The HEROES Act; A Response to AZ (section 30615)

So on social media, a friend was complaining about how Senate Republicans have been obstructing any chance at relief.  A friend of hers blamed it on the Democrats in Congress for passing the HEROES act, which he claims is chockfull of unnecessary and insensible.

Since he posted a list of complaints on Quora, we have a chance to analyze his views in some detail.

And I warn you, this is going to be a long one.  That’s why I’m going to break down responses by section.

Indepence Day Echoes

When was the last time you read the Declaration of Independence?  Not just the first paragraph, but the entire thing.

We recently had occasion to re-visit this cornerstone of our nation, and were surprised to find echoes in the grievances against King George.  A surprising number of them could be applied to our current… White House Occupant… who we’ll call T-Rump Rex.

A Very Stable Genius

DJT
I am the very model of a Very Stable Genius,
In matters diplomatic I am practically avenious!
The Dictators all say that I am really quite congenious;
From the Kremlin to the Philippines, and anywhere insidious,
I compliment the workings of the minds of the nefarious.
And anyone who questions me or expresses contradicting views
I quickly can refute them by proclaiming that it’s all fake news!

A Real Stable Genius

Someone pointed out that Trump claims that he is a stable genius.  Well, if he wants to boast about being the smartest ass in the barn, he'll need to take that up with Francis the Talking mule.

Or Mr. Ed.

Who Says We Need News Media? The Founders of this Country.

Eqsuire Magazine reports that the Trump administration wants to kick the press out of the White House. 

"There has been no decision," Sean Spicer, Trump's press secretary, said about the plan today. But Spicer acknowledged that "there has been some discussion about how to do it."

Donald Trump has already started hammering away at the press, recently refusing to answer a senior correspondent from CNN at his first press conference.  This was in retaliation for CNN’s report that the CIA had briefed Trump, President Obama, and Vice President Biden,  that reliable sources indicate that Russian intelligence may have compromising photos and video of Trump.

Does California Let Non Citizens Vote?

Recently on Facebook, someone stated that the Popular vote showing Hillary Clinton leading over Trump was inaccurate because “a large portion of people voting for Hilary were illegals and dead people”, and he followed that up with “the entire state of california gave illegals the right to vote”.

  

I asked for the source, and he sent me a link to this InfoWars story.  He also sent me a link to the Washington Times, which is simply a direct copy and paste of this story.

  

While it would be easy simply to dismiss the claim out of hand, I believe that anytime someone takes the effort to try to back up their statements, the least I can do is read their citation and analyze it...

History Fun: Why Independence?

A friend of mine, inspired by our Independence Day celebrations, wrote “…we Declared our Independence from England partially to get away from heavy taxation and decreasing civil liberties.”

It’s a common refrain: Britain taxed us too much, so we left.  If only bad old England hadn’t taxed us so much.

 

But the thing is, that’s not true.  While taxes were certainly a part of the complaint, they weren’t a major complaint.

 

I’m not going to do a complete history of the Revolutionary War – I’d be posting for MONTHS.  No, this is just addressing the root causes of the war.  That is, I’m going to tell you just WHY we “Declared our Independence from England.”

A Conservative’s Arguments on Voter Fraud Dissected

I have several relatives who don’t really understand the entire story behind Voter ID laws.  Periodically, they post something like this:

And since I’m an avid reader who tends to keep better informed than about 98% of the population, I always feel compelled to set the record straight.

The Education of Jackie Sims

Apparently Jackie Sims of Knoxville, Tennessee, has never read porn.

At least, that's my conclusion, based on her claim that the book The Immortal Life of Henrietta Lacks is pornographic, as reported in The Huffington Post.

I actually own this book, by Rebecca Skloot.  And I've read a bit of porn in my day.  And I would never equate the two.

It's the story of a poor black woman who went in to try to get treated for cervical cancer.  Instead, without her knowledge or consent, samples her tumor were taken.  The cell samples thrived in petri dish, while Ms. Lacks died a horrible death.

The cells are still alive to this day.  Ms. Lacks died in 1951.

History Fun: Separation of Church And State

There are those that argue that same-sex marriage is forbidden by the Bible, and others who will point out that since the United States is a secular nation, it doesn't matter what the Bible says.  And still others maintain that we founded as a Christian nation.

The fact is that our Constitution, the guiding document and supreme law of the United States forbids government - all government - from adopting a state religion in any way, shape, or form.

Let's isolate the part about religion:

"Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof..."

The first part, "shall make no law respecting an establishment of.."  This is something that most Americans do not understand, because we've been separate from England for so long. And let's be honest, history is one of the most tortured and abused subjects in our educational system.  Unless you're an enthusiast, you only know what was briefly covered in your public schooling, which means you really don't know much history at all.

Sorry, but it's true.  History is the class you slept through, and you only liked it when you got to make dioramas of log cabins or teepees.

Kim Davis is no Hero.

There is a loud and misinformed minority that believe that Kim Davis, the Rowan County Clerk who refused to issued wedding licenses to same sex couples even after receiving a court order that she is in fact required by law to do so, was thrown in jail because of her Christian beliefs.

That is not true. In fact, the person who put Kim Davis in jail is Kim Davis. She's in jail because she refused to obey the court order.  Did she have to obey the court order?  Yes, she did.  Why?

Because Kim Davis promised to do exactly that.

Her religious faith has not been at issue at any time in this entire series of events - at least, not as far as the law is concerned.

Kim Davis took this oath of office:

"I, (Kim Davis), do swear that I will well and truly discharge the duties of the office of (Rowan) County Circuit Court clerk, according to the best of my skill and judgment, making the due entries and records of all orders, judgments, decrees, opinions and proceedings of the court, and carefully filing and preserving in my office all books and papers which come to my possession by virtue of my office; and that I will not knowingly or willingly commit any malfeasance of office, and will faithfully execute the duties of my office without favor, affection or partiality, so help me God."
-- The Courier-Journal, September 6, 2015

Let's break this down, with some emphasis on key points.

"...making the due entries and records of all orders, judgments, decrees, opinions and proceedings of the court, and carefully filing and preserving in my office all books and papers which come to my possession by virtue of my office"

 Note that it says ALL , not SELECT.  She promises that she will stamp and record everything that her office is responsible for, period, no exceptions.

The court order she received clearly falls into the category of "all judgements, decrees, opinions, and proceeds of the court."

