Reply from Sandy to My Last Post

meowser-48.jpg posted by meowser

Sandy from Junkfood Science just posted a long reply to my last post; since the thread had died by then, I thought I’d put it up top, because there are some issues she brings up that I wanted to tackle (and give other people a chance to also). This is the post in its entirety:

Arguments based on the past are irrelevant when we’re discussing healthcare REFORM. For everyone’s sake, the fat community desperately needs to understand the reality of what is being planned and put into place, the complete picture and consequences, and understand what words (like ‘quality’ of care) actually mean — not get caught up in what they’d like to see happen or what they think is right. Nor can anyone afford to believe media, anecdotes and social marketing. (RWJF interests, for example, have widely infiltrated online communities.)

The noncompliance examples given are spurious. What will label doctors noncompliant are pay-for-performance measures — those clinical guidelines and performance measures that make money for stakeholders (i.e. pharma). The medical literature has well documented that most all of these P4P measures are unsound and don’t actually improve patient outcomes or lower costs (and are all too often to the detriment of certain patients), yet the interests beind them have imbedded themselves in every level of the HHS and the CDC (see July 30th post). Under government managed care, the numbers of P4P measures have exploded and the consequences for doctors who fail to comply with them are steadily becoming more severe. Doctors who don’t do what the government says, already find their livelihood and licensure jeopardized (failure to comply is already on a schedule of increasing pay cuts, and negative ratings on their practices). Electronic medical records that are being required of every Medicaid/Medicare provider are being set up to monitor their compliance to P4P measures (tests ordered, prescriptions written, etc.) which will determine their pay, and automatically report their patients’s (our) medical information to the government to identify those for case management by government/insurance company. Medicare already pays doctors and hospitals 20-30% less than comparables, Medicaid pays 30-40% less, meaning fewer doctors and hospitals can afford to care for the poor. More importantly, out of necessity, care is restricted to what the government will cover.

Compounding the discrimination, they aim to pay doctors based on patient outcomes –- which means if you are fat or have a chronic disease and your health indices don’t meet guidelines, your doctor will receive less reimbursement –- doctors won’t be able to afford to take care of these patients and the patients will have increasing difficulty finding a doctor practice to accept them. Under their planned medical home model of government managed care, however, we won’t have the ability to just go to see any doctor to get the care we want. Instead, you’ll get the cheapest care because you’re costing the practice and hospital. Politicians are also looking at some troubling ways to ‘incentivize’ compliance among patients, calling it tough love. Look at what already happened to poor mothers on Medicaid in increasing places — noncompliance with healthy lifestyles contracts means no more government assistance or additional subsidized care needed for their special needs babies. There is nothing moral or compassionate about third-party health management.

You really don’t want your doctor having to answer to a third party payer (the government or government insurance plan), rather than provide the care he/she feels is best for you (especially if you are fat, aging, poor or have a disability). That also goes against every tenet of medical ethics. It’s why so many doctors and nurses have and will leave the profession rather than be forced to do that. Their conscience won’t let them be shills for pharmaceutical companies and political stakeholders or, worse, have to participate in things they know will hurt people.

Stakeholders are promoting bariatrics and weight loss interventions as saving the system money (while actually making THEM money) — they are not interested in the efficacy (soundness of the scientific evidence), long-range complications and deaths. Fat people are seen as undesirables in the prejudicial visions they have for a healthy perfect populace. But, the public largely believes obesity is a person’s fault and the obesity industry realized years ago that the public wouldn’t support paying for weight loss interventions for fat people – that’s why those same interests starting making it about their ‘health’ and turning to ‘obesity-related’ health indices, with a pill and lifestyle intervention for each. Another example of the need to understand what is going on: Did you know they are already eliminating funding for repeat hospitalizations for complications from the same diagnosis for all patients under government healthcare (Medicare/Medicaid)? This most affects elderly, about 20% of whom are rehospitalized after a medical incident due to complications. (And bariatric patients, of course.) Talking with ICU nurses last weekend, they were in tears because they saw that they were going to have to turn people away or give minimal care because the hospital was facing being unable to afford to provide it free and without compensation. And the hospital had already cut staffing, especially of the most experienced medical professionals, and they were being worked to death with mandatory overtime.

The most significant consequence of the clinical guidelines and pay for performance guidelines under managed care will be denying subsidized care to fat people who haven’t lost weight, to the disabled and to seniors; or providing suboptimum care. Such people are being said to be burdens on the system and not cost effective to expend much money on, under the comparative analysis method they are planning to use to prioritize healthcare spending. You need to understand how healthcare spending is planning to be allotted.

Most important: You are confusing health COVERAGE with heathCARE. As Big Liberty said, what will happen is that fat people and seniors who need care beyond the government’s free basic coverage, will have to find a way to pay for it themselves or suffer. Discrimination can be disguised as equitable.

The best hope for fat people and everyone getting older is a system that allows as many choices of plans and care providers as possible. Not one where the government eliminates their options.

First, Sandy, thanks for stopping by.

But I do think the past (especially the recent past) with regards to UHC is very relevant. You’re trying to tell us that we’re going to be the only country on the face of the earth where, if UHC is implemented, Big Brother is going to force us to live on plain broccoli and work out five hours a day and we’d better like it, when even current forms of U.S. government-sponsored health care, by all indications, are NOT like that. I have recent experience working at a VA Hospital; I did their medical records. Believe me, if they were only treating total goody-two-shoes whose abs you could bounce dimes off of, they wouldn’t treat anybody.

Also, all the problems you mentioned about third-party interference in care are going on right now. You’ve even written about it yourself! American doctors right now are experiencing more and more bean-counter interference from third parties (i.e. insurance companies). People kill themselves because they can’t get care approved by the bean counters.

This American for-profit health care wonderland where nobody interferes with individual doctor-patient decisions, and those decisions are always made in the patient’s best interests, doesn’t exist. (Just ask anyone who’s tried to get a birth control pill or Plan B scrip filled in the Bible Belt.) In fact, it’s likely it never really has; in the pre-HMO days, we (especially us hysterical wimmenz!) had to worry about sleazy doctors and hospitals goading us into accepting medically unnecessary surgeries and other treatments to line their pockets; now, in the name of preserving the ludicrously overprivileged lifestyle of insurance company executives, we are told that the care we’ve paid all our lives for might not be there at all when we need it, and that that’s just the way it is.

