Yves here. Oddly, this article largely skips over the impact of ending or greatly cutting back the ACA on health insurers and medical care providers. I am not strong on the details here, so hopefully knowledgeable readers can pipe up in comments. However, insurers spent a lot adapting their systems and procedures to the ACA.
One of the features of the ACA that Health Care Renewal criticized was its explicit effort to further corporatize medicine. From a 2015 KHN article:
One of the main ways the Affordable Care Act seeks to reduce health care costs is by encouraging doctors, hospitals and other health care providers to form networks that coordinate patient care and become eligible for bonuses when they deliver that care more efficiently.
The law takes a carrot-and-stick approach by encouraging the formation of accountable care organizations (ACOs) in the Medicare program. Providers make more if they keep their patients healthy. About 6 million Medicare beneficiaries are now in an ACO, and, combined with the private sector, at least 744 organizations have become ACOs since 2011. An estimated 23.5 million Americans are now being served by an ACO. You may even be in one and not know it.
While ACOs are touted as a way to help fix an inefficient payment system that rewards more, not better, care, some economists warn they could lead to greater consolidation in the health care industry, which could allow some providers to charge more if they’re the only game in town.
ACOs have become one of the most talked about new ideas in Obamacare. Here are answers to some common questions about how they work:
What is an accountable care organization?
An ACO is a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending. At the heart of each patient’s care is a primary care physician.
In Obamacare, each ACO has to manage the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.
I am very much opposed to pressuring doctors to abandon solo practices. I don’t see strong evidence of the alleged economies of scale operating (save by MBA overlords forcing doctors to limit time with patients, as in degrade service), plus larger operations can have diseconomies of scope. And in practice, if the adminisphere is big enough, it will be colonized by those afore-mentioned MBAs, who take a cut well in excess of their contribution.
I have a primary physician who isn’t part of a larger group, and she does so by virtue of having about half of her practice revenues not coming from insurance-covered services. She likes being a GP but luckily also likes the other stuff, and the mix seems to lead to a viable business.
By Julie Rovner, who has covered health care for more than 30 years. Originally published at Kaiser Health News
Any day now, the 5th Circuit Court of Appeals in New Orleans could rule the entire Affordable Care Act unconstitutional.
At least it seemed that two of the three appeals court judges were leaning that way during oral arguments in the case, State of Texas v. USA, in July.
Trump administration health officials have said they will continue to enforce the health law pending a final ruling from the Supreme Court. But that is not a guarantee that President Donald Trump won’t change his mind. That’s what he did in 2017 in canceling some payments to health insurers.
There’s no doubt that invalidating the ACA in whole or in large part would have a dramatic effect on the nation’s health system ― and not just for those 20 million or so Americans whose coverage directly flows from the law.
“Billions of dollars of private and public investment ― impacting every corner of the American health system ― have been made based on the existence of the ACA,” said a brief filed by a bipartisan group of health policy experts. Declaring the law null and void “would upend all of those settled expectations and throw healthcare markets, and 1/5 of the economy, into chaos,” they wrote.
And with health care continuing to be a top issue in the presidential campaign, both Democrats and Republicans could find themselves scrambling for a fast stopgap solution if the law were to suddenly go away.
First, Some Background
At issue in the ACA case is whether the language in the 2017 GOP tax bill reducing to zero the tax penalty imposed for failing to have health insurance should render the rest of the law invalid.
A group of Republican state attorneys general and governors say it should. They argued that without the tax, the Supreme Court’s justification for upholding the law in 2012 no longer exists and so the law is now unconstitutional. U.S. District Judge Reed O’Connor agreed with them last December.
Supporters of the law ― including not just Democratic attorneys general, but also the Democratic-led U.S. House ― and bipartisan groups of legal and health policy scholars say that’s just nonsense, that the law not only can function without the individual mandate penalty but is functioning now.
What would go away ― meaning which provisions consumers have become accustomed to ― if the law is eventually struck down? Let’s take a look.
Insurance Protections
Most people think the health law directly affects only those Americans who purchase their own insurance through the exchanges the law created (and who get subsidies if their incomes are between 100% and 400% of the poverty level). That’s about 10 million to 12 million households.