Furthermore:

"...I will not knowingly or willingly commit any malfeasance of office, and will faithfully execute the duties of my office without favor, affection or partiality, so help me God." 

So she swore to process everything, no exceptions, and she promised complete impartiality, that is, that she wouldn't allow her personal beliefs or convictions  By stating that she would not issue the wedding licenses because it violated her religious convictions, she clearly violated the part of her oath where she promised to do her job "without favor, affection or partiality." 

There is no question that Kim Davis willfully broke the law.

She's trying to wiggle out of it by claiming that she understood the oath to mean "...in upholding the federal and state constitutions and laws, she would not act in contradiction to the moral law of God."

She is basing this spurious claim because the oath ended with the words "So Help Me, God"

So what does that phrase actually mean?

"used to make a ​promise in a very ​formal and ​serious way"--Cambridge Dictionary Online

"The essence of the phrase is to emphasize that one means what one is saying or has said. It therefore implies greater care than usual in the act of the performance of one's duty" -- Wikipedia

Basically, it means that you are calling for God to help you keep your oath.  In this case, it means that Kim Davis called on God to make sure that she would "faithfully execute the duties of my office without favor, affection or partiality."

Kim Davis: Sinner, not Martyr

Kim Davis claims that she is keen on following the dictates of her faith; but in fact, she pays it only select lip service.  And this is apparent to us because she broke her oath of office.

Homosexuality is forbidden by the book of Leviticus.  Leviticus also mentions oaths:

^"Do not swear falsely by my name and so profane the name of your God. I am the Lord."--Leviticus 19:12

Let's review the facts:

1. Kim Davis took an oath of office when she assumed the position of County Clerk
2. In that oath, she promised to make all records presented to her in accordance with law.
3. In that oath, she also promised to do so impartially, without inserting her own opinions into the mix.
4. She called on her higher power to ensure that she did not break her oath of office.

I can only come to these conclusions:

1. She broke her oath of office by refusing to issue the licenses.
2. She broke the law by refusing to obey the lawful order of the court.
3. She committed a sin by breaking the oath she swore to God that she would uphold.

And yet there are STILL those who think that Kim Davis is justified in breaking her oath in order to enforce her personal religious beliefs over the law in direct violation of the Constitution.

To those people, I would task them with reading Mark 12:17

Then Jesus answered them, “Render to Caesar the things that are Caesar’s, and to God the things that are God’s.”

Ultimately, it is Ms. Davis' right to believe in anything she chooses.  But it is not her right to impose her own beliefs in place of the law while holding the office of County Clerk.  Not only is that a violation of the Constitution, it's a breach of the promise she made to not do exactly that.

Kim Davis does not have to stay in jail, however.  She can walk out the instant she agrees to abide by the oath she swore to uphold the law as Count Clerk of the Courts.  Or she can walk out the moment she steps down from that office because she can no longer honor her oath of office.

As ever, her eternal salvation is up to A Higher Power.  But we'll note that in Leviticus, most violations are solved with lots of rocks.

There Is No Third Choice This Election

Not since Ed Edwards ran against David Dukes for governor of Louisiana has a population been offered such a poor choice of candidates.  In 1992, it was a convicted felon former governor vs. a militant racist.  Now it's Republican vs. Republican.

  

And it's sad the best candidate that the Florida Democratic Party could come up with to unseat corrupt Republican governor Rick Scott is the spineless flip-flopping weasel former Republican governor Charlie Crist.

  

Yes, Crist is a political will o' the wind, lacking any real conviction beyond getting elected.  But he really was a far more progressive Republican, who really did, for the most part, stand for the common man in most decisions.  He did work to lower home insurance rates – and succeeded.  He did lower property taxes, no mean feat. And he did spend more on education per capita than Rick Scott ever did.  

  

And he did it all without violating Florida’s ‘Sunshine Law.’ which mandates that everything that state employees and elected officials do on the job are not only on the public record, but must be made readily accessible to public view.

  

Contrast that with Rick Scott, who ordered his staff to communicate only by private email accounts, in a thinly veiled attempt to circumvent Florida law.  Rick Scott’s first actions in office were to kill a federally funded rail project that would not have used any Florida tax dollars and would have created up to 10,000 jobs a year during construction and would have created nearly a thousand permanent jobs, and gutting the education budget by 1.3 billion dollars which decimated school systems across the state.

 

And now Scott has the gall to describe himself as “the Education governor,” based on the fact that he put some (but not all) of that money back a year later, AFTER programs were cancelled and teachers left the state for better paying jobs (or for jobs, period).

 

This year’s gubernatorial race is Republican versus Republican, and not very savory Republicans at that.  It’s totally corrupt versus morally bankrupt.
  

Many voters on the fence are considering voting for a third party candidate, Adrian Wyllie of the Libertarian Party,  in order to display their disgust for the choices.   They intend to send a message that they are not going to support totally unacceptable choices anymore.  At the very least, they feel that voting for a candidate that doesn’t make them want to vomit will help them sleep at night.

But the sad truth is that they will not be sending any messages.  Their third-party candidate won’t win.  Sorry, Wyllie.  Too many people are far too sensible to support the inadequacies of the Libertarian Party platform, which really boils down to “Government is the problem, so elect US to run the government so we can PROVE that!” 

 

If you think Scott is bad, wait until the Libertarians have reduced everything to a smoking ruin.  Hate the “Lexus lanes” on our highways?  Libertarians want to privatize ALL the roads, so you’d have to pay a toll to leave your driveway.  But the good news is that you’d be allowed to run your chemical waste dump in your backyard.  You’ll need the money to pay for your kid’s education, because Libertarians don’t want to pay for THAT, either.  Of course, they describe it as "individual liberty."

  

Most reasonable people would agree that your rights end where mine begin, and vice-versa.  But Libertarians are NOT reasonable people.  You don't want an oil refinery next to a school?  Too bad - if you feel that you can prove they've harmed you, you can sue them.  They are the party of throw the baby out with the bath-water.

 

The sad fact of the matter is that in this country, we do not have any adequate mechanism to vote against anything.  We can only vote for something else, and usually that something else is equally repugnant.

And the folks running the political campaigns are just fine with that. It's status quo.

 

Look, it’s a coin toss over who will win the race this November.  Almost all Republicans are going to vote for Scott, because that’s what they do these days.  Democrats are choking on having a Republican candidate, but many, and probably most, will vote the party ticket grudgingly.