You (and also Big Liberty) seem to think all we need to do to get everyone completely covered without bean-counter interference is to allow everyone to purchase policies from out of state. Maybe I’m dense, in fact that’s probably a given, but maybe at least one of you could explain to me how that prevents the sort of rescission and cherry-picking or excluding coverage for preexisting conditions that we’re seeing now, and won’t lead to even more price-gouging and the sale of completely worthless junk policies from fly-by-night companies.

This rescission shit is serious. It’s not to be taken flippantly. Insurance companies actually have rescission quotas, a certain number of policies they have to find (or make up) a reason to kill each month in order to stay profitable. And if you’re on a group policy, they can slap surcharges on your company for your treatment so huge they have no choice but to either scrape together some reason to fire you, or sharply reduce coverage for everyone to make up for the surcharge. I worked for one company which, over a five-year-period, switched carriers four times, and finally wound up offering pretty much a total junk policy that would have cost so much out of pocket it wouldn’t have been worth signing up for. That’s what we poor old disabled fatties you claim to be beating the anti-UHC drum for are facing here, being totally fucked between now and Medicare.

Right now I have what I’d say is B-minus to C-plus coverage. I know it could be worse, and with trends in this country the way they are, and having experienced what I have, I can ill-afford to be smug about it. So what happens to me, someone who is increasingly difficult to employ because of size, age, and multiple disabilities, and isn’t eligible for state-run care or Medicaid, if my company lays me off, or drops or guts our coverage, and I can’t hook on anywhere that offers something better because this gutted care has become industry standard and everyone thinks I’m too high-maintenance? You think the free market will take care of me? How, when all carriers’ entire business, their whole reason for being, is set up to avoid people like me whenever possible?

OK, readers, I open the floor to you. (And once again, please stay on topic; I don’t want this thread to become open season on Sandy. As we used to say in “program,” principles before personalities.)

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40 Responses to “Reply from Sandy to My Last Post”

  1. wellroundedtype2 Says:

    I share some of Sandy’s concerns about Pay for Performance and resurrection of the worst aspects of managed care under a private OR public system, and the direction things are heading in, both are only be getting worse. As health care costs go up, companies are having a harder and harder time affording to insure their employees, so they have to pass along the costs to employees, which in effect is a decrease in wages for the employee.
    If I were the health care czar, what I would put as the priorities are:
    – Better health outcomes (reduction in early death, serious illnesses and acute events)
    – Everyone has access to the things that contribute to good health, including, but not limited to, appropriate medical care
    – Promoting providing information and transparency around the best procedures and the risks associated with procedures, as well as costs.
    On this last point, for example, my employer-based insurance company covers bariatric surgery if an enrollee meets certain criteria and then “complies” with the strict guidelines prior to the evaluation and surgery (such as keeping a food diary, and submitting weight by mail or fax every two weeks). The costs of the surgery are covered largely by my employer — not by me, and the surgeon and surgery center are the ones making money. A more transparent process would mean I would have to pay more for the surgery if I want it, and that I would be provided accurate information about the benefits and options if I choose NOT to have the surgery, even if I qualify.
    What’s hard to see with private insurance (and public insurance) is the actual costs of care. I’m not suggesting we go back to the time when people paid cash (or chickens) for the doctor or midwife, but if there were a better way to know how much we were going to need over our lifetimes, on average, and we were able to pay that, and have insurance for everything above and beyond that, I would be willing to have a tax that I paid for the yearly cost of my care — this is what my employer does, in essence, with me paying only a portion.
    Knowing how the state’s health plans (public and private) are managed in my state is simultaneously reassuring and scary. Private insurance companies may bee better at keeping their administrative costs down than the government but don’t care about saving money for those paying the claims (or why would costs have continued to rise so dramatically?). The government would be more likely to reign in costs, but at what cost to doctors and nurses, when we already have a shortage of health care providers?
    I am in favor of health care reform. On the whole, I would rather have a solution that provides universal coverage than the current system. However, I do agree with some of the concerns that Sandy has raised here and on her blog. I don’t think electronic records are some magical cure, nor do I think that paying only for “best practices” is always in the patient’s best interest, that P4P leads to cherry picking patients and can make it hard for patients to find “medical homes” if their problems are seen as intractable.
    I think our economy would improve if more people could afford to leave the jobs they feel trapped in so they can continue to receive coverage. I believe we would have many more entrepreneurs. I think we would have people treating their health issues earlier in the game. I think that there’s been a huge amount of societal neglect that has resulted in some of the huge disparities in health and health care that we see today. Right now, those in the public health care system (community health centers and medicaid, medicare) have many fewer choices of doctors than those in the private system, and they are much more likely to have to be compliant if they want to get care (many P4P measures have been tested in CHCs).
    I want more doctors and nurses in the health reform conversation. I want more patients in the conversation. I would be okay with many fewer dollars going to those making money off of poor health (this includes the diet industry, pharma, insurance companies, and the wealthiest of the doctors) but I’m not interested in abolishing the private system — I don’t think it’s wise at this time.
    I can’t get private life insurance, I would have to pay a stifling amount for coverage for me and my husband’s health insurance given our “preexisting conditions” on the private market — we would probably have to participate in the state pool in order to get it.
    I do pay more for health care than others who do not have the conditions I am managing — in the form of copayments but not co-insurance. On the private market, that is in effect what happens. Is it fair? I don’t know — I have many other privilleges but not the one of “no preexisting conditions.” I work dilligently in order to maintain my health — and health insurance.
    Sorry for the thesis! Can you tell I think about this all the time?

    • Tiana Says:

      I share some of Sandy’s concerns about Pay for Performance and resurrection of the worst aspects of managed care under a private OR public system, and the direction things are heading in

      That’s what I was thinking, too. Many other countries have some sort of universal healthcare system, but none (or only a few) of the problems mentioned above. It’s entirely possible that the US government will “do it wrong”, so to speak, but that doesn’t mean it’s a bad idea in general. Nothing indicates that private insurance companies are capable of doing a better job.

  2. Meowser Says:

    Can you tell I think about this all the time?