But many of the insurance protections in the law also protect those who have insurance through their jobs. These provisions include allowing adult children to stay on their parents’ health plans and requiring that insurers cover people who have preexisting health conditions at no additional charge to those patients. The law also requires that ACA-compliant policies provide preventive care with no out-of-pocket cost, and bans annual and lifetime insurance coverage limits.
It also limits insurers’ amounts of profit and administrative expenses. That makes for a lot of chaos right there should the entire law disappear. But there is more.
Medicare And Medicaid
Most people with a passing familiarity with the health law know it expanded the Medicaid program for those with incomes up to 138% of the poverty level (at least in states that opted into the program).
The law also made big changes to the Medicare program, including closing the notorious “doughnut hole” that left some seniors with big drug bills despite having insurance. The ACA also extended coverage of more preventive benefits for people with Medicare coverage.
Generic Biologics
An important, though frequently overlooked, portion of the health law created the first legal framework and regulatory pathway for copies of expensive, already FDA-approved biologic drugs, called biosimilars, to reach the market. Biologic drugs are among the most expensive medications and treat life-threatening ailments such as cancer, rheumatoid arthritis and macular degeneration. It is unclear what would happen to the stream of biosimilars already approved if the law is struck down ― will their approvals be revoked? What about medications currently in the approval pipeline?
Funding For The Indian Health Service And Training More Health Professionals
Among other little-known features of the ACA is a provision that permanently authorized the U.S. Indian Health Service, which provides health coverage for more than 2.5 million American Indians and Alaska Natives. An overturn of the law could leave in doubt the legality of some of the program’s operations.
Here’s one more provision you may not have thought about. On the theory that if more people have health insurance more people will seek medical care, the ACA has an entire section devoted to increasing the supply of not just physicians, but nurses, therapists, dentists and community health centers. Many of these training programs could founder if the ACA is overturned.
And those now-ubiquitous calorie counts on restaurant menus? Those are there because of the ACA. Some people may not be sad to see those go away. But if the ACA is invalidated, the health system will likely change in ways that no one can predict.
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Funny that I was just reading this …
Lately I’ve noticed some Democratic politicians defending the current healthcare system by saying it preserves “choice” for Americans. As a former health insurance exec who helped draft this talking point, I need to come clean on its back story, and why it’s wrong and a trap 1/11
When I worked in the insurance industry, we were instructed to talk about “choice,” based on focus groups and people like Frank Luntz (who wrote the book on how the GOP should communicate with Americans). I used it all the time as an industry flack. But there was a problem. 2/11
https://twitter.com/wendellpotter/status/1206623259698974724
those ‘now-ubiquitous calorie counts on restaurant menus’ are a step backwards, not forwards.
Op-Ed: Counting calories won’t reduce obesity. So why are we requiring restaurants to post them?
My experience is that cutting out any calorie-dense food will cause weight loss or stabilization. Granted, the items I dropped (sodas and ice cream) are high in carbohydrates, but ice cream is also high in fat.
Seems like your body doesn’t demand that you replace the lost calories, and of course it’s easier than just eating less of everything. Hmm – using small bowls and plates might help, too.
Texas is not a medicaid expansion state.
so there’s a medicaid gap…last i looked, the top income level for an adult who s not “disabled” or “pregnant”(as defined by opaque texas/fedreal law) is around $230/month for a family of 4(this has undoubtedly changed. last time i found this number was a few years ago)
but the subsidies don’t kick in until something like $2600/month(same caveat: this sort of opacity is one of my main beefs with healthcare, in general)
eligibility for medicaid may as well be a black box, or a coin flip….in may, caseworker called and told wife that she made too much money(“fraud!!!!”) and would be dropped at the end of the month…so we scrambled around, prepared to go into massive debt in order to gain access to the school’s insurance…..but then the word was “never mind”…with no explanation at all.
in september, all texas teachers got a $5k a year raise…which puts us over the top as far as eligibility for medicaid, as near as we can tell.
so we’ve been just waiting for the shoe to drop, as the “enrollment period” passes us by.
considering murphy’s law, and all…I expect medicaid to drop my wife just as soon as these judges* rule that ACA is out…and that the quick return of the preexisting condition denial regime will throw a further wrench into obtaining chemo for my wife(which would make these judges* a literal, if slow motion, death panel).