 

The next biggest block – and in some places, the biggest voting block period – is the No-Party-Affiliation voters.  They aren’t Republicans, they aren’t Democrats, they aren’t Libertarians or Independents (which is a political party), they aren’t even necessarily liberal or conservative.  These are the voters who are going to decide the next governor.

And they’re going to get it wrong.
 
They will believe that they are going to send that message by voting for “someone else.”  The problem is that the “vote for someone else” really allows one of the two dominant party candidates to have more votes that the other.

Any vote that is not for Charlie Crist is effectively a vote for Rick Scott because Wyllie will not have enough votes to win.  At the very best, he'll come in at a distant third, and at worst he sucks enough support from Crist to pull him down to second place.

And we get four more year of Governor Sleazebag.

In an ideal world, we would have the ability to vote against a candidate.  We could vote “none of the above.” 

And with a binding none of the above vote, if that NOTA entry wins, both candidates are off the poll, and in 90 days there would be a new vote, where the candidates will have to offer different candidates if they intend to be on the ballot.  

  

I would expect that the first election would be a bloodbath, as most races would have to be re-created in under a month.  Both dinosaur parties would try to run the same old scum, and waste hundreds of millions of dollars to lose the election to an ideal.

 

No, we’ll probably never have a binding “none of the above” option. 

So let’s open up the primaries to all voters.
 
I know it sounds counter-intuitive, but hear me out.

When George Washington warned us against the vagaries of political parties, he correctly predicted that each party would draw farther apart from its opposition.  At first, the parties would be fairly close together on most issues, but over time each would retreat from the central position that is the actual ideal.

Closed primary races contribute to that.  Just look at the recent GOP candidates: when voters rejected Republican candidates, the party response was, “Well, I guess they voted for the Democrat because our guy wasn’t conservative enough.”  Yes, it’s ludicrous, but the Democrats do the same thing, inching farther to the left.

 

That’s because left to their own devices, political parties do not pick the candidate most likely to win an election, they choose the candidate that most strongly reflects their ideals.  Which sounds fine, until you wind up with a ticket of clueless bozos to choose from.

If we opened the primaries to everyone, it means that we, the people - ALL the people – would get to choose the candidates.  And understand, we’d still be choosing Republican candidates during the Republican primary, and a Democratic candidate for the Democratic primary, and so on.  But come election day, we’d be choosing between candidates that ALL of us feel exemplify the best their party has to offer.

  

And the cost? Guess what - we are ALREADY paying for the primaries that most of us don't get to go to!  Opening the primaries allows us to get full value for our tax dollars.

 

And wouldn’t that be a better choice than simply trying to not vote for a scumbag?

But in the meantime, if you can't stand Rick Scott, you need to vote for Charlie Crist. Seriously.

Wieland VS God, et al

The Huffington Post reports that Missouri State Representative Paul Wieland and his wife are suing the U.S. Department of Health and Human Services over the Affordable Care Act's contraception mandate.

  

His lawyer’s argument is  predictably lame:

Making birth control more accessible to the Wielands' daughters -- ages 13, 18 and 19 -- would be "exactly the same" as forcing Mormon parents to "provide a stocked unlocked liquor cabinet in their house whenever they're away for their minor and adult daughters to use," argued Belz, who is special counsel with the public interest law firm the Thomas More Society.

No, Mr. Weltz, it would not.  No one is requiring that you have contraception in your home. 

And let’s do a reality check: the Mormon parents probably live in a town with bars and liquor stores. And those bars and liquor stores will sell booze to anyone with ID showing they are of legal age to consume it.  On the other hand, the ACA only mandates that insurance plans completely cover the costs; their daughters would still need to get a prescription – which in the case of the Wieland’s 13 year old daughter would require parental consent.  The Wieland’s older daughters are of age, and can do as they like.  They are adults, Mr. and Mrs. Wieland.  

  

So it appears that the risk of Mormon kids binge-drinking is actually greater than that of Mr. Wieland's daughters protecting themselves from unwanted pregnancies.

But the Wielands feel that their faith is threatened:

"The government is holding a gun to our head and saying this: 'Either you give up your conscience or you give us your money.'"

Of course, the Wielands are not actually paying for the contraceptive coverage: the mandate is that the insurance companies pay for it.  Just like Ford or Honda pays for that spare tire in your trunk.  You don't have to use that spare tire.  But it's there for those who do.  Same with birth control: you don't have to use it, but it's there if you want it.

 

So much for the money argument.

   

But the Wieland’s argument is still completely without merit, if their religion is the foundation of it. 

  

Consider the Garden of Eden.

If you are a Christian, you should remember the Garden of Eden: God warned Adam and Eve not to eat the forbidden fruit - the only rule he made for them. Everything in the Garden was theirs, except for that one tree and its fruit. But God didn't remove the tree. It was there in the middle of the garden. It wasn't hidden. It wasn't guarded by a dragon. It wasn't inside a walled fortress. No, it was readily accessible, and the only thing keeping Adam or Eve from eating it was willpower. It was a test.

God's plan includes temptation. If you can't resist temptation, you don't get into Heaven. And if there is no temptation, you can't resist it. And if you can't resist it? You don't get into Heaven.

 

Of course, if you’re a Christian, and particularly if you are a Catholic,

you know that even if you commit a sin, you can still get into Heaven

by confessing the sin and performing an act of absolution, or penance.

Representative Wieland is working against the will of God by attempting to remove temptation. If his daughters do not have the opportunity to choose good over evil, they cannot be considered to be good because they have not been tested.

 
Nowhere in the Bible does it call on us to REMOVE sin. There is not one place in Scriptures that commands that. There is no commandment to destroy temptation, only to avoid giving in to it.

If he is the "good Catholic" he professes to be, Wieland should be more concerned with how he's raising his daughters and less with all the things in the world he believes defy his faith.  Those things exist as part of God’s plan.  

If you believe in that sort of thing.

A Conservative’s Premium Argument Dissected.

An ongoing series addressing the arguments of my conservative relatives.  They’ve drunk of the Tea Party Kool-aid.  I despair for them, but I will at least examine the arguments they make to support their views, which is more than they do for me.

For reference, here is the link to the  actual text of the ACA:
 

The Patient Protection and Affordable Health Care Act
  

From now on, any counter-arguments made about the law must contain references to the law.  No excuses, I’ve given you the link to the act.  I’m digging through it, you can – and should – too.

