults could be kicked off their parents' health plan;
4 million small businesses could lose tax credits that help them cover their employees; and
57 million Americans who have a pre-existing condition could be denied coverage, simply because they had the misfortune of getting sick.
These cuts aren't really about addressing the deficit. Indeed, due to the extension of the tax cuts for America's most affluent people and other tax giveaways, this plan increases the deficit.
These cuts are about attacking progressive priorities that don't fit within extreme right-wing ideology -- and the end result would hurt millions of Americans across the country.]]>No More Free Rides, Says Judgetag:www.huffingtonpost.com,2011:/theblog//3.8277832011-02-24T14:21:07-05:002011-05-25T18:35:25-04:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/
The American Center for Law and Justice filed the suit against the Justice Department on behalf of five individuals who refuse to buy insurance, claiming that the individual responsibility provision is unconstitutional and violates their religious freedom. U.S. District Judge for the District of Columbia Gladys Kessler rejected this argument, stating that this provision is authorized by the commerce clause in Article I, section 8 of the Constitution.
Judge Kessler stated in her opinion that not buying health insurance was an active decision on the consumer's part and has serious consequences, as it ends up affecting those who do have insurance. She notes that the uncompensated costs are passed on to the insurers, which are then passed on to the consumer, raising costs for everyone.
In a footnote, she writes,
In short, those who choose not to purchase health insurance will ultimately get a "free ride" on the backs of those Americans who have made responsible choices to provide for the illness we all must face at some point in our lives.
And she's right. Cost-shifting increases family premiums by an average of $1,017 per year.
With respect to court challenges, the judicial scoreboard now stands at 3-1-1. That's three full substantive victories for the Act, one partial victory-partial loss, and one defeat -- plus a dozen procedural victories.
And while the media has flocked to cover judicial rulings against the Affordable Care Act in both Virginia and Florida, it's important to note that those cases are no more important than those in favor of the law. But opponents of reform don't want you to know that. They'd like you to believe that rulings against the Affordable Care Act have more significance than those upholding the law.
The sad reality for opponents of health reform is that scoreboard is now 3-1-1 in favor of upholding the Affordable Care Act: three wins, one loss (Judge Vinson's decision in Florida striking down the whole law) and one partial victory (Judge Hudson in Virginia struck down the individual responsibility provision but left the rest of the law in place).
Ultimately, it will be up to the Supreme Court to decide the constitutionality of the law.
Here's a reminder of just a few of the benefits Americans could if conservatives succeed in striking down the Affordable Care Act:
• Insurance companies could continue to game the system, accepting premiums from consumers for years, and then rescinding their policy when they get sick or need coverage the most. Additionally, they could continue to get away with spending less and less of our premiums dollars on actual medical care, instead spending it on things like "administrative costs" and lining the pockets of Insurance Companies' CEOs.
• Women could be charged more simply because of their sex. Before health care reform, women in the individual market could be charged as much as 140% more than men just because they're female. And what's more, some insurance companies could get away with denying a woman health care because she was a victim of domestic abuse.
• Young adults, who graduate college only to find a job market that has little room for them, would no longer have the option of staying on their parents' plan until age 26. That means they'd have to risk going without coverage or fork over what little savings they have to purchase health insurance.
We can't go back to that system. And much to the chagrin of conservatives, who have tried to gain political points by preventing implementation of the law at every turn, the Affordable Care Act will continue to be implemented across the country --benefiting millions of Americans every single day.]]>Radical, Judicial Activismtag:www.huffingtonpost.com,2011:/theblog//3.8170722011-02-01T16:33:19-05:002011-05-25T18:30:24-04:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/
In a decision that constitutes radical judicial activism run amok, Judge Vinson declared the "individual mandate" portion of the Affordable Care Act unconstitutional.
He then took the opportunity to insert his political philosophy into public policy, striking down the entire law! This decision flies in the face of fourteen other decisions, contradicts decades of legal precedent, and could jeopardize families' health care security. And to make matters worse, this is the very kind of judicial activism that most conservative justices and politicians have argued against for years.
In the recent Virginia ruling, Judge Henry E. Hudson adhered to precedent, narrowly tailoring his opinion by only striking down the individual mandate in December. Judge Vinson, however, took his ruling about ten steps further. He declared that, "Because the individual mandate is unconstitutional and not severable, the entire Act must be declared void."
Then, in comparing the Affordable Care Act to a watch, Judge Vinson said, "The Act, like a defectively designed watch, needs to be redesigned and reconstructed by the watchmaker."