we’ve considered trying to jump the gun and somehow back out of medicaid and go on and obtain the insurance(copay, deductable, etc=$10K per year, negating the raise)…but fear that this will trigger accusations of “fraud”, somehow….because that’s the default assumption with all these poor people programs, as evidenced by the constant subtle and overt reminders…none of which actually give you actionable information.
we don’t know, either, if getting the insurance now(at great cost and hardship going forward) will prevent the preexisting condition thing.
so i keep one eye on this court case…but no matter what those judges do, the fear, uncertainty and doubt loom large in our lives.
rickf&ckingperry moved mountains at the time to all but outlaw obamacare navigators…with considerable FUD and veiled threats that speaking to one’s neighbor about healthcare could land you in jail.
we were lucky to have found a navigator analog, who has helped a great deal with all this…neither of us has ever had insurance, and the whole mess may as well be written in hebrew or one of those click languages…but even with a direct line to that saintly woman, there’s a whole lot of unknowns. we can’t plan…only react to whatever the machinery spits out, almost at random.
I keep thinking about my one visit to an ER in Toronto, some 35 years ago. I had stitches that were due to be removed when we were there. we went in, waited while they triaged some victims of a car wreck, and then they removed the stitches. My grandad ran around with his wallet open, trying to pay somebody…”sir, it’s paid for”.
nobody even asked about money, and seemed confused that he was concerned about it.
that’s how it should be.
that even the “experts” can’t say for sure how these judges* will effect ACA, or the system in general…one way or the other…says volumes to me.
(* remember when gop was all bent out of shape about “activist judges”….”legislating from the bench”? )
Citizen’s United looked after their concern about activist judges – hard for them to complain after that ruling created corporations as equal to people out of thin air.
Also, “original intent” is going to disappear as a discussion point after the Republican defense of Trump is done because the articles of impeachment are structured around what the founders were concerned about when drafting the impeachment clause. Now, the President can’t be impeached until a statutory crime can be proven beyond the shadow of a doubt (and not even then since the President is immune from investigation and prosecution per Trump).
“Texas is not a medicaid expansion state.”
Doesn’t this mean that your wife’s coverage does NOT depend on the ACA? I’m no lawyer, but logic suggests there’s no connection. Hate to disagree with you on something like that, but at least it might be good news.
I feel for anyone whose health, even life may depend on such a byzantine system. Almost makes me glad I’m old.
the preexisting part is my main worry.
that prohibition is a good good thing
i also worry about lifetime caps
cancer is ridiculously expensive
aside from those, you’re right
aca is almost unnoticeable in texas
Amfortas, you will be in my prayers.
Who knows, God may be surprised enough to hear from a Realtor that she’ll listen.
Things are a little better for me in California, Medicare will cover most of the cost of my Chemo, however how much of the cardiac ablation I had done last week will be covered is another question entirely.
When I was signing and initialing the little electronic pad required for admission ( You don’t get a paper copy, it’s “Sign here to acknowledge you have read and understood our privacy policy, initial here to…)
I was informed that some of the specialists and care I would recieve were not covered by Medicare.
No specifics,
I’ll happily pay the balance when I win the lottery.
I used a pen with the metal point retracted to add a tag line to my signature on the pad(s). “All rights reserved, bill paid after receipt of hard copies of detailed bills, then my signature.
The nurse said she didn’t care. Everyone I talked to in the medical field from janitors to M.D.s said they would vote for Bernie BTW.
I know dozens of working-class stiffs who can’t afford to buy the insurance, so they get a bronze plan or an HSA and they can’t afford to use it.
These guys are raising families on $15/hr average. The ACA represents a black hole of unrequieted loss to them from which there is no recovery. They make too much to qualify for anything, yet they could barely afford to live *before* ACA came along.
There is now 2 generations that completely despise both Democrats and Blacks because of Obama and the ACA now.
Own Goal, Team Blue!
Team Blue Own Goal.
In California, under Obamacare, people under a certain income level, whether they are healthy or not, either have to pay for private insurance extortion, or get automatically enrolled in Medi-Cal.
Problem is, monthly premiums for Medi-Cal and services rendered, even when one doesn’t want to be, or need to be, covered by anything, are clawed back from the recipients estate.
“For Medi-Cal members who died on or after January 1, 2017: (See Changes to Estate Recovery effective January 1, 2017 due to Legislation Senate Bill 833)
Repayment will be limited only to estate assets subject to probate that were owned by the deceased member at the time of death.