Of course, in some cases, the actual act doesn’t come into play.  In this case, you must cite a study that contradicts the studies cited here.  I can be wrong, but only facts will sway me, not links to opinion pieces by conservative pundits.

In this installment, we will analyze an article in Forbes that claims they have a study that shows that the ACA will increase insurance premiums as much as 99% for men.  So who authored this study?  The Manhattan Institute, a Libertarian think tank.  Among its patrons are the infamous Koch brothers.

Based on a Manhattan Institute analysis of the HHS numbers, Obamacare will increase underlying insurance rates for younger men by an average of 97 to 99 percent, and for younger women by an average of 55 to 62 percent. Worst off is North Carolina, which will see individual-market rates triple for women, and quadruple for men.

So there’s the claim.  But the article goes on:

“Premiums nationwide will also be around 16 percent lower than originally expected,” HHS cheerfully announces in its press release. But that’s a ruse. HHS compared what the Congressional Budget Office projected rates might look like—in 2016—to its own findings. Neither of those numbers tells you the stat that really matters: how much rates will go up next year, under Obamacare, relative to this year, prior to the law taking effect.

The claim here is that although HHS is saying that premiums are going to be lower than projected, that’s only in comparison to their previous statements on premiums.  In other words, the premiums are only lower than projected ACA premium costs, and not 16% lower than pre-ACA health plans.

Here is something to note, right off the bat:

Earlier this month, I and two colleagues from the Manhattan Institute… published an interactive map that detailed Obamacare’s impact on individually-purchased health insurance premiums in 13 states plus D.C. As the accompanying article described, Obamacare increased premiums in those states by an average of 24 percent.

But those states were largely blue states that had set up their own, state-based insurance exchanges.

I just want to hold on to this: in states that did NOT fully utilize the ACA, premiums are expected to increase an average of 24%.  Remember this.  It implies that this excessive premium inflation only occurs in states that are not fully implementing the ACA.  To me, that indicates that the ACA is having a positive effect, even if it’s less than hoped for.

 

But here’s the more important omission, and the flaw that basically runs a stake through the heart of this study:

So, we conducted two comparisons between pre-ACA data and post-ACA data, as reported by HHS. The first comparison is between the cheapest plan available to 27-year-olds pre- and post-Obamacare. The second is between the cheapeast plan available to the average exchange participant, and to the typical 40-year-old pre-Obamacare.

On the face of it, it looks, fine, right?  Even when you visit the Institute website, we find that indeed, they omitted a key piece of data:

Our pre-ACA dataset consists of the five least expensive plans (by monthly premium) for the most populous zip code in every county. To cover a significant age range we collected rates for 27, 40, and 64-year old male and female non-smokers. We adjusted these rates to take into account those who are denied health insurance coverage as well as those who receive a surcharge. Using the "denial rate" and "surcharge rate" from the federal government's repository, we assumed that those who are surcharged pay 75 percent more and those who are denied, find insurance elsewhere at three times the original rate. We used this to develop a weighted average of the five least expensive insurance plans for every zip code we identified. To develop a state-wide average, we took the state-wide average for every age-gender combination.

Here’s the fatal flaw of this study: while the study does compare the lowest priced available pre-ACA insurance plan against the costs of the lowest-priced post-ACA plan, the study doesn’t actually compare the coverage or benefits of the plans.  Nowhere does the study indicate that the plans being compared offered a similar scope of coverage and benefits.
 

The Kaiser Institute makes this point:

…plans offered in the exchanges –along with coverage sold to individual and small businesses outside the exchanges–must meet several new regulatory requirements. For example,insurers must cover a minimum set of services called essential health benefits…

The Manhattan Institute study didn’t compare premiums on similar plans, they simply compared the lowest priced plans without regard to the difference in coverage.  If the pre-ACA plans do not offer the same scope of coverage, no valid comparison actually exists.

It’s like comparing the costs of raisins against apples.   A single apple costs many times what a single raisin does.     But when you factor in the fact that we eat raisins by the handful, your perception of costs must shift.  A serving of raisins costs the same as a serving of apple.

 

Comparing health insurance plans by premium costs alone without regard for the benefits covered will not yield valid results.

 

McClatchy News Services took a look at several studies on the effects of premiums by the ACA:

“Our analysis found no widespread trend toward sharply higher prices in the individual market,” said a statement by Christine Eibner, a senior economist at RAND, a non-profit research organization based in Santa Monica, Calif.

 “We know what the cost of employer-based insurance is, and these rates are what you’d expect to see for similar benefits,” said Gary Claxton, vice president of the Kaiser Family Foundation. “These rates don’t look to be so high that we should have the sort of widespread sticker shock.”

In a study of 12 states, Avalere found that minimum premiums for a 40-year-old non-smoker averaged $261 for a Silver plan. Maryland had the lowest-cost Silver plan at $197 per month, while Vermont’s lowest-priced Silver plan cost the most at $383.

But McClatchy did include the Manhattan Institute study in their research:

New research by the conservative Manhattan Institute appears to be an outlier. Its report found nine states will see premiums increase, on average, under Obamacare next year, while five others will see average rate declines.

In other words, the Mahattan Institute’s study varies widely from the results of all the other studies.

 

The New Republic believes that all the studies may be accurate.  But it starts by making the point that the premium costs only apply to individual plans, not the group health plans that most of us are part of.

Remember, everything you are about to read is about the “non-group” market only—i.e., it describes changes for people who buy coverage on their own, directly from insurance carriers or through brokers. That’s a relatively small number of people. The vast majority of Americans get insurance through large employers, Medicare, or Medicaid. That's not going to change anytime soon, so none of the following really applies to them

The article then makes the point I just made:

1. Thanks to Obamacare regulations on insurers, the “sticker price” of coverage will go up. Non-group coverage today is usually pretty cheap. One reason is that it frequently has big gaps in coverage—no benefits for maternity or prescription drugs, for example, or deductibles that reach into five figures…

Under the law, all plans will include a basic, essential set of benefits—and must be sufficiently generous to cover at least 60 percent of the typical person’s medical bills. (That’s the standard for "bronze" plans. "Silver," "gold," and "platinum" insurance options would cover a greater share of expenses.) Insurers must also sell coverage to anybody who wants it, regardless of medical condition, without raising prices or withholding benefits. These and other requirements make insurance more comprehensive and more widely available, which is what reformers promised to do. But the regulations also make it more expensive.