    You don’t say! 😛

  3. buttercup Says:

    Just a quick word on those so-called high administrative costs of government run health care programs. I work for the Department of Welfare in my state. I’m a caseworker. I manage over 500 combination food stamp/medical assistance cases, well over 1000 individuals. I make just under 40K a year. The top administrator in our office makes well under 75K. The top administrator in our county probably makes about 100K if that. Take that number of clients multiplied by several hundred caseworkers and put them into a privately managed plan in Allegheny County with bonuses and executive perks and salaries and you are not going to come out anywhere near even on the math. The government agency I work for does things pretty economically compared to the private sector, and we take care of the most vulnerable populations there are. The ones who could NOT be insured by private sector insurance, and even if they could, could not afford it.

    And Meowser? I love you. Thank you for this post. I would be the first one “recissed” if it came to that and it scares the shit out of me.

    • wellroundedtype2 Says:

      Here’s my take on this — I completely agree that the salaries of state employees, especially at the top, are much much lower than in the private sector. Take the profit motive out, and you get lower costs. However, in both non-profit and government managed situations, the costs of workers can be more — for good reasons, like actually paying people “lower down on the chain” what they are worth and not having contractors who are not paid benefits. I would just want to be realistic about the cost savings.

      • Rosa Says:

        Aside from salaries, though, you’re taking out the profits – the part that goes to shareholders and into bonuses and lobbyists.

        I haven’t had time to look it up, but I do wonder how much of the 5% extra GDP the US pays for healthcare compared to Canada is in commercial profit.

  4. bigliberty Says:

    “You’re trying to tell us that we’re going to be the only country on the face of the earth where, if UHC is implemented, Big Brother is going to force us to live on plain broccoli and work out five hours a day and we’d better like it, when even current forms of U.S. government-sponsored health care, by all indications, are NOT like that.”

    Clearly you’re mischaracterizing her. When I read her posts, I see not this broad generalized sweep of the brush that applies to everyone, but that wellness care dictates imposed on doctors *by law* and in a centralized fashion (cookie-cutter model) can naturally result in substandard or worse care for the most vulnerable and unpopular in our population, by how the model itself is defined.

    This:

    “You (and also Big Liberty) seem to think all we need to do to get everyone completely covered without bean-counter interference is to allow everyone to purchase policies from out of state.”

    Isn’t true. I think even in my post I mentioned it was an example of how one could increase competition, but it’s not like I laid out a health care plan, or claimed that everyone could get covered that way. I just know a sufficient amount of economics and economic history. I know that centralization doesn’t drive down prices (rather, the opposite). I know that centralization doesn’t increase choice (rather, the opposite). I know that centralization doesn’t filter out bias (rather, it can magnify existing bias, if it lines up with popular opinion). I know that if you claim you can cover more people with the same amount of money, you have to ration care, which means some people will get less care than they’re getting now, or substandard care. And I know who is already lined up to be scapegoated.

    I think, respectfully, you’re missing the point a bit. The point isn’t that we live in a health insurance utopia at the moment.
    Which is why this comment:

    “That’s what we poor old disabled fatties you claim to be beating the anti-UHC drum for are facing here, being totally fucked between now and Medicare.”

    Is mischaracterizing what Sandy is trying to do. She’s not trying to claim we live in a perfect time where everyone who needs care is cared for — she’s trying to tell you that switching to the plan being offered by the administration right now is only going to make things worse for a greater number of people, in the long run when the bills start coming in and the deficit starts to grow to the point where the Fed is worrying about too-high inflation (which is a hidden tax on all of us).

    We’ve gone far over the line of a good economic balance between government regulation and private control of the industry, and we’re nowhere near the ideal system as it stands. But the idea that a wellness care system will reduce cost by curing most chronic disease on which some of the greatest “excesses” of the current system are blamed, is false.

    We hear it every day — just lose fifty pounds and your diabetes/depression/PCOS/etc will go away. Just lose 100 pounds and you will never *get* any of those ills, and tack cancer, arthritis, dementia, stroke, etc to that list. This “common knowledge” about chronic disease is currently being used by the administration as talking points on how the system isn’t going to cost as much as those wily economists project it will, because they’re going to cure fatness and oldness and poverty, dontchaknow! It’s a crock. And while the vast majority of voters, amazingly, believes you can become permanently thin and escape your genetics and live forever if you eat and exercise “right,” *we* know that isn’t true. So who do you think is going to be blamed when they try to make good to their promise of keeping costs down and those damn chronic disease-havers just won’t get better?

    You put your case out there as an example of the kinds of people who fall through the cracks of the current system. But why do you think the attitude about whether or not you’re labeled “high maintenance,” and what that entails, will change under a government-run plan? Sandy brought up a few cases where people had to jump through certain lifestyle hoops in order to keep their Medicare coverage. It stands to reason that those same kinds of hoops could be extended to cases like your own, under a government-run plan. Would they be extended immediately? No. But as the costs of running the plan eat up a larger and larger chunk of GDP, fingers are going to start to point. And as much faith as I like to have in my political officials having some kind of sense, rest assured fingers aren’t going to be pointing at flaws in the system or the reasoning behind some of the economic calculations made to make it palatable to the public initially. The fingers will point at the doctors, who will point them at you.

    While some people can’t leave their current doctor if he/she is fatphobic, many people can. In a wellness care system run by a centralized body dictating standards to everyone, choice will disappear completely. And sure, doctors may or may not enforce the mandates sent to them from above, but do you really think the centralized body wants that to happen? Don’t you think they’ll try to root out that kind of doctor-based noncompliance? And *that* is what Sandy is talking about. That is what she has so painstakingly tried to show you, with her posts on programs that already exist to give you an idea of what you’re in for, to show you with evidence of conflict of interest that the people making these mandates aren’t interested in actual science or fact, but of serving their special interest lobbyists.

    And you can argue that that is the case now, and surely pharma has a lot of power now. But it’s largely private money. Public money is a much bigger potential windfall, and when you can get your desire for everyone to be on a pill and a diet and getting surgery X in order to insert device Y written into *regulations* that doctors and hence patients must follow, and you don’t even have to convince the poor bastards that your methods make their quality of life better anymore? Don’t you see how that kind of power puts another firewall between the regular healthcare consumer and sound science? And how that’s not a good thing?

    As for employer coverage, and how one’s job can hinge on the price of healthcare benefits, I think it’s something that needs to change. But taking healthcare plan decisions out of the hands of employers and putting them into the hands of government czars or the committees they appoint is going from bad to worse. At best, it will shift the costs in a different way — for instance, your employer’s taxes will go up as the costs of this healthcare plan are double, triple or more of what was initially projected. And when your employer’s taxes go up, their spending will go down. That includes spending on jobs, retirement/life insurance/other benefits, research and development (more jobs), and so forth.