Repayment will be limited to payments made, including managed care premiums paid, for nursing facility services, home and community based services, and related hospital and prescription drug services received when the member was an inpatient in a nursing facility or received home and community based services.”
https://www.dhcs.ca.gov/services/Pages/TPLRD_ER_cont.aspx
So, 56 year old man in excellent health, refusing to buy private insurance, forced onto Obamacare, gets hit by car, goes to hospital, million dollars in extortionate fees charged by med and pharma, his house is grabbed away from his kids by the state.
Ran out of time before I could add this:
“Undocumented immigrant adults make up the majority of California’s uninsured population, about 58 percent, according to the Insure the Uninsured Project.”
http://www.comstocksmag.com/kaiser-health-news/medi-cal-expand-eligibility-undocumented-adults-some-say-they-wont-enroll
“The measure signed by Gov. Gavin Newsom on Tuesday extends coverage to low-income, undocumented adults ages 25 and younger for the state’s [Full Scope] Medicaid program. Since 2016, California has allowed children under 18 to receive taxpayer-backed health care despite immigration status. And state officials expect that the plan will cover roughly 90,000” people.
4. Will [ALL] undocumented immigrants be eligible for full-scope Medi-Cal?
“An immigrant who meets all eligibility requirements, but is not in a satisfactory immigration status for full scope Medi-Cal is entitled to emergency and pregnancy-related services and, when needed, state-funded long-term care.
https://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/Medi-CalFAQs2014b.aspx
Good luck putting a lien on their mini-fundia rancho south of the border.
Retirees in Paradise who got burned out?, no problemo.
Bernie would get far more votes from citizens, and legal immigrants, if he proposed that everyone in the U.S. be covered by Medicare For All, but with illegals’ home countries being billed for their care.
I wish I understood how anyone could be comfortable with our current health care situation. My whole adult life I’ve felt on the verge of disaster.
What we have is a system of legal extortion (your money or your life) And that other thing where prices are raised by people in control just because they know their customers have no where To turn (Insulin)
And then you get on Medicare and think things will be better. But to be completely and reliably covered we have to have 3 policies. Each. And we have to re evaluate them every year to make sure they still cover what we need. Or expect to need. Which might not be the same thing.
How can so many people be comfortable and even happy with this situation?
“How can so many people be comfortable and even happy with this situation?”
I can only give you my thoughts from my circle of relatives/friends/aquaintances.
1) Some get insurance paid for by their employer. The deductibles may be high, but
a) the individual makes enough money that the deductibles/co-pays/coinsurance aren’t a problem financially or
b) they’ ve been lucky enough not to encounter any major health problems.They really don’t know how bad the system is. They have been fortunate not to have been burned by the system (yet).
c) they read all of these insurance horror stories but yet they believe it just won’t happen to them.
2) People are afraid that their quality of care will go down if we open up MFA. They are afraid that they won’t be able to see their doctors in a timely manner due to the influx of new patients. iow, they may not be exactly happy with the system as it is now, but fear it will become much, much worse under M4A.
Just my experience, fwiw.
And those people are everywhere, I guess.
Agree strongly with points 2 & 3. Many people I’ve spoken with about it think a switch to M4A will cause long wait times for doctor visits and medical procedures. They also think their taxes will go up ( this is true, but they don’t trust that higher taxes will be more than offset by eliminating private insurance premiums , co-pays, deductibles. ) They also think their choice of doctors will be more restricted. Of course, choices are already restricted. Anyone who has gone out of network for care knows this.
Correction, I should say point (b) and point 2
aiee their choice of doctor will be more restricted! M4A precisely means no cost at the point of service and no docs are off limits to anyone, there are no networks or bullshit ACOs (except unfortunately in Bernie’s inferior-to the-house version).
I should say point (b) and point 2
I would also like to add something to 1):
They get their insurance paid for by their employer and they really don’t think they will be laid off, thus losing their insurance
The Obamacare Free Rider song, by The Epistemic Hairball All-Star Shoe Band…
Everybody SING!
“You’re going to have such great health care, at a tiny fraction of the cost, and it’s going to be so easy.”
– Candidate Trump, 2016 FL campaign rally
Re: your intro at the top.