And this is a fair observation, and it is borne out by the studies.  Yes, premiums for individuals is going to go up, but so is what they are getting.  And  the article goes on to point out something else we should keep in mind:

Under the law, subsidies are generally available to anybody with income that is less than four times the poverty line—which is about $46,000 a year for an individual and $94,000 a year for a family of four. Most Americans make less than that. The amount will vary by income, with poorer people getting more assistance. But among those families receiving assistance, the subsidies will be worth an average of $2,600 per year, according to another recent Kaiser Family Foundation study. That's a lot of money. And remember the subsidies act as discounts: If you are eligible for a subsidy, you don’t have to wait until you file your tax return to get your money back. Instead, the government will calculate your subsidy when you apply for insurance,

Conservatives note that subsidies aren’t free: They cost money, which the law generates through a combination of taxes (mostly on wealthy people) and reduced spending (mostly through Medicare paying less for goods and services).

This means that where the Manhattan Institute study may be correct in some instances about how much higher premiums will be, the study did not account for income or the attendant tax credits for individuals in the lower income brackets.

And The New Republic reaches the same conclusion I do:

…the lack of good data on what people pay today makes it almost impossible to be certain how premiums will change, and they're not even sure the comparison is valid. If you're paying more for a more comprehensive and stable insurance policy, does that qualify as "rate shock"? But, when pressed by reporters like me, they say the majority of people will probably end up paying less than they do now, as long as you account for subsidies, Medicaid, and the ability of young adults to enroll in special catastrophic plans or stay on their parents' policies.

But even cheap insurance can seem expensive when you're struggling just to pay other bills. How you react to the new prices will depend a lot on how much you value protection from financial shock and access to medical care—and whether you care about paying a modest penalty for having no insurance.

The bottom line is that three out of four surveys indicate that individual health insurance costs will be lower on average than they were prior to the ACA, when you factor in all the coverage benefits in addition to the mere dollar figure of the monthly premium.

A Connservative’s Argument, Dissected (part 3)

This is the third  part of my dissection of my conservative relatives’ arguments against The Patient Protection and Affordable Health Care Act. Part One can be found HERE.  Part Two can be found HERE.
 

Here is the first article one of my relatives offered to support their position:

 

15 Reasons Why The Obamacare Decision Is A Mind Blowing Disaster For America

  

Here is the link to the  actual text of the ACA:

  

The Patient Protection and Affordable Health Care Act

   

From now on, any counter-arguments you make about the law must contain references to the law.  No excuses, because, hey, I’ve given you the link to the act.

  

So here are the second group of five reasons out of the fifteen outlined by Michael Snyder for End Of The American Dream:

#11 Obamacare is going to result in a much bigger federal government.  In order to fully implement all of the provisions of Obamacare, hordes of new government bureaucrats will be required.

 We’ll grant this one, but so what?  The Homeland Security Act vastly expanded the size of the federal government.  And I guess Mr. Snyder didn’t notice that we still have millions of Americans looking for work.

 

I find #11 to be essentially correct; the ACA brings the added bonus of creating new jobs for Americans.

#12 Thanks to Obamacare, you are going to have to wait much longer to see a doctor.  Just look at what happened once Romneycare was implemented in Massachusetts….

In fact, we have already seen the start of this process in Massachusetts, where Mitt Romney’s health care reforms were nearly identical to President Obama’s. Romney’s reforms increased the demand for health care but did nothing to expand the supply of physicians. In fact, by cracking down on insurance premiums, Massachusetts pushed insurers to reduce their payments to providers, making it less worthwhile for doctors to expand their practices. As a result, the average wait to get an appointment with a doctor grew from 33 days to over 55 days.

Once again, Mr. Snyder’s citation is a dead end: the link to a New York Post article has expired.  But FactCheck.org has looked into this very topic:

Those who claim the law caused longer waiting times frequently cite annual surveys by the Massachusetts Medical Society. Its 2010 survey did find that the average wait time for internal medicine had gone up by six days since 2005 — to 53 days. But results were mixed — the average wait for family medicine went down by 15 days from the year before to 29 days. Wait times for other specialties were down too, since 2005, including those for cardiology, gastroenterology and orthopedic surgery.
 
Regardless of waiting times, however, access to care and use of care overall have actually gone up, according to the Urban Institute’s Sharon K. Long, a professor at the University of Minnesota’s School of Public Health.

Of course, when you combine the ongoing doctor shortage with the increase in the number of patients trying to see them, it is likely that wait times will increase.  But the solution is to lobby Congress to help medical students settle their student loan debt so more of them will move into medical practice as doctors, instead of opting for more immediately lucrative medical technician positions.

I find that Reason #12 airs a valid concern, but does not support repeal of the ACA.

#13 Obamacare contains all kinds of insidious little provisions that most people don’t even know about.  The following is one example from the Alliance Defense Fund….

“Did you know that with ObamaCare you will have to pay for life-saving drugs, but life-ending drugs are free. One hundred percent free. If this plan were really about health care wouldn’t it be the other way around?”

It sounds like they’re saying that you can kill yourself for free, but you have to pay to live. It’s almost the return of the Death Panels.  I can’t find anything in the ACA about euthanasia benefits.

 

So what are these “life-ending drugs” they speak of?  According to Alliance Defense Fund literature:

ObamaCare and its Mandates Fact Sheet

HHS Mandate

• Provides “free coverage for early-abortion pills, contraceptives, sterilizations, and “education and counseling” about choosing and using those things (Women’s Preventive Services Guidelines and HHS Mandates Pg. 2)
• While these items are “free”, nearly all other medications (heart pills, insulin, etc.) still cost the same.

They are referring to mifepristone, or RU-486.  Labelling it a “life ending drug” requires no small amount of hubris. And in fact, insurance plans are not required to cover drugs to induce abortions.

I find that reason #13 is false, at least given that the single example of “insidious little provisions” turns out to be false.

#14  As if the U.S. government was not facing enough of a crisis with entitlement spending, it is being projected that Obamacare will add 16 million more Americans to the Medicaid rolls.  You and I will be paying for all of this.