    The point is, being switched to a government plan is not a going to guarantee that the price of healthcare won’t be responsible for the loss of jobs in the future. It’s just shuffled around a bit more and hidden, but the consequences are still there. Government health care is not free, and it’s not just something the rich or middle class will pay for. We we all pay for it, the transaction is just going to be one where the choice of the product we buy with our money is removed even further from us.

    Again, you seem to argue that since you and others like you have the potential to fall between the cracks of this system, that means the system is broken and the only fix is to take it out of the hands of private industry. It’s a very black and white view, and ultimately very crucial details are lost when painted with such a general brush. The system under which we are currently is a mixed economic, not private, system. Not only that, but the mixture tends more to the public than the private. As such, two or three companies tend to crowd out all competition in a particular state, because the costs of operating in that particular state are so high that small companies can’t survive in competition with economies of scale.

    And why is it so expensive to operate in particular states? It is, wholly and absolutely, a function of state regulations which in effect prohibit competition. The regulations being the mandate to cover a certain list of conditions, regardless if the individual purchasing the plan him/herself has any of those conditions. And the argument for mandating the conditions is that people don’t have much of a choice of healthcare due to the employer-based model, so they can’t pick and choose their coverage. But the reason *that* is true is because it isn’t cost effective for the insurance companies to have individualized coverage because of the list of conditions they are compelled to cover from the get-go, and it’s forms this neat loop.

    It doesn’t have to be this way. Buying plans across state lines is a start — it has the ability to break up a few of the existing semi-monopolies in various states. But as the cost of entering the market as a health insurer goes down, in-state companies can now form which before couldn’t compete with the economies of scale. And since there are now more companies offering products, the big, old companies can’t be sure that their plans will be purchased anymore, and now they have to try to listen to the pulse of the consumer more closely. Hence real demands — like individualized plans that will cover particular things and not others — will start to be met, because there’s money to be made and the overhead is low enough to make it worthwhile.

    I know a lot of people here distrust market mechanisms, but there is no logical reason to do so. Government should step in only to increase safety and competition, but beyond that, the market will respond to the demands of the consumers.

    And for those who will fall between the cracks of *that* system — because there will always be people who fall between the cracks — a much more reasonable system can help to subsidize them and their families. Not a system based on faulty premises. Not a system based on pie-in-the-sky cost estimates or health outcomes. Not a system based on the existence of a Fountain of Youth. Not a system that degrades, alienates, and scapegoats “deviant” groups.

    • Emmy Says:

      The worst possible outcome – and the one that may well happen, based on US states’s past fumbling attempts to introduce universal coverage – is to try to shove everyone into the US health care system as it stands without massively overhauling said system.

      Trying to give everyone “insurance”, turning them loose on a for-profit system, and sending the bill to the government may bankrupt it beyond even the national debt’s ability to juggle. Because the US system is designed to run up enormous bills. As I understand it (and I may be wrong) this is what happened to TennCare. They tried to make insurance available to everyone, everyone promptly went and USED that insurance to get treatments, the doctors presented the government with their usual huge bills, and the state government sh*t themselves.

      Giving everyone preventative care brings down costs compared to giving everyone late-intervention care. Giving everyone preventative care does NOT bring down costs compared to giving only the few who could afford it late-intervention care, and expecting it to do so will disappoint. And the immediate impact of suddenly giving more people access to the late-intervention care, who are already sick and too late for the early care to help them? Ouch.

      It needs doing, but it’s going to be painfully expensive. And even more painfully expensive if some way isn’t thought up to provide care at a lesser cost than what the insurance companies currently overbill for. That may mean setting up a lot of clinics and nurses to provide lower-tier care… lower-tier sucks, but it beats no care at all.

      I badly wish the US health care system could be completely torn out and replaced by the UK system of NHS + private-if-you-want-it but that’s REALLY hard to do, there are too many powerful interests entrenched and opposed.

      • Lori Says:

        Trying to give everyone “insurance”, turning them loose on a for-profit system, and sending the bill to the government may bankrupt it beyond even the national debt’s ability to juggle. Because the US system is designed to run up enormous bills

        Yes. This, exactly. And the solution isn’t to just give the people making money in the for-profit system more power; it’s to stop making health care a for-profit industry.

      • kb Says:

        Lori said exactly what I want to. Our system now DOESN’T let doctors choose what they want to do, at least, not unless the patient can pay cash for it. While, yes, government sponsored plan can be more interference, I’ve seen waaaay more interference and fat prejudice from insurance companies, this so called “choice” that isn’t-I can get one insurance option through my job, which means I get to go to one clinic for preventative care, and one hospital for anything complicated. How, exactly, is government going to take more choice than that?

      • kb Says:

        also, when has the market been in your favor? I do want to see when a market mechanism is in favor of people who are typically underseved-those who can’t pay. just recently here, I’ve seen problems in power company setup(government option got voted down, guess what these “free market” companies decided to do after that?) health insurance(for both me and my grandfather), and flying. I have yet to come up with a situation that counters my distrust of market pressures as a moral good, but if you have one, I’d be really interested to hear it(I’m not being sarcastic. I really am looking for good counterexamples).

    • Emmy Says:

      some more specific points:

      I know that if you claim you can cover more people with the same amount of money, you have to ration care, which means some people will get less care than they’re getting now, or substandard care.

      If you claim you can cover ANY number of people with ANY amount of money, you have to engage in a certain amount of ‘rationing’, as in determining what services are suitable value for money. It’s a hard job, a very hard job. And sadly it can fall prone to being influenced by lobby groups and sensationalism. One very angry person needing a million-dollar treatment may be better able to raise a fuss and finally get that treatment covered than a large number of people needing something much cheaper but in a worse position to speak up for themselves.

      It always hurts when you’re on the losing end. But this isn’t specific to government coverage, or even to insurance. Choices always have to be made. It may be easier to raise a fuss and get an expensive new thing covered under government schemes than private insurance – it seems to be, but I don’t know for sure. I also don’t know if that’s good or bad.

      In a wellness care system run by a centralized body dictating standards to everyone, choice will disappear completely. And sure, doctors may or may not enforce the mandates sent to them from above, but do you really think the centralized body wants that to happen? Don’t you think they’ll try to root out that kind of doctor-based noncompliance?