One of the advantages of single payer systems is that it allows solo practitioners or small groups to exist easily because they don’t need much on the business side. They need to run an efficient practice with enough patients going through the door, but they don’t need an army of billing Oompah-Loompahs in a back room brawling with insurers.
For anyone wondering, here’s a link to the criminally low – generally $12,490 for one person, $16,910 for two – 100% Federal Poverty Levels. I wish every article that references those levels would provide at least a link, if not a chart, so all can determine what they might qualify for, and also see how the US Government treats its most vulnerable citizens .
Why only Alaska and Hawaii levels – Alaska’s oddly being the highest – are higher, is anyones’s bleak guess.
“For anyone wondering, here’s a link to the criminally low – generally $12,490 for one person, $16,910 for two – 100% Federal Poverty Levels.”
Those figures need to be doubled in order to approach reality, IMHO and in my own lived experience. Ever notice how they never impose upper limits on prices? Inflation most definitely affects the poor, in the most regressive ways.
Shorter version of a prior comment in moderation:
Yes, the Federal Poverty Levels™ should be at least doubled, in some areas even more. There appears to be utterly no moral compass left in the country’s powers that be. As to not capping price levels, I’ve witnessed extortionist RENTS being allowed my entire adult life; renters then being finger wagged regarding unaffordability when they try to buy a small home to get from under predatory landlords. No Federal Tax policy whatsoever to compensate their ‘investment’ in extortionist rents.
AMEN, and not just rents…. I’ve noticed that anything which is not included in the “official” inflation index is inflated through the roof. And those are exactly the things needed for a decent basic life. Housing. Education. Healthcare.
Who cares if you can buy a 5-foot TV if you can’t afford the house to put it in, or the usurious monthly cable bill?
thanks for posting this. I always assumed I wouldn’t get a subsidy because I earn too little (since quitting my FT job and moving down here) but that link takes you to a place where you can plug in your info for the ACA and it just might be I can. Also bookmarked for future reference.
You’re welcome. I hope you have a good outcome!
Part of the reason why I think that our ridiculous and broken healthcare system has existed for so long, is because a lot of people are not aware of anything different, or if they are, they feel that it is simply not politically possible in the US. It does not help the fact that many of our politicians in both major parties have adopted anti-single-payer talking points for why we cannot have something like Medicare For All. We have been inundated with scaremongering about “socialized medicine” for decades.
While a lot of people are indeed unhappy about our medical system, it has been entrenched for so long, it is going to be very difficult to change it because the opposing forces to it are extremely powerful.
Still, I am grateful to Trump for getting rid of the mandate. After all, the bronze plan for Cigna where I work is around 9% of my meager income, and the deductible is around $4,000 dollars. I am uninsured, as what is the point of paying premiums for a plan that I that does not cover much of anything and that I could never afford to use?
One of my adult kids recently had a broken bone with resulting cast etc. The deductible is $6,500, so nothing was covered by insurance. However, the primary reason to have that insurance for these events is to get the insurance company pricing which is substantially lower than “list”. Because it is an Excellus plan, everybody is in network and the out-of-pocket costs haven’t bad (for the US; in Canada cost would have been $0). However, it was not possible to get estimates up front or during treatment for anything. “We have to send it to the insurance company first” was the standard answer. It is an expensive, slow, and utterly opaque system. The bills are still filtering in even though the initial visits were over 6 weeks ago. I think there is so much money sloshing around in the system that cash flow is not much of an issue unless you are in a rural system.
no price discovery, it ain’t a “market”
Also no equality of information, and frequently “consumers” who are in no position to shop, even if there were price discovery – as in, unconscious.
“Markets” in health care have always been pure fiction, as anyone who has seen the theory would know. They would be highly unethical if they existed.
“larger operations can have diseconomies of scope.” I’m not grasping this point and why it could be so. (Economies of scale and scope are usually cited as why large oligopolies are more cost-effective therefore market-dominant). Any explanation?
Please try using Google or Qwartz. I’m responding but honestly you should have been able to sort this out. This is a very thinly resourced site. It is frustrating to do research for readers that they ought to have been able to perform on their own.