Unfortunately, Mr. Snyder’s source is an article behind the paywall of Investor’s Business Daily.  However, the Congressional Budget Office is free.  And the source of the information in the first place.  And it reports: 

According to the current estimates, from 2016 on, between 20 million and 23 million people will receive coverage through the new insurance exchanges, and 16 million to 17 million additional people will be enrolled in Medicaid and CHIP as a result of ACA.  

And do you know who has been paying for these 16 million people prior to the ACA?  You and I.  Only we paid more because people only went to the hospital when they had a health crisis, resulting in higher costs.  And because they weren’t in any sort of plan, the bills were a lot higher than if they’d been enrolled in Medicaid to begin with.

 

But Medicaid is administered by the states, and the states can opt out of expanding Medicaid coverage.  In those states that choose not to expand, the rest of us will cover the costs of indigent care through higher premiums instead of through tax dollars.  Either way, we pay.  And that’s just the facts.

 

So while #14 is true, it is also not a reason to repeal Obamacare.

#15 The Congressional Budget Office estimates that Obamacare will add more than a trillion dollars to government spending over the next decade.  Considering the fact that the U.S. government is already drowning in debt, how in the world can we afford this?

I must preface this with the fact that there is a difference between spending and debt.  Not all spending contributes to the deficit.  Deficits occur when spending is mandated without a revenue stream in place to fund the spending, or the mandated revenue stream brings in fewer funds than are disbursed.  But if you mandate spending, and install an adequate revenue stream, you do not create a deficit.

Once again, Mr. Snyder cites himself to support this claim.  In his article, he cites a story in USA Today talks about the deficit, but it says nothing about the ACA’s effects on the budget deficit.

But Politifact has examined claims from US Representative Morgan Griffith (R-Va) that the ACA will add $6.2 trillion to long-term deficits.  His claims are based on a January 2013 GAO study.  That study analyzed two scenarios: one in which the ACA remained completely intact, and the other in which the coverage requirements were kept, but all the cost containment measures were phased out.

The GAO reports that if the ACA moves forward, and that all of its cost containment measures remain in place, the act will reduce the primary deficit by 1.5 percent over 75 years.  Yes, that is a very small number, but it’s still a reduction.

In the other scenario, the ACA is stripped of its cost containment measures, it would increase the primary deficit by 0.7 percent over 75 years.

Politifact also examined Grover Norquist’s claim that eliminated the ACA would shave $35 Billion  from the national deficit and found that that was true.  However, they also examined Carol Shea Porter’s claim that repealing the ACA would increase the budget deficit and found that yes, it would, by around  $1,280 billion.  How can that be? Well, the ACA mandates a lot of fee reductions and creates several new revenue sources.  Eliminate the act, you lose both the savings and the extra funds it generates.

Mr. Snyder also does not address the fact that the deficit is currently falling at the fastest rate in 60 years, at least according to research done by Politifact.

I must concluded that #`15 does not provide a reason to repeal or impede the ACA.

Reasons 1-5 * Reasons 6-10 * Reasons 11-15

A Conservative’s argument, dissected (part 2)

This is the second part of my dissection of my conservative relatives’ arguments against The Patient Protection and Affordable Health Care Act. Part One can be found HERE.  Part Three can be found HERE.
 

Here is the first article one of my relatives offered to support their position:

15 Reasons Why The Obamacare Decision Is A Mind Blowing Disaster For America
 

Here is the link to the  actual text of the ACA:

The Patient Protection and Affordable Health Care Act
 

From now on, any counter-arguments you make about the law must contain references to the law.  No excuses, because, hey, I’ve given you the link to the act.
 

So here are the second group of five reasons out of the fifteen outlined by Michael Snyder for End Of The American Dream:

#6 Obamacare is going to impose nightmarish paperwork burdens on doctors, hospitals and the rest of the healthcare system.  This is going to significantly increase our healthcare costs as a nation.

Here’s the thing; I actually worked at a 200 bed hospital’s billing department.  And I can assure, our current network of private insurance companies created nightmarish paperwork burdens many years ago.  Which is why, in 1975, Congress created the National Uniform Billing Committee  (NUBC) to simplify health insurance paperwork.  It’s still in business, and the ACA doesn’t override it in any way.
 

Sadly, the link Mr. Snyder supplied is dead, and so is any possibility of analyzing its evidence in support of reason #6.  But Politifact has looked into similar claims made by Junior Senator Ted Cruz on this subject.

The tracker that Cruz relied upon has unexplained holes, miscalculates some burdens and folds in paperwork associated with non-health-care programs such as student loan changes. Significantly, too, we could not tell how the document’s largest single entry--46 million of the declared hours--was calculated.

We rate this statement, based on a partially unsupported hour count plus unrealistic Mount Rushmore math, as Mostly False.

So much for Reason #6.

#7 Obamacare is going to send health insurance premiums soaring.  This is especially true for younger Americans.

So, the first supporting evidence offered by Mr. Snyder is another article by Mr. Snyder.  This doesn’t bode well, does it? Interestingly, Mr. Snyder notes a WSJ article that pointed out that Americans already pay more for healthcare than anyone else on the planet, with a very low return on the investment.  But then he references another WSJ article entitled “Health Insurers Plan Hikes”.

Aetna Inc., some BlueCross BlueShield plans and other smaller carriers have asked for premium increases of between 1% and 9% to pay for extra benefits required under the law, according to filings with state regulators.

Funny, he skipped this statement:

…the increases apply mostly to the new policies insurers write after Oct. 1, consumers could be subject to the higher rates if they modify their existing plans and cause them to lose grandfathered status.

In other words, if you currently have insurance with theses companies, you probably will not see any increase in your rates or premiums.
 

Now, for new policy holders, or people changing their current policies, yes, your rates could go up between 1% and 9%.

But the WSJ article does go on and on about the rate increases, giving the impression that everyone’s rates are going to skyrocket, even though they don’t offer any actual evidence of it in the article.  The actual rate increases mentioned are actually quite low:

Aetna, one of the nation's largest health insurers, said the extra benefits forced it to seek rate increases for new individual plans of 5.4% to 7.4% in California and 5.5% to 6.8% in Nevada…

…Regence BlueCross BlueShield of Oregon said the cost of providing additional benefits under the health law will account on average for 3.4 percentage points of a 17.1% premium rise for a small-employer health plan…

…Celtic Insurance Co. says half of the 18% increase it is seeking comes from complying with health-law mandates.