      On the NHS, I still get a choice of which doctor I see. 🙂

      Lower compensation than the massive profit-driven industry has its downsides (there’s always a shortage of doctors and nurses, always). But it also has its upsides… people seem to be more focused on HELPING people than how they can squeeze the most money out of them, and the government’s ability to bully them for failing to meet pointless targets is limited.

  5. Meowser Says:

    Thanks Buttercup, heart pingback to you, too.

    BL, I haven’t been to bed yet and it’s light out, so I need some time to go over your points one at a time. But as I’ve said previously, single-payer health care is not even on the table in this country; Dennis Kucinich is struggling to get a bill passed that will allow it even on the state level. The likelihood of everyone winding up on a government-run plan any time soon is pretty tiny, so this is kind of like neurodiversity-versus-the-curebies stuff all over again, where we’re basically arguing over whether something that doesn’t exist and probably won’t ever exist, should exist. Our system, if our elected officials don’t completely capitulate to the insurers (and I’m not holding my breath on that either, believe me) is a lot more likely to resemble France’s or Germany’s — a mix of public and private coverage — than the U.K.’s or Canada’s.

    And it’s Medicaid, whose standards and per-capita funding change from state to state, that is having the issues with making people jump through hoops to keep their coverage, not Medicare.

  6. Shinobi Says:

    I think it is really important to note that the bill currently being considered in the house does NOT implement a form of Universal Health Care. I’m not totaly sure what government competition in the market will do, but it wouldn’t surprise me if we saw more Not for profit type insurance companies doing better than ones who are paying their CEO the big bucks and beholden to shareholders.

    One thing it does do that everyone should be happy about and that will help reduce costs in the long term is encourage people to create living wills and plan for end of life care. This may be a big hidden cost reducer. One of the things our hospitals spends big money on is hooking dying people up to big machines and trying to save them, even when they are terminally ill. It is possible that we will see a big cost reduction just from encouraging terminally ill patients and the elderly to explicitly state whether or not they want to be put in the Intensive Care and have extraordinary steps taken to save them. Right now, if you don’t say you don’t want it you end up on breathing machines and int he ICU, and that is expensive all around.

    I think that will be a really important part of this bill in the long run that may help us reduce our health care costs dramatically.

  7. wellroundedtype2 Says:

    There are so many components to health reform that it’s hard to sort it all out, but breaking down just one of the points has to do with who pays for health care.
    Currently, the government collects money from everyone (everyone who has an income) to pay for Medicare. The health care costs of people on Medicare (due to age or disabililty) are paid by the pool of money that we all pay into, and the individuals getting care themselves. These are partly subsidized by the health care system, because Medicare pays less than private insurance does.
    Public money also goes to cover Medicaid and a few other programs (such as health insurance for children, pregnant women, community health and public health).
    I don’t think most people are talking about getting rid of these programs.
    For those not covered on the above programs, they basically have three choices:
    1. Work for an employer who offers health insurance — and the costs of insurance and care are shared by the employer and employee, to varying degrees.
    2. Buy your own health insurance — and you are paying for everything.
    3. Don’t have health insurance, and then pay as things come up or if you can’t afford it, get charity care or public health care from a clinic which is subsidized by the government. The health care system also absorbs and passes along costs to everyone else in the system for those who can’t afford to pay. Charity care often pays for catastrophic care for those who can’t afford it.

    The idea of universal coverage is that everyone in group 3 would be in group 1 or 2 or in a public plan. To me, this doesn’t automatically mean we start rationing care. Some people would start seeing the doctor who haven’t been, but many would go on waiting until they felt they needed to. People like me who do work for government can and do speak up when assumptions are made about “cost savings” and “compliance” on the backs of patient care.

    One way that the whole system could save money would be to simplify and standardize how billing is done. I know that the systems for getting prescriptions have been streamlined a great deal (there may be more to do in this area, it’s not my area of expertise) but if billing were as simple and straightforward as prescription refills (I know it’s inherantly more complex, but it still could be made less burdensome for health care providers) that could save lots of money for providers.

    To me, it comes down to: What do we want to be free of?
    Free of additional taxes? Free of government control of our health? Free of corporate greed? Free of the fear that we won’t get the care we need if we lose our jobs? Which of these freedoms are more important to us? Where can we exert our influence?

    My vision for a better health system is that people who need care get it in a predictable, reliable way. That care includes preventive care — pap tests and regular visits with my doctor that keep me on track with managing my diabetes to prevent complications, like blindness. The reduction in diabetes complications of the past decade is no accident — this has to do with standardizing and improving care for people with diabetes, many of whom are poor, are people of color.

    I ran across this quote from Molly Ivins this morning from a tribute to her after her death two years ago in The Observer:
    “There’s not a thing wrong with the ideals and mechanisms outlined and the liberties set forth in the Constitution of the U.S. The only problem is the founders left a lot of people out of the Constitution. They left out poor people and black people and female people. It is possible to read the history of this country as one long struggle to extend the liberties established in our Constitution to everyone in America.”

    So, that’s what I think health reform is about. And I think that we need to go about it carefully, with respect to everything Big Liberty and Sandy are concerned about. We need to demand that controls to be put into place to protect the most vulnerable, and all of us.

    • meowser Says:

      Well, one thing they definitely need to make sure happens is that there are enough providers to go around who accept new patients. That, I gather, is one of the major problems with MassCare; they insisted everyone pay for care without actually having enough primary-care providers for everybody. (Talk about your insurance-company gift.)

      Of course, I have a quick and dirty solution to that, which I know the AMA will just hate. What you do is this: You offer all RN’s who have been in full-time practice 10 years or more an opportunity to take the nurse practitioner exam and become NP’s (who can then see patients); then, to replace them, you let all LPN’s and LVN’s who have been in full-time practice 10 years or more take the RN exam; and likewise with CNA’s taking the LPN/LVN exam. There might be some who don’t want the upgrade and some who won’t pass the tests, but I bet most will leap at the opportunity and most will pass. (There’s no way you’d learn less in 10 years on the job than you would in 2 extra years in the classroom.)

      I know the AMA would hate it, but until they start increasing the number of residency slots for family practice physicians drastically, there are going to be shortages, and they can do so much with practitioner-in-a-box services (especially after hours) it’s not even funny. It would save a bundle from sending people to the ER with non-emergency health needs.

      • buttercup Says:

        There you go with that crazy “Logic” thing again!