First, economies of scale are a nice theory but often don’t operate in practice. Banking is a classic example. Once you get past a not-high threshold in terms of asset size, banking exhibits mild diseconomies of scale. Every study ever done on banking in the US has affirmed this result. They differ only on the size threshold where the diseconomies start.
Second, diseconomies of scope is a well known concept. I am surprised you are reacting as you do. The classic conglomerate discount I discussed in my Rohatyn post. It’s pretty well accepted that having a common administration of unrelated or “not as related as you want to believe” business doesn’t create any economies. Having managers oversee distinct businesses with limited or not-obtainable synergies = diseconomies of scope. The sprawl makes the combined business less efficient than if it were broken up and the components were run on a stand-alone basis. The abject failure of “universal banking” is another example. Financial services is also recognized as having diseconomies of scope.
Thanks for your reply. Yes, I did think of banking, but that doesn’t actually produce anything (and scale and scope of different if related matters). Conglomerates are an obvious example of diseconomies of scope, but it’s not obvious that the various activities producing and providing health care are unrelated businesses. Rather one would want health care delivery to be well integrated, with clear and continuous lines of communication between various providers. (Diseconomies of scale, with patients getting lost in the shuffle of overly large organizations and imposed standardizations, thereby not receiving the individual and differentiated care needed, might be more germane). But I was thinking of classic industrial organization, where economies of scope, “joint and several production”, tend to drive unit costs down to some point.
The underlying point is that health care inflation is not mostly a demand side problem, but a production/supply-side matter. Kenneth Arrow of all people wrote a paper 50 years ago making that point: that health care is a non-market good and competitive markets would not provide socially optimal health care, as he imagined market competition would in most cases. It’s the perpetual effort to force health care into the market mode, stripping its institutions of their relative autonomy and disaggregating them into individual incentives that results in so much dysfunction. Rationalizing our health care system is a problem for systems theorists, “operations research”. Instead we put the system in the hands of “health care economists”. Do other countries not so afflicted with the burden of excessive health care costs even produce such creatures?
I believe that the original district court decision was not based upon the system’s continued functionality without the tax penalty if you didn’t have insurance during a taxable year; it relied upon Justice Roberts’ very narrow ruling that it was ONLY because of the tax implication of non- compliance that the ACA is a constitutional exercise of the Federal Government. Now that the penalty has been eliminated, the district court intuited that the ACA is no longer constitutional, which is, regardless of the policy implications, a pretty defensible ruling.
There is another issue, which is that evidently some preexisting law that was included in the ACA, and that had never been subject before to a constitutional challenge. What happens to that? The district court judge threw that baby out with the ACA bath water. That part of the district court’s ruling might get overturned in New Orleans, but I think the rest of the ruling will stand, before being turned over to the marsupials en regalia in Washington. The argument that affirming the lower court’s ruling will create havoc and chaos in the health care industry, which I am sure will be raised in dozens of amicus curaie briefs, may well save the day, if Roberts can figure out how to reverse his own prior ruling. However, the horror show that will result for people insured under the ACA will not matter a whit.
And yet, they had no problem with the havoc and chaos they caused in the passage of it, why would there be any problem with the havoc and chaos caused by repealing it?
I’m under the impression that if a District court finds something Unconstitutional it applies ONLY in that District, not in the entire US. Now, of course, if that decision is reviewed and upheld by the Supreme Court then it applies to the entire US.
Here is reality: If its ruled unconst and that goes into effect it will crash the entire heath care insurance and delivery markets as its so entwined in everything at this late state.
” They argued that without the tax, the Supreme Court’s justification for upholding the law in 2012 no longer exists and so the law is now unconstitutional. U.S. District Judge Reed O’Connor agreed with them last December.”
Hell, *I* agree with them. However, what’s unconstitutional is the Mandate, and it’s a good question whether that is necessary. I’m familiar with the arguments for it, but I’m not convinced. Removing the penalty (much more of a fine than a tax – SCOTUS was really reaching) effectively removed the Mandate, with minimal apparent effect. People still get Obamacare policies if they think they benefit, and not if they don’t. There’s been some slippage, IIRC, but not drastic, and probably related to other Trumpian measures against the ACA. I consider the Mandate seriously offensive, both against the Constitution and against common sense (since when can the Federal gov’t require citizens to buy some defective commercial product – conditional only on being alive?), so I wouldn’t miss it. But then, I’m on Medicare.