The WSJ gives the appearance of higher rates by including the NON related increases.  The BC/BS of Oregon’s increase is only 3.4%.  Celtic’s increase is really 9%, the highest increase in the article.

“Soaring?”  Really?
 

The second source is an opinion piece written back in 2009 by Prateik Dalmia, an international studies major at Johns Hopkins University.

Young people are  least likely to need health insurance because we tend to be healthier than the remaining population. With good reason, we often choose to go uninsured…   we are the poorest segment of the population. We have not had time to build up capital, many of us have accrued student loans and after graduation we face a crippled economy due to no fault of our own…

Mr. Dalmia is absolutely correct that the young are least likely.  But he’s dead wrong that that means they don’t need or shouldn’t have health insurance coverage.
 

Senator Angus King  (I-Maine) was a young man once, and talks about his first experience of having health insurance with Salon:

Forty years ago, when King was 29 years old, he was provided health insurance as a staffer for then-Sen. Bill Hathaway, D-Maine, and for the first time in a decade went to a clinic for a checkup.

“I had a health policy that included in it a free annual physical as a part of the policy and they had evening clinic hours. And I wouldn’t have taken the day off — and if that hadn’t been covered under the insurance there’s no doubt in my mind that I wouldn’t have gone to have the checkup,” King said.

“It was a routine checkup and the doctor found this mole, and I went in a week later to have the stitches out. The doctor told me I’d better sit down and that I had melanoma…. A month later I found myself having every cancer test you could imagine. Ultimately I had a fairly major surgery. The point of the story is that without the surgery I would have died.”

The ACA works several ways to help; first off, refer to page 14:

‘‘SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.
‘‘(a) INGENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age.

That will cover most young adults for a few years after college, and through the period where a young person is trying to find a full-time job.  And even then, there are tax credits and other assistance to help someone at a low income level acquire coverage.
 

So we have to dismiss reason #7; its citations fail to support claims of “soaring premiums.”

#8 Many small businesses are going to be absolutely crushed by the provisions in Obamacare that require them to provide expensive health insurance coverage for their employees.  This is going to make them even less competitive with companies in other countries where businesses are not required to provide healthcare for their workers.  This is also going to make it even less attractive for businesses to hire new employees.

I want to highlight something that jumped out at me:

This is going to make them even less competitive with companies in other countries where businesses are not required to provide healthcare for their workers.

Which countries is Mr. Snyder referring to?  Japan?  Germany?  Both are highly industrial nations with strong, first-world economies.  And employers are not required to pay for healthcare because their governments already do so.  If Mr. Snyder is calling on Congress to completely dismantle our polyglot network of numerous health insurance and healthcare providers in order to replace them with a nationalized healthcare system, I am duly impressed.  Certainly, going that route would remove a tremendous burden from every level of business nationwide.  In fact, it would also eliminate the paperwork burden, as well as the income problem.
  

But the article he cites does not call for nationalized healthcare; it’s a press release from the National Retailers’ Foundation saying they are “dismayed” that the SCOTUS upheld the ACA.
  

But neither Snyder nor the NRF refer to Title 1, Part V, Subtitle E, Part II, SMALL BUSINESS TAX CREDIT, SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL BUSINESSES.   It starts at the bottom of page 119.  They can get a credit for up to half of what they spend.
  

We can also take a look at the model system: “Romneycare.”  A 2008 survey found that “a majority of firms” had a positive experience meeting the Massachussetts mandate.
  

Politifact found that 87% of small businesses employing 25 to 49 people already offer health benefits.  94% of companies with 50 to 199 employees already offer coverage.  And those with less than 25 employees may already qualify for the tax credits mentioned above.
  

I conclude that #8 doesn’t offer any evidence that businesses will be “absolutely crushed.”

#9 Obamacare is going to make the emerging doctor shortage in America a lot worse.  Surveys have found that we could potentially see hundreds of thousands of doctors leave the medical profession because of Obamacare.

In this case, Mr. Snyder turns to… himself.  He wrote an article for The Economic Collapse Blog about “The Coming Doctor Shortage.” To prove his case there, he references an opinion piece in The New York Post. The only citation offered there is a discredited poll.  But Mr. Snyder backs himself up by referring to another article he wrote himself.  And in that article, he refers to the same NY Post opinion piece, as well as the discredited poll used in the Post column.
  

So far, we’ve got one survey that he’s referenced several times.  And it was a survey that even Fox “News” admitted had no scientific merit.
  

But back in 2011, the Association of American Medical Colleges looked at the doctor shortage:

A physician shortage was already expected before ACA was signed into law in March 2010, and now that gap could worsen. According to projections released last fall by the AAMC Center for Workforce Studies, there will be a shortage of about 63,000 doctors by 2015, with greater shortages on the horizon…

So in fact, there was already a doctor shortage, even before the ACA.  That is “the emerging doctor shortage.”
  

But then we learn this little tidbit:

Several factors are contributing to the growing demand. On top of the 32 million Americans who will get insurance cards if the ACA is fully implemented, 15 million more will become eligible for Medicare in the coming years. Meanwhile, physician supply is projected to drop because of baby boomer retirement and other factors.

In other words, while we we are losing doctors because they are reaching retirement age, most of the shortage is due to millions of Americans receiving health insurance that will for the first time make a doctor visit affordable.  But what are the “other factors?”  Are they ACA related?  This article doesn’t say, but it does report that the ACA does have provisions to ease the crisis:

The ACA did take steps to address the shortage. For example, the reform law will redistribute some unused residency slots and increase funding for the National Health Service Corps..

But the AAMC report concludes that the biggest hurdle to training new doctors is funding for training, and regulations that require residencies in hospitals in order to earn their doctorates. Residencies limited by recent budget cuts at both the state and federal level.
  

AARP reports that simply enrolling more medical students isn’t the issue; the matter of student debt is the true culprit:

While students may enter medical school wanting to practice primary care medicine, they graduate saddled with heavy debt — $250,000 is not unusual — which prompts them to switch to a more lucrative specialty. The starting salary for a primary care physician is $150,000 to $170,000; a radiologist or gastroenterologist can make two to three times that.

Only one in five graduating internal medicine residents plans to go into primary care medicine, the Journal of the American Medical Association reports.

But what about doctors retiring?  Fortunately, MedPage Today links to a Deloitte Study for Health Solutions took a survey that has some answers.
  