      • Lori Says:

        I am so in favor of expanding nurse-managed care. I try to use nurse managed care whenever I can, and it has been, overall, so much better than the care I’ve gotten from doctors. The wait times are shorter, the appointments are longer, and much of the time the NPs treat you like an actual human being who has agency in making your own health care decisions. Nurse managed care, in my experience and that of other people I’ve known, is cheaper, more efficient, and more compassionate than traditional PCP care.

  8. Sniper Says:

    I actually stopped reading JFS because of the outrageous posts on single payer health care. As a Canadian, I am very tired of people writing about UHC as if every country which subscribes to it is populated by government-controlled sheep. We chose UHC because it is fair and humane. As for the Democratic health care plan, it is not even close to “socialized medicine”.

    • meowser Says:

      As for the Democratic health care plan, it is not even close to “socialized medicine”.

      I know, Sniper, and that’s the truly sick joke of it. What’s being proposed has been getting more and more watered down to the point where it just seems like Obama et al are taking dictation from the insurers. Rich people stick together, when the chips are down.

      Which is why I doubt any “free market” solution is going to help me, or people like me. There’s a reason the insurance companies are spending over a million dollars a day to defeat anything that even smells like UHC, and it’s not because they fear the loss of customers like me. It’s because they fear the loss of the customers who are their artisan bread and olive oil — the young, thin, perfectly healthy and dependent-free (especially men), who just pay and pay and pay and file for almost nothing. They’d throw a freaking party if they didn’t have to cover people like me anymore.

      People like me are who cut-rate, unregulated-state insurers would just love to get their mitt (romneys) on. Because the “legit” insurers won’t touch us with a ten-mile penile prosthesis, they’ll promise us the moon and stars, they’ll cover all our preexistings at a price we can afford, and we’ll fall for it and sign up with them, only to find out they can weasel out of coverage of almost anything they want to because, hey, who’s going to stop them? They’re Big Badass Cut-Rate Insurance Company, and I’m not.

      Yeah, I can sue them for fraud, great — fat lot of good that will do me if I’m mired in major depression again because I won’t have gotten my psych meds or seen my shrink. They’ll wind up nickel and diming me over the piddliest things (I actually had one insurer say they wouldn’t pay for a Pap smear because I had PCOS and therefore the test was for a “preexisting condition” — I’m not kidding). And as soon as I need anything expensive — surgery, chemo, antiretrovirals — it’s rescission time. So then I can get another cut-rate policy and start the fun all over again. Wheeeee.

      It doesn’t matter what their “overhead” is. Insurance companies are not about passing any savings on to their customers. If they know you are desperate, they have you over a barrel, and if they know you will cost them more than they will save, they will do whatever they can to squeeze as much out of you as possible before dumping your ass on to the curb. I will not be a profitable customer for any insurer, and I’m not even the most expensive kind of customer, the kind who requires frequent hospitalizations and super-expensive drugs. I don’t even want to know how badly they’re gonna get stiffed.

    • Cynicalfatty Says:

      This Australian is very tired of it too. They’re negating and ignoring our experiences.

  9. bettylou Says:

    This scare-tactic coming from some in the FA community is disturbing, and they often do just shout down people who disagree. I don’t understand the argument that we don’t want government inteference nor the assumption that if we just prevent a government plan, we’ll all be okay. Right now, we have interference from employers and for-profit health insurance, but the same people who try to scare us about government-run healthcare say nothing about this.

    By the way, you should be commended for having a dialogue on this issue. The other side is much more likely to ban people who disagree with them or to shout them down.

  10. Girlsailor Says:

    As a poor, fat person with mental health issues to boot who lives in a country with socialized medicine (Sweden), I am very thankful that I do not live in the US under the current health care regime. I would simply not afford the medical care that I need if I lived in the US and I wouldn’t qualify for Medicare.

    As a fat person any health care system is tricky to navigate and the Swedish system is not an exception, but it is certainly not worse here than in the US. There are other drawbacks on a socialized medical system but the benefits far outweighs the negatives, imo.

    I’m just putting this out there as a bit of perspective.

  11. Electrogirl Says:

    “And the solution isn’t to just give the people making money in the for-profit system more power; it’s to stop making health care a for-profit industry.”

    YES. This. This is the root of America’s health care evils, in my opinion. I haven’t met a single medical professional who is in health care to get rich. Both of the specialists whom I see regularly (neurologist and psychologist) take Medicare, even though it means taking a loss. The insurance companies aren’t concerned with trivial details such as the health of their patients. They’re in this for money, and sick people who actually need their services cost them money.

    I am incredibly afraid that the insurance companies’ “more profit, less sick people” mindset will spread to whatever government agency ends up managing the new health care agency. They will be under incredible pressure to spend as little as possible.

    Well, people with disabilities are expensive. Let’s trim some costs there. You’re taking a new drug for epilepsy, prescribed the neurologist who knows you and your condition? Take one of the older generics instead! Who cares whether it works or whether you can tolerate the side effects, we can say that we’re covering your medication.

    You have chronic pain, and your doctor has prescribed physical therapy and massage to give you some relief? Denied. We might approve some generic Vicodin if you ask nicely. What, you’ve had horrible side effects from every drug therapy you tried? Sucks to be you.

    I could go on and on and on. (For the record, I am epileptic and my sister has chronic pain as a result of Lyme disease.) Right now we have the privilege of being covered under Mom’s good health insurance. She’s worked for local government for more than 20 years, despite the fact that she’d rather be doing something else, for precisely this reason. But what will happen when we go out to make lives of our own? Who would hire a woman with epilepsy who needs expensive drugs and regular visits to an expensive specialist? Even if I found someone willing to hire me, how could I possibly afford insurance?

    I rather doubt that government healthcare would cover anything beyond the bare basics for expensive disabled citizens. That’s really rather shortsighted of them, given that I have a much better capacity to work and, y’know, pay taxes when I have my freaking drugs.

    Right now I’m looking at two options for when I get out of college. I could go my mom’s route and get a government job with nice cushy government job insurance. Once you pass probation there, they can’t fire you without cause- and they have to have solid evidence for that. Or I could move to Canada.

  12. Electrogirl Says:

    Er, I was kind of unclear there, sorry. In the second-to-last paragraph, I mean ‘the national healthcare thing that they’re hashing out on Capitol Hill right now’. In the last paragraph, I mean ‘the insurance option you get as a government employee, which tends to be rather nice compared to lots of other jobs’.