With all due respect, Judge Vinson, if anything, the health care system before passage of the Affordable Care Act was a broken watch that forced hardworking Americans to spin their wheels while insurance companies had the right to discriminate against those who are -- or have been -- sick and to take away coverage if they get sick.
If this decision were allowed to stand, it would have devastating consequences for America's families.
Children with pre-existing conditions would once again be denied access to health care; insurers could take away health coverage and reinstate lifetime limits on coverage; small businesses would once again be priced out of the market; and seniors would lose their access to no-cost preventive services and help with the cost of prescription drugs.
If that's not enough, consider this: Insurance companies could continue to arbitrarily jack up premiums without meaningful oversight, all the while using more and more of your money to line CEOs pockets instead of spending it on actual health care.
While we are extremely disappointed with this activist ruling, we're not all that surprised.
Instead of filing the lawsuit in Tallahassee, the capital of Florida, then-Attorney General Bill McCollum chose to file the suit in Pensacola, where three out of three sitting federal judges were appointed by Republican Presidents. By going forum shopping, Attorney General Bill McCollum all but guaranteed this outcome.
We are confident, as this and other cases are decided on appeal, that the Affordable Care Act will be upheld in its entirety. We further expect that implementation of the law will continue uninterrupted, and, as a result, our nation will move much closer to the achievement of high-quality, affordable health coverage and care for all Americans.]]>The Right-Wing Attorneys General Fight Against the Poortag:www.huffingtonpost.com,2010:/theblog//3.7841742010-11-16T10:56:00-05:002011-05-25T18:10:25-04:00Ron Pollackhttp://www.huffingtonpost.com/ron-pollack/
Led by Florida Attorney General Bill McCollum, 20 states have joined the suit, arguing that the "personal responsibility provision" is unconstitutional. This issue will be argued in a federal court in Florida in mid-December, even though a federal judge in Michigan has already ruled the provision is constitutional.
The individual responsibility provision, which requires people to purchase health coverage if they can afford it (many of whom will be receiving substantial tax-credits so they can afford it), is tied together with the prohibition that prevents insurance companies from denying coverage to people with pre-existing conditions. As a result, the attorneys general, if they prevail, would allow insurance companies to continue denying health coverage for people who need it the most.
The attorneys general in the Florida case are taking their political vitriol about the Affordable Care Act one very unfortunate step further: They are seeking to invalidate an expansion of the Medicaid program that would extend health coverage for approximately 16 million low-income uninsured people.
This part of the lawsuit is of critical significance. That is why -- along with the AARP, the American Academy of Pediatrics, the American Public Health Association, and the National Association of Community Health Centers -- Families USA has signed a friend-of-the-court brief seeking dismissal of the attack on the Medicaid expansion.
Medicaid is a program designed to provide health coverage for low-income children and parents as well as people with disabilities and low-income seniors. It is jointly funded by the federal government and the states, and it is administered by the states. Millions of Americans depend on Medicaid for health coverage. Many millions more, however, who are needy under any reasonable standard, do not currently qualify for the program due to unreasonable and stingy eligibility standards.
Consider the following: For parents of dependent children, in 34 states the eligibility standard is below the federal poverty level ($18,310 for a family of three). In 17 of those states, the eligibility standard is barely $9,000 for a family of three.
For childless adults without dependent children, it's even worse: In 43 states, these adults are ineligible for Medicaid coverage even if they are literally penniless. Clearly this is something that should be fixed -- and, thankfully, the Affordable Care Act takes an important step to achieve that.
Starting in 2014, every American whose income falls below 133 percent of the federal poverty level will be eligible for Medicaid. These are hardly princely lavish incomes. For a family of three, that is approximately $24,350 in annual income. For an individual living alone, that is an income of approximately $14,400.
Incredibly, the right-wing ideologues have labeled this Medicaid expansion as "radical." They intend to invalidate it and deny health care coverage for millions of people who otherwise could not afford it.
Their key argument is that this is an undue burden on the states. But this argument ignores essential facts: In the first there years of this Medicaid expansion (2014 - 2016), none of the costs for newly eligible people will be paid for by the states. Thereafter, the states pick up some portion of the costs, but it never goes above 10 percent.
In the process, however, states and local governments -- which pick up the costs of charitable care in public hospitals and other safety-net institutions -- will save significant costs. Moreover, for people who do have private health coverage, their premium costs will be lowered as they no longer have to pay the cost shifts of uninsured people who received care they couldn't afford.
The suit by the attorneys general is clearly part and parcel of a political attack against the Affordable Care Act. That political attack, however, can do cruel damage to low-income, uninsured people who need health coverage but can't afford it. That suit deserves to be dismissed immediately and there is ample legal precedent for that outcome.]]>