Deloitte summarizes the study:

Most U.S. physicians are concerned that the future of the medical profession may be in jeopardy and consider many changes in the market to be a threat. They believe that the performance of the U.S. health care system is suboptimal, but the Affordable Care Act is a good start to addressing issues of access and cost.

Most also believe that…

• Medicaid and Medicare reimbursements may be problematic, prompting many physicians to limit or close their practices to these enrollees.
• Physician-hospital integration is expected to increase.
• Clinical decision support information technologies that reduce unnecessary services and increase clinician adherence to evidence-based practices are of interest to physicians

So while there is indeed a shortage of doctors, and the Affordable Care Act will create many new patients who will increase demand for a shrinking pool of doctors, the ACA is seen primarily as a tool to help address the problem.
  

So I’ll have to pass on #9 being a valid reason to dump the ACA.

#10 Obamacare has already forced the cancellation of dozens of doctor-owned hospitals.

This time, Michael Snyder’s reference is a blog post at Survival Blog written by someone identified only as… Michael.  I don’t think that’s a coincidence, I think this is yet another occasion where Mr. Snyder is referencing himself.  In the Survival article, the first reference leads us to a comment in a forum at God Like Productions which in turn links to an article at something called CNS News. It is a spinoff of the Media Research Center, a conservative propaganda service.
  

Already, this one has a bad smell to it.
  

But it is the first story to actually reference the  ACA!  Specifically, Title VI, Section 6001 of the Patient Protection and Affordable Care Act.
  

CNS News summarizes the affects thus:

Physician-owned hospitals are advertised as less bureaucratic and more focused on doctor-patient decision making. However, larger corporate hospitals say doctor-owned facilities discriminate in favor of high-income patients and refer business to themselves.

The new health care rules single out such hospitals, making new physician-owned projects ineligible to receive payments for Medicare and Medicaid patients.

And what does the act say?  It’s pages of updates to Section 1877 of the Social Security Act (42 U.S.C. 1395nn) . Fortunately, the Centers for Medicare and Medicaid Services sums it up nicely:

Section 6001 of the Affordable Care Act of 2010 amended section 1877 of the Social Security Act to impose additional requirements for physician-owned hospitals to qualify for the whole hospital and rural provider exceptions. A physician-owned hospital is now generally prohibited from expanding facility capacity. However, a physician-owned hospital that qualifies as an applicable hospital or high Medicaid facility may request an exception to the prohibition from the Secretary.

So the ACA does limit expansion of doctor-owned hospitals, and we have to admit that building a new hospital would certainly count as expansion.  But what about payments for Medicare and Medicaid patients?

Section 1877 of the Social Security Act (42 U.S.C. 1395nn) prohibits physicians from referring Medicare patients for certain designated health services (DHS) to an entity with which the physician or a member of the physician's immediate family has a financial relationship unless an exception applies. It also prohibits an entity from presenting or causing to be presented a bill or claim to anyone for DHS furnished as a result of a prohibited referral.

So in fact, the limits on payments for doctors referring patients to facilities owned by said doctor were already in place before the ACA.  But it does not flat-out deny claims for Medicare and Medicaid completely.
  

Bloomberg Law explains the origin of this limit on Medicare and Medicaid payments for referrals, The Stark Law:

The Stark law essentially prohibits a physician from referring Medicare, Medicaid, and other federally covered patients to a provider that provides designated health services (DHS).1 The first DHS was clinical laboratories owned by physicians. The federal government determined that physicians may be over utilizing lab services and billing for those services where the physician owns the lab. Later, the government expanded DHS to include inpatient and outpatient hospital services.2 Again, the concept underlying the prohibition was that if physicians had any financial relationship with entities providing DHS, the physicians would overutilize those services because they would be financially compensated.

Whether or not such abuse is commonplace is a subject of much debate.  The Stark Law went on to include Whole Hospital Exception:

The federal government recognized the ramifications of the Stark law and adopted a number of different exceptions to it, including the Whole Hospital Exception, which allowed physicians to own a hospital or part of a hospital as long as the investment interest is in the entire hospital.3 The exception included hospitals in existence at the time the law was adopted and those that were developed after the law was adopted.

So, to bring you up to speed, the government made it illegal for doctors to refer patients for additional services from laboratories and other facilities owned by said doctor so that said doctor would be tempted to pad his bill by ordering extra services or diagnostics.  However, as long as a physician’s investment was in the ENTIRE hospital, as opposed to just the lab, or just an operating room, he could refer Medicare and Medicaid patients to the hospital for treatment.
  

The ACA removed the Whole Hospital Exception, as well as limiting the expansion of hospitals.

But how has that affected these facilities ability to operate profitably – or at all?  The Wall Street Journal reports:

The Affordable Care Act aimed to end a boom in doctor-owned hospitals, a highly profitable niche known for its luxury facilities. Instead, many of the hospitals are wiggling around the federal health-care law's growth caps and even thriving.

Meanwhile, to grow without running afoul of the rules, some of the country's roughly 275 doctor-owned hospitals are expanding their operating hours, increasing procedures in ways not restricted by the law and rejecting patients on Medicare, the federal insurance program for the elderly and disabled.

 In 2011, the first year of the law's restrictions, more than half of the 30 largest doctor-owned hospitals showed operating margins that either matched or surpassed their 2010 figures, and some had operating margins of more than 40%. Only a handful showed drops of more than a few percentage points that year, according to American Hospital Directory data.

So it may be premature to weep for the doctors who own hospitals. Kaiser Health News goes so far as to categorize physician-owned hospitals as “the biggest winners under two programs in the health law.”
  

And as for construction of new physician-owned hospitals? 

Physician-owned hospital breaks ground in Austin

Other than the press release from Physician Hospitals of America (PHA), we can’t find documentary evidence of “60 hospitals canceled due to Obamacare.”  It certainly is possible that 60 planned hospitals have been canceled, but the ACA is helping the existing facilities make money hand-over-fist, and it hasn’t stopped at least one new hospital from being built.
  

So I must rate Reason # 10 as possible, but irrelevant.  Thousands of projects get canceled every day for a variety of reasons, and since new facilities can still be built, citing the ACA can only be an excuse, not a reason.
  

This ends the second part of the dissection; we’ll handle “Reasons 11-15” next.

Reasons 1-5 * Reasons 6-10 * Reasons 11-15