    *wishes for an edit button*

  13. meowser Says:

    At Fattypattie’s, she makes a good point about one of the things that really drives up health-care costs, which is that billings (especially from hospitals) are conflated with actual costs. When you go to the ER and the hospital bills the insurance company $15 for a couple of aspirins, is that their actual cost? Of course not. Aspirin is dirt cheap. But they inflate everything they can on those bills for a reason. It’s to cover all the stuff they don’t get legitimately get paid for, either by patients who can’t pay (although contrary to popular belief, they do get billed) or by the insurance companies who won’t.

    I do a lot of ER notes. You’d be amazed what percentage of ER patients are going there for things that really are not emergencies at all and require absolutely no hospitalization, but they have no other choice, either because they are uninsured or they can’t get off work to see a regular doctor during regular business hours (or they are working nights and sleeping days because they are on swing shifts, etc.). It’s an unbelievable waste of resources, not least because the billings for these services are so over-the-top inflated. They could do so much with 24-hour advice-nurse lines (who you could call to find out if your problem requires medical attention at all, and if so how urgent it is) and after-hours providers in a box without compromising quality of care at all. In fact, it would improve quality of care for people who really do have emergencies.

    • Rosa Says:

      This is why I miss my HMO (I changed jobs and the new job *laughed* at the cost of the HMO insurance – and tried to snidely imply there was something wrong with them, too. Bastards.)

      But anyway – because the HMO was designed to keep costs down, they had a bunch of off-hours options.

      *There are several after-hours clinics (after my car accident I went to one at 10 pm because that’s when I got off work).
      *There is an actually helpful nurse line (the insurance I have now has a nurse line but the only answer I’ve ever gotten from them is “if you’re worried go to the emergency room”)
      * The nurse line is integrated with their scheduling department so they can look and say “OK, if you don’t need to go to the emergency room, there’s a clinic that’s open til midnight but it’s 4 miles away. There’s one near you that opens at 7 tomorrow morning…”

      I don’t know how they deal with chronic stuff, or anything acute that’s not accident- or pregnancy-related, but I did have a very expensive pregnancy (the hospital billed upwards of $80,000) and paid one bill total, for $200. With our current insurance, where they are still disputing a tooth extraction from 8 months ago (my partner got two teeth pulled so OBVIOUSLY one of those bills is fake, right? Nobody has more than one wisdom tooth)…I don’t even want to think about being as sick as I was and having to cope with the current insurance company. But it’s the only option we have.

  14. Sara Anderson Says:

    In I think 07, Washington State passed a law requiring that fraudulently-denied insurance coverage damages be paid in triple. I don’t know how well it’s been tested, but my health insurance is based in WA and has been very sweet to me (as health insurance goes) through a huge health ordeal. I have a hard time believing that it’s a coincidence that Group Health is held up as a model of good health insurance, and that the laws on the books make bad-faith denials an actual financial liability.

  15. Heather#2(?) Says:

    I may be incredibly naive on how the health care debate traspired up until a little while ago, but was “let doctors decide what’s needed, let patients get second opinions if they wanted them ever on the table?” (which as far as I know is how health care is run in Ontario where I live).

    It seems to me that if the gov’t is going to take over healthcare or just offer it as an option to those w/o insurance one of the best ways to cut costs is to not micromanage doctors and hence, save all that money on people doing the micromanaging, all the reports being filed for micromanaging etc.

    If you spend some time in surgery forums (which I did a lot of recently), you start to see how jerked around people are when there’s not gov’t funded healthcare. People routinely have their surgeries pushed back b/c insurance or worker’s comp decided to have yet another second, third, fourth opinion (some people are notified the day before their surgery). These people booked the time off work, or re-arranged their lives based on the fact that they were more or less going to be incapacitated for a couple of weeks and now they discover they won’t be (at least not yet). The number of people who end up giving up is scary (not because the surgery wasn’t important but because each person only has so much fight in them regardless of how important something is).

    The thing that scares me about free market economies is the chalk in the milk thing. It’s an actual example from England in 18th or 19th century. A company realized that they could cut costs by mixing chalk in with water and calling it milk. Now, one way a person might deal with this is to buy other milk (if they even realize this is happening). But if the other milk companies realize that their milk is better, they raise prices and it becomes rich person’s milk. Basic items such as milk and health aren’t opt-outable in the same way perhaps lobster is (you don’t like the price of lobster, don’t buy it). The only people who have any control over the invisible hand of free markets are those with the ability to choose otherwise (the rich). I don’t like the idea of having to hope that a bunch of rich people will agree with me and choose what I would choose if I had more money. Historically, when markets aren’t regulated, things are worse for the average joe and better for the rich. If someone could explain how health care isn’t or won’t be like chalk in the milk, I’d greatly appreciate it.

  16. Blimp Says:

    Life is an inalienable human right. That means that state-of-the-art health care must be made available to all who are not enemies of the nation that we have established to honor that right, and other inalienable rights, insofar as our nation has the power to do so.

    We certainly cannot honor that principle while bailing-out incompetent or criminal bankers and speculators. Nor can we honor it while trashing our labor standards through free-trade agreements and outsourcing. Nor can we honor it while bound by environmentalist or “dual-use” dogmas which prohibit our use of the most powerful technologies available. Nor can we honor it without a 100% commitment to continued progress in science and technology, which provides the only means of staying ahead of population growth, or of allowing it to continue.

    So, either we have a system of universal, single-payer health care, in which every honest claim of a doctor or hospital or pharmacy for reimbursement is honored and paid by the government, or we make sure that everyone has enough income to pay for it themselves, or we establish a system in which everyone who is able to pay their own medical bills must pay, and the government pays for the rest. The third option was established by Franklin D. Roosevelt and the Hill-Burton Act, creating a system of public hospitals that provides excellent medical care to all, then tries to collect payment afterward. Under that system, people who could afford it bought private health insurance so that they would not be driven into bankruptcy by unexpected medical bills. Today, that system is failing because (1) we tolerate HMOs and other private managed-care insurance schemes and (2) we don’t adequately fund public hospitals for uncompensated care and (3) we demand full payment, or too large a payment, from people who cannot afford real private insurance, and therefore cannot be blamed for their bankruptcy on the grounds that they’re too cheap to buy real private insurance, or don’t put enough priority in their budget for their own medical care and (4) the whole economy is in Hell and accelerating toward the Middle Ages and (5) our culture has degenerated to the point that real science lacks political support, creating the kinds of abuses that are documented on the JunkFoodScience blog.

    So, back to paragraph 2. We need to massively increase the budget for government subsidization of health care, if we intend to honor the right to life. The problem with President Obama is that he demands a drastic reduction of the budget, and demands establishment of an “Independent Medicare Advisory Council” (Nazi Tiergarten 4 euthanasia board) in order to ration care, to accomplish the savings. He employs unlawful intimidation of Congressmen and State Governors who do not support the establishment of this unconstitutional board. He also intends to keep the HMOs, and make the government buy coverage for the uninsured from them! He’s also made a deal with the big Pharmaceutical cartels, in return for their “promise” to lower drug costs, to stop the government, esp. the Congress, or the agencies that administer Medicare and Medicaid, from negotiating for lower prices. He also has no intention of even slowing down the bailouts, or doing anything else that will help our economy grow in terms of per-capita physical productivity. Those who would like to see Obama expelled from office AND revive the physical economy, visit LaRouchePAC.com

  17. Tigerlily55 Says:

    I find it interesting that Sandy from JFS does not allow comments on her blog (unless I’m missing something) but she doesn’t have a problem with coming over here to push her points.

    I have a problem with the “crossing state lines” argument. The fact is that some states mandate certain coverage and have consumer protections in place. If that was changed, all those consumer protections would be dismantled. Choosing your coverage sounds nice, but other than choosing whether or not to have pregnancy coverage, is there anything you would want to *delete* from your coverage? Mental health coverage (if you’re lucky)? Chiropracter? Maybe having an OBGYN and a family doc?

    It seems Sandy is also pushing this phony end of life planning scare ( See her August 2nd post). That has also made me question whether to read her blog any more. Of course I can’t tell her that because there’s no contact information on her blog…. Oh, now I get it. She’s libertarian. You can check her out on Source Watch.

  18. lifeonfats Says:

    As a Canadian, I am very tired of people writing about UHC as if every country which subscribes to it is populated by government-controlled sheep. We chose UHC because it is fair and humane. As for the Democratic health care plan, it is not even close to “socialized medicine”.

    That’s what so many of those protesting UHC in the US think, that once the government gives us a public option, we will become sheep. Not to mention, I’ve heard many protestors complain whatever plan we do get, it will benefit “lazy welfare recipients” and they have to pay for them. But many poor people already get state-funded medical assistance.

    It’s funny that these people complaining about a public plan don’t realize Medicare/Medicaid is a public plan, and we pay taxes toward it. So why are they saying UHC is socialized medicine? What’s Medicare and Medicaid then?

    Healthcare reform has been on Obama’s lips since he ran for President—we knew he wanted UHC—why are so many only starting to complain now? The topic’s been around for a year.

    • Lori Says:

      Honestly, I don’t think people are afraid of us becoming sheep; I think they’re afraid of people realizing that sometimes the government really can do it better (and cheaper, and more humanely) than the free market. And, if the experiences of people in pretty much every other country that has UHC is an example, then people WILL see that the government can do healthcare better than the for-profit private sector, and see it pretty quickly.

  19. Lori Says:

    I just wanted to add, too, that while car insurance certainly has a lot of competition, try getting anything close to a reasonable rate if you live in an inner city. Places where poor people live are considered to be higher risk areas, and so people are charged outrageous amounts for their insurance. Competition, as far as I can tell, hasn’t brought prices down. It’s made truly good insurance completely out of the reach of many lower-income people (or even middle-income people, like us) in urban areas and has left us a few, as a previous poster pointed out, “water and chalk” options where we pay out the butt for nothing more than the privilege of being able to drive legally.

  20. Sarah Says:

    Oh, now I get it. She’s libertarian. You can check her out on Source Watch.

    Right, so that’s a perfectly valid reason to write her off.
    *eyes roll*

    It’s very cool that Meowser has allowed a vigorous discussion on the topic of health care here, and I don’t understand why you’re all so pissy about it. I fail to see what gets learned if we only allow one position to be heard.

    • Tigerlily55 Says:

      I probably could have worded that better. Apologies. However, if you go to sourcewatch she’s responsible for articles that are pro-business. That makes me think her pro-business leaning is what’s behind her thoughts about healthcare.

      As I stated, her August 2nd post is putting forth the scary tactics about end of life counseling. What they are talking about is advance directives, and living wills and medical power-of-attorney. These things are taking place already but now medicare will pay for them. They are voluntary! You don’t have to do them. I’m glad that my parents had theirs in place before we needed them.

      I really lost respect for her with this type of tactics.

  21. Lavona Says:

    I would rather have most any private insurance plan than medicare .. I’m over 66 and still working in order to avoid medicare which was complicit in my mom’s early and painful demise for reasons covered in Sandy’s message.

    Are there problems with insurance? yes but a lot of it stems from lack of tort reform and all the rules put in by government.

    Government leads the way in limiting coverages .. a few years ago one could get a powered wheelchair if they needed it to get around and to work. Medicare/Medicaid put in a rule that it had to be needed for home use only, and within a year, it was that way in private plans too.

    There are options out there .. Blue Cross/Blue Shield plans are NOT profit making companies and in fact, are not technically insurance.

    Medical care is expensive .. that is in part because we have the best in the world and it is still a smaller percentage of expenditures (including insurance etc) than in many countries.

    What bothers me is that being overweight is now considered a choice that can be changed and frankly at some point it is not a choice anymore but a fact of life. Sounds like we are supposed to just die and get out of the way .. we’re the “clunkers” that need to be removed. My husbands GP can’t believe he is in such good health. He can’t be because he is fat .. and he’s been fat and healthier than most anyone for nearly 70 years …

    I don’t think there is any way that we will benefit in this mess, no matter what happens … it will be worse, not better.

  22. Meowser Says:

    Tort reform — meh. The states that have tort reform haven’t seen any reduction in health insurance premiums over what the rest of the country pays. California’s tort reform law passed 34 years ago. The cap on “pain and suffering” payouts was capped at $250,000 and hasn’t increased one dime since then. You’d think that would be plenty of time to see a difference, and there hasn’t been any. Insurance companies are not about passing any savings on to their customers. The idea that they would if only there were less demands on them from their policyholders would almost be hilarious, if so many people didn’t believe it